2021 House of Delegates Virtual Meeting

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Order of Business

Saturday, May 1, 2021

9:00 – 10:30 am

• Opening Remarks from the Speakers – Theodore B. Jones, MD; and Phillip G. Wise, MD

• Candidate Forum – Theodore B. Jones, MD

• Address of the President – S. “Bobby” Mukkamala, MD

• Address of the President-Elect – Pino D. Colone, MD

• Report from the Chair of the Board of Directors – Anita R. Avery, MD

• Report from the Treasurer of the Board of Directors – John A. Waters, MD

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OFFICERS, 2020-2021

REGIONAL DIRECTORS

DESIGNATED DIRECTORS

SECTION DIRECTORS

DELEGATION TO THE AMA

In Memory

The members of the Michigan State Medical Society remember with respect their colleagues who have passed away since our last annual meeting.

Okezie Aguwa, MD Kristin Krizmanich-Conniff, MD C Alkema, MD Joseph Kroon , MD James Askins, MD Armand LaSorsa, MD Roger Byrd, DO Lawrence Lee , MD Donald Cady, MD JoAnne Levitan, MD Nicanor Castedo, MD Philip Margolis, MD John Colombo, MD Rodney McFarland, MD Julius Combs, MD Mark Menning, MD Bernardo Danan, MD Richard Oslund, MD Michael Dawson, MD Lawrence Pawl, MD Samuel Dismond, MD Daniel Postellon, MD Ernesto Duterte, MD Minoo Rao, MD Thomas Egleston, MD Robert Reed, MD Ali Esfahani, MD David Rovner, MD John Feilla, MD Charles Safley, MD Lynn Gray, MD, MPH Brian Schafer, MD Oliver Grin, MD Courtland Schmidt, MD Alan Hendra, MD Michael Stone, MD Anita Herald, MD Dennis Tibble, MD Victor Hill, MD Luis Tomatis, MD Jeffrey Jacobs, MD Prabhundha Vanasupa, MD Larry Jennings, MD Gordon VanOtteren, MD Julian Joseph, MD Robert Weber, MD Francis Judge, MD Burton Wolters, MD Zubeda Khan, MD George Zuidema, MD John Koh, MD, FACS

MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES May 1, 2021 Roster of Delegates

OFFICERS: Theodore Jones MD Speaker Phillip Wise MD Vice-Speaker T. Jann Caison-Sorey MD, MSA, MBA Secretary

County: Barry Natalia DiPaola MD Delegate

County:Berrien Dennis Szymanski MD Delegate

County: Genesee Khalid Ahmed MD Delegate Qazi Azher MD Delegate Laura Carravallah MD Delegate Edward Christy MD Delegate Deborah Duncan MD Delegate Venkat Rao MD Delegate Macksood Aftab DO Alternate Delegate Scott Garner MD Alternate Delegate Asif Ishaque MD Alternate Delegate Paul Kocheril MD Alternate Delegate Rama Rao MD Alternate Delegate Brenda Rogers-Grays DO Alternate Delegate

County: Grand Traverse - Leelanau - Benzie Sam Copeland DO Delegate Diane Donley MD Delegate Cyrus Ghaemi DO Delegate Bradley Goodwin MD Delegate Scott Monteith MD, FAPA Delegate Kenneth Musson MD, MS, FACS Delegate Edward Rutkowski MD Delegate Bradley Evans MD Alternate Delegate

County: Ingham Iftiker Ahmad MD Delegate Tyson Burghardt MD Delegate Douglas Edema MD, MPA, FACHE Delegate Kenneth Elmassian DO Delegate Ved Gossain MD Delegate Narasimha Gundamraj MD Delegate Raza Haque MD Delegate Richard Honicky MD Delegate Ronald Horowitz MD Delegate James Richard DO Delegate Dawn Springer MD Delegate David Walsworth MD Delegate Joseph Wilhelm MD Delegate

County: Jackson Courtland Keteyian MD Delegate Walter Korytowsky MD Delegate Jon Lake MD Delegate MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES May 1, 2021 Roster of Delegates

County: Kalamazoo Ruqiya Tareen MD Delegate

County: Kent Michelle Condon MD Delegate Megan Edison MD Delegate Eric Larson MD Delegate Gerald Lee MD Delegate Rose Ramirez MD Delegate Brian Roelof MD Delegate Adam Rush MD Delegate Herman Sullivan MD Delegate John VanSchagen MD Delegate David Whalen MD Delegate Phillip Wise MD Delegate John Beernink MD, FACS Alternate Delegate Sandra Dettmann MD Alternate Delegate Harland Holman MD Alternate Delegate John O'Donnell MD Alternate Delegate

County: Lenawee Lawrence Desjarlais MD Delegate

County: Macomb Adrian Christie MD Delegate Lawrence Handler MD Delegate Ronald Levin MD Delegate Vincente Redondo MD Delegate Aaron Sable MD Delegate Akash Sheth MD Delegate

County: Midland Thomas Johnson MD Delegate Thomas Olen DO Delegate

County: Monroe Irving Hwang MD Delegate Busharat Ahmad MD Alternate Delegate

County: Muskegon Wayne Fuller MD Delegate F. Remington Sprague MD Delegate

County: Northern Michigan Irene Kazmers MD, FACP, RhMSUS Delegate Melanie Manary MD Delegate Louis Zako MD Alternate Delegate

County: Oakland Jaime Aragones MD Delegate Barry Auster MD Delegate George Blum MD Delegate Betty Chu MD, MBA Delegate Peter Duhamel MD Delegate Jay Fisher MD Delegate MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES May 1, 2021 Roster of Delegates

Oakland cont. Ashok Gupta MD Delegate Sherwin Imlay MD Delegate Kamalesh Lahiri MD Delegate David Lee MD Delegate Robert Levine MD Delegate Shahrokh Mansoori MD Delegate Alan Mindlin MD, FACS Delegate Steven Newman MD Delegate Moon Pak MD, PhD Delegate Donald Peven MD Delegate Theodore Roumell MD Delegate Manveen Saluja MD Delegate Jason Schairer MD Delegate Raouf Seifeldin MD Delegate Colleen Sheehan MD Delegate Karol Zakalik MD Delegate

County: Ottawa Bryan Huffman MD Delegate Edward Fody MD Alternate Delegate

County: Saginaw Christopher Allen MD Delegate Jennifer Romeu MD Delegate Miriam Schteingart MD Delegate Caroline Scott MD Delegate Kristine Spence DO Delegate Steven Vance MD Delegate Julia Walter MD Delegate Mildred Willy MD Delegate Anthony Zacharek MD Delegate Waheed Akbar MD Alternate Delegate Scott Cheney MD Alternate Delegate Joseph Contino MD, FACS Alternate Delegate Elvira Dawis MD Alternate Delegate Virginia Dedicatoria MD Alternate Delegate Karensa Franklin MD Alternate Delegate Mohammad Khan MD Alternate Delegate Jorge Plasencia MD Alternate Delegate Michael Warren MD Alternate Delegate

County: St. Clair Anup Lal MD Delegate Sara Liter-Kuester DO Delegate John Pelachyk MD Delegate

County: Washtenaw Richard Burney MD Delegate Evelyn Eccles MD Delegate Cheryl Farmer MD Delegate Terence Joiner MD Delegate Charles Koopmann MD Delegate Angela Kuznia MD, MPH Delegate Anna Laucis MD Delegate James Mitchiner MD, MPH Delegate MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES May 1, 2021 Roster of Delegates

Washtenaw cont. Joseph Nnodim MD, PhD, FACP Delegate Robert Sain MD Delegate James Szocik MD Delegate Barbara Threatt MD Delegate Jerry Walden MD Delegate

County: Wayne Susan Adelman MD, FACS Delegate Ghassan Allo MD Delegate Hassan Amirikia MD Delegate Edmund Barbour MD Delegate Charles Barone MD Delegate Joseph Beals MD Delegate Deloris Berrien-Jones MD Delegate Brooke Buckley MD Delegate E. Chris Bush MD Delegate Denise Collins MD Delegate Steven Daveluy MD Delegate Cheryl Gibson Fountain MD Delegate Holly Gilmer MD Delegate Sarah Gorgis MD Delegate Sara Hegab MD Delegate Aliya Hines MD, PhD Delegate Clara Hwang MD Delegate Anne-Mare' Ice MD Delegate Edward Jankowski MD Delegate Theodore Jones MD, FACOG Delegate Katherine Joyce MD Delegate Lauren Keshishian MD Delegate Samer Kirmiz MD Delegate Patricia Kolowich MD Delegate Henry Kroll MD Delegate Navid Mahabadi DO Delegate Federico Mariona MD, FACS, FACOG Delegate Chandan Mehta MD Delegate Alireza Meysami MD, RhMSUS Delegate Usamah Mossallam MD Delegate Ijeoma Opara MD Delegate Mohammed Rehman DO Delegate Katherine Reyes MD, MPH Delegate Latonya Riddle-Jones MD Delegate Michael Sandler MD Delegate Blake Sanford MD Delegate Krishna Sawhney MD Delegate George Shade MD Delegate Mhd Tayseer Shamaa MD Delegate M Salim Siddiqui MD, PhD Delegate Emily Smith MD Delegate Richard Smith MD Delegate James Sondheimer MD Delegate Neelima Thati MD Delegate Bright Thilagar MD Delegate Theresa Toledo MD Delegate Robyn Torof MD Delegate Donald Tynes MD Delegate MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES May 1, 2021 Roster of Delegates

Wayne cont. Patricia Wilkerson-Uddyback MD Delegate Atsushi Yoshida MD Delegate Eunice Yu MD Delegate Lucia Zamorano MD Delegate Anthony Adeleye MD Alternate Delegate Barika Butler MD, MHCM Alternate Delegate Maria Shreve MD Alternate Delegate

County: Wexford-Missaukee Martin Dubravec MD Delegate

Delegate-At-Large: Immediate Past President Mohammed Arsiwala MD Delegate

Delegate-At-Large: Medical School Dean, Central Michigan University George Kikano MD Delegate

Delegate-At-Large: Medical School Dean, Michigan State University Andrea Amalfitano DO, PhD Delegate Norman Beauchamp Jr. MD, MHS Delegate

Delegate-At-Large: Medical School Dean, University of Michigan Marschall Runge MD, PhD Delegate

Delegate-At-Large: Medical School Dean, Oakland University Duane Mezwa MD, FACR Delegate

Delegate-At-Large: Medical School Dean, Wayne State University Jack Sobel MD Delegate

Delegate-At-Large: Medical School Dean, Western Michigan University Hal Jenson MD, MBA Delegate

Members-At-Large: MDHHS Chief Medical Officer Joneigh Khaldun MD, MPH Delegate

Medical Student Section Victor Agbafe Student Delegate Samuel Borer Student Delegate May Chammaa Student Delegate Mara Darian Student Delegate John Dewey Student Delegate Preetha Ghosh Student Delegate Katherine Grayden Student Delegate Moustafa Hadi Student Delegate Jessyca Judge Student Delegate Anna Kang Student Delegate Jesper Ke Student Delegate Remonda Khalil Student Delegate Nicole Lee Student Delegate Ashton Lewandowski Student Delegate Darian Mills Student Delegate Aayush Mittal Student Delegate Michael Moentmann Student Delegate MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES May 1, 2021 Roster of Delegates

Medical Student Section cont. Divyani Patel Student Delegate Leah Rotenbakh Student Delegate Mackenzie Schmidt Student Delegate Brianna Sohl Student Delegate Alangoya Tezel Student Delegate Melanie Valentin Student Delegate Manisha Verma Student Delegate Youstina Abdallah Student Alternate Delegate Kriti Babu BS Student Alternate Delegate Jennifer Byk Student Alternate Delegate Zoey Chopra Student Alternate Delegate Sanjay Das Student Alternate Delegate Anne Grossbauer Student Alternate Delegate Trisha Gupte Student Alternate Delegate Halimah Hamidu-Egiebor Student Alternate Delegate Sarosh Irani Student Alternate Delegate Mirna Kaafarani Student Alternate Delegate Sarah Kelly Student Alternate Delegate Man Yee Keung Student Alternate Delegate Tiffany Loh Student Alternate Delegate Samuel Michalak Student Alternate Delegate Chan Tran Nguyen Student Alternate Delegate Rachel O'Dell Student Alternate Delegate Narmeen Rehman Student Alternate Delegate Swara Sarvepalli Student Alternate Delegate Gulenay Saydahmat Student Alternate Delegate William Vander Pols Student Alternate Delegate Carson Wilmouth Student Alternate Delegate Francis Yang Student Alternate Delegate

International Medical Graduate Section Rima Jibaly MD Delegate

Resident and Fellow Section Kaitlyn Dobesh MD, JD Delegate

Young Physician Section Vacant

Specialty Society: MI Society of Addication Medicine John Hopper MD Specialty Society Delegate

Specialty Society: MI Allergy & Asthma Society Lawrence Hennessey MD Specialty Society Delegate

Specialty Society: MI Society of Anesthesiologists Michael Lewis MD Specialty Society Delegate Neeraja Ravikant MD Specialty Society Alternate

Specialty Society: MI Chapter of the American College of Cardiology Sunilkumar Rao DO Specialty Society Delegate

Specialty Society: MI Society of Colon and Rectal Surgeons Shawn Webb MD Specialty Society Delegate Pasithorn Suwanabol MD Specialty Society Alternate MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES May 1, 2021 Roster of Delegates

Specialty Society: MI Dermatological Society Karen Chapel MD Specialty Society Delegate Joseph McGoey MD Specialty Society Alternate

Specialty Society: MI College of Emergency Physicians Sara Chakel MD Specialty Society Delegate

Specialty Society: MI Society of Eye Physicians and Surgeons Patrick Droste MD Specialty Society Delegate

Specialty Society: MI Academy of Family Physicians Loretta Leja MD Specialty Society Delegate Brandon Karmo DO Specialty Society Alternate

Specialty Society: MI Neurological Association Amit Sachdev MD Specialty Society Delegate

Specialty Society: MI Association of Neurological Surgeons Hazem Eltahawy MD, PhD, MHCM, FRCS, FACSSpecialty Society Delegate Jason Schwalb MD Specialty Society Alternate

Specialty Society: MI Orthopaedic Society Christopher Betzle MD Specialty Society Delegate

Specialty Society: MI Chapter of the American Academy of Pediatrics Joshua Meyerson MD Specialty Society Delegate

Specialty Society: American College of Physicians, MI Chapter Martha Gray MD Specialty Society Delegate

Specialty Society: MI Psychiatric Society Carmen McIntyre MD Specialty Society Delegate Duane DiFranco MD Specialty Society Alternate

Specialty Society: MI Association of Public Health & Preventive Medicine Annette Mercatante MD, MPH Specialty Society Delegate

Specialty Society: MI Radiological Society Katharine Scharer MD Specialty Society Delegate

Specialty Society: MI Rheumatism Society Amar Majjhoo MD Specialty Society Delegate

Specialty Society: MI Academy of Sleep Medicine Virginia Skiba MD Specialty Society Delegate

Specialty Society: MI Chapter of the American College of Surgeons Thomas Thornton MD Specialty Society Delegate

Specialty Society: MI Thoracic Society Sarah Lee MD Specialty Society Delegate Heidi Flori MD Specialty Society Alternate

Specialty Society: MI Society of Thoracic & Cardiovascular Surgeons Robert Jones MD Specialty Society Delegate MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES

Reference Committee A – Medical Care Delivery Sherwin P. T. Imlay, MD, Chair, Oakland Patrick J. Droste, MD, MI Society of Eye Physicians and Surgeons Edward P. Fody, MD, Ottawa Raza U. Haque, MD, Ingham Amar Q. Majjhoo, MD, MI Rheumatism Society John M. Pelachyk, MD, St Clair Jorge M. Plasencia, MD, Saginaw M. Salim U. Siddiqui, MD, PhD, Wayne Trisha Gupte, Wayne State University

Board Advisor: Paul D. Bozyk, MD

Staff: Virginia K. Gibson Stacie J. Saylor

* * * * * * * * * *

Reference Committee B – Legislation Donald R. Peven, MD, Chair, Oakland Bradley P. Goodwin, MD, Grand Traverse Narasimha R. Gundamraj, MD, Ingham John A. Hopper, MD, MI Society of Addiction Medicine Irene S. Kazmers, MD, FACP, RhMSUS, Northern Michigan Navid Mahabadi, DO, Wayne Anthony M. Zacharek, MD, Saginaw Darian Mills, Michigan State University

Board Advisor: Thomas M. George, MD

Staff: Stacey P. Hettiger Scott Kempa Josiah Kissling

* * * * * * * * * *

MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES

Reference Committee C – Internal Affairs and Bylaws Kenneth Elmassian, DO, Chair, Ingham Edward Christy, MD, Genesee Betty S. Chu, MD, MBA, Oakland Cheryl D. Gibson Fountain, MD, Wayne Theodore B. Jones, MD, Wayne David W. Whalen, MD, Kent Phillip G. Wise, MD, Kent Mara Darian, Wayne State University

Board Advisor: Mark C. Komorowski, MD

Staff: Rebecca J. Blake Jennifer L. Finney

* * * * * * * * * *

Reference Committee D – Public Health Annette M. Mercatante, MD, MPH, Chair, MI Association of Public Health & Preventive Medicine Angela L. Kuznia, MD, MPH, Washtenaw Loretta M. Leja, MD, MI Academy of Family Physicians James C. Mitchiner, MD, MPH, Washtenaw Rama D. Rao, MD, Genesee Dawn E. Springer, MD, Ingham Lucia J. Zamorano, MD, Wayne Samuel Borer, Central Michigan University

Board Advisor: Thomas J. Veverka, MD

Staff: Dara J. Barrera Mary Kate Barnauskas

* * * * * * * * * *

MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES

Reference Committee E – Scientific and Educational Affairs Neeraja T. Ravikant, MD, Chair, Oakland Lauren M. Azevedo, DO, Young Physician Section Virginia R. Dedicatoria, MD, Saginaw Jon M. Lake, MD, Jackson Anna M. Laucis, MD, Washtenaw Federico G. Mariona, MD, FACS, FACOG, Wayne Katharine A. Scharer, MD, MI Radiological Society Neelima Thati, MD, Wayne Anna Kang, Wayne State University

Board Advisor: Brian R. Stork, MD

Staff: Beth A. Elliott Brenda J. Marenich

* * * * * * * * * *

Reference Committee on Ways and Means Dennis C. Szymanski, MD, Chair, Berrien E. Chris Bush, MD, Wayne Ronald B. Levin, MD, Macomb Venkat K. Rao, MD, Genesee Edward J. Rutkowski, MD, Grand Traverse Barbara A. Threatt, MD, Washtenaw

Board Advisors: Anita R. Avery, MD Richard C. Schultz, MD

Staff: Lauchlin W. S. MacGregor

* * * * * * * * * *

MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES

Resolution Review Committee Theodore B. Jones, MD, Chair, Wayne Barry I. Auster, MD, Oakland Laura A. Carravallah, MD, Genesee Kaitlyn D. Dobesh, MD, JD, Resident and Fellow Section Martha L. Gray, MD, American College of Physicians, MI Chapter Bryan W. Huffman, MD, Ottawa Charles F. Koopmann, Jr., MD, FACS, Washtenaw Rose M. Ramirez, MD, Kent Caroline G. M. Scott, MD, Saginaw David T. Walsworth, MD, Ingham Phillip G. Wise, MD, Kent Sanjay Das, Central Michigan University

Staff: Rebecca J. Blake Carrie J. Wheeler

* * * * * * * * * *

MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES RESOLUTION INDEX

RESOLUTION TITLE REFERENCE COMMITTEE 01-20 Suspend and Abolish the Medicaid Work Requirement Reaffirmation 09-20 Medication-Assisted Treatment in Physician Health B Programs 18-20 Medicaid Expansion Reaffirmation 27-20 “Red Flag” Law to Enhance Safe Gun Ownership Reaffirmation 30-20 Promote NBPAS as Board Recertification in Michigan Reaffirmation 31-20 Bring Insurance Credentialing into Legal Compliance on A Maintenance of Certification 39-20 End Time Limited Board Certification Reaffirmation 44-20 Uniform Standards for Brain Death Determination E 46-20 Depression Screening in Adolescents after Sport-Related D Concussion 49-20 Long-Acting Reversible Contraception Access in Michigan Reaffirmation 54-20 Resentencing for Individuals Convicted of Marijuana- B Based Offenses 59-20 Interest-Based Debt Burden on Medical Students and Reaffirmation Residents 61-20 9-1-1 Dispatcher Telephone CPR Training D

01-21 Stop Continuous CME Mandates Reaffirmation 02-21 Vision Qualifications for Driver’s License E 03-21 Oppose Routine Use of Gonad Shields B 04-21 Dissemination of Information to County Medical Societies C 06-21 Maternal Levels of Care Standards of Practice Reaffirmation 08-21 Prohibit Persons from Carrying Firearms and Explosive Reaffirmation Devices in Public Spaces 10-21 Financial Impact and Fiscal Transparency of the American A Medical Association Current Procedural Terminology Program 11-21 Updates to Organ Donation and Transplant Policies D 13-21 Upholding the Integrity and Vitality of the State and C County Medical Societies 15-21 Electronic Prescribing Waiver for Michigan’s Free Clinics B 16-21 Medicaid Dialysis Policy for Undocumented Patients A 18-21 Medical and Dental Care for Prisoners A 20-21 Designated Directors Serving as Chair of the MSMS Board C of Directors 21-21 Address Adolescent Telehealth Confidentiality Concerns A MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES RESOLUTION INDEX

22-21 Expanding Access to Medication for the Treatment of B Opioid Use Disorder 24-21 Improved Outreach to Minority Communities Regarding D the COVID-19 Vaccine 25-21 Public Health Considerations to Reduce Harm in D Encampment Removals 26-21 Decarceration During an Infectious Disease Pandemic B 28-21 Access to Menstrual Products in Correctional Facilities E 30-21 Over the Counter Hormonal Contraception E 31-21 Availability of Medical Respite Centers E 35-21 COVID-19 Vaccine Distribution Regarding People D Experiencing Homelessness 36-21 Insurance Coverage of Adverse Childhood Experiences Reaffirmation Screening

BOARD TITLE REFERENCE ACTION COMMITTEE REPORT #1-21 Resolution 50-20 – “Remove Clinic-Specific Caps on B Buprenorphine” #2-21 Revisions to the MSMS Policy Manual and the 2021 C Sunset Policy

MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES

REAFFIRMATION CALENDAR

RESOLUTION DESCRIPTION 01-20 Suspend and Abolish the Medicaid Work Requirement 18-20 Medicaid Expansion 27-20 “Red Flag” Law to Enhance Safe Gun Ownership 30-20 Promote NBPAS as Board Recertification in Michigan 39-20 End Time Limited Board Certification 49-20 Long-Acting Reversible Contraception Access in Michigan 59-20 Interest-Based Debt Burden on Medical Students and Residents 01-21 Stop Continuous CME Mandates 06-21 Maternal Levels of Care Standards of Practice 08-21 Prohibit Persons from Carrying Firearms and Explosive Devices in Public Spaces 36-21 Insurance Coverage of Adverse Childhood Experiences Screening

1 RESOLUTION 01-20 2 3 Title: Suspend and Abolish the Medicaid Work Requirement 4 5 Introduced by: Annette Mercatante, MD, for the St. Clair County Delegation 6 7 Original Author: Annette Mercatante, MD 8 9 Referred To: Reaffirmation Calendar 10 11 House Action: 12 13 14 Whereas, Michigan’s Medicaid work requirement affects people enrolled in the Healthy 15 Michigan Plan (HMP), Michigan’s Medicaid expansion plan, and 16 17 Whereas, pursuant to the requirement, people age 19 to 62 who depend on the plan must 18 certify to the state that they have spent at least 80 hours per month either working, or getting 19 trained to work, and 20 21 Whereas, approximately 670,000 Michigan residents (approximately five percent of the state 22 population) get health care through the HMP, which covers low-income adults, and 23 24 Whereas, about twenty percent (130,000) of HMP enrollees would be exempt from the work 25 requirement, while the other 80 percent (540,000) would not be exempt, and 26 27 Whereas, approximately five to ten percent of the non-exempt population is expected to 28 lose coverage per the Michigan House Fiscal Agency’s estimate that up to 54,000 Michiganders 29 would lose Medicaid coverage through implementation of the state’s proposal to take Medicaid 30 away from people who do not meet the work requirement, and 31 32 Whereas, the Kaiser Family Foundation has estimated that, if a work requirement were 33 implemented at the national level, approximately 1.4 to 4 million enrollees (six to seventeen 34 percent of non-elderly, non-disabled adult Medicaid enrollees) would lose coverage, and 35 36 Whereas, Michigan’s Medicaid expansion has been extremely successful, extending 37 coverage and access to care to more than one million low-income adults in Michigan since April 38 2014, and improving their physical and financial health, and 39 40 Whereas, the HMP currently provides coverage to more than 668,000 low-income 41 Michiganders while also providing economic benefits to the state and reducing uncompensated 42 care for hospitals and other safety net providers, and 43 44 Whereas, the HMP has cut Michigan’s uninsured rate in half since expansion began in April 45 2014. Half of non-working adults reported that having Medicaid made it easier to look for work, 46 and nearly 70 percent of those already working said Medicaid made it easier to work or made them 47 better at their job, and 48 49 Whereas, most Medicaid adults are already working; among those who are not working, 50 most report barriers to work, and 51 52 Whereas, those in better health and with more education are more likely to be working. 53 Even when working, adults with Medicaid face high rates of financial and food insecurity, as they 54 are still living in or near poverty. Half report that they are very or moderately worried that they will 55 not have enough money to pay normal monthly bills, and more than four in ten say they are very 56 or moderately worried about having enough money for housing, rates similar to non-working 57 adults with Medicaid. While income gained from work can improve financial security, this pattern 58 shows that low-income workers still face substantial insecurity given the nature of their jobs. 59 Additionally, people who meet Medicaid work requirements through participating in volunteer 60 activities will not gain income to improve their financial security, and 61 62 Whereas, there are high rates of functional disability and serious medical conditions among 63 Medicaid adults, especially among those not working. More than a third (34 percent) of those not 64 working live with multiple chronic medical conditions such as hypertension, high cholesterol, 65 arthritis, or heart disease, and half (51 percent) have a functional limitation, including mobility, 66 physical, or emotional limitations, and 67 68 Whereas, many adult Medicaid beneficiaries do not use computers, the internet, or e-mail, 69 which could be a barrier in finding a job and in complying with work reporting requirements. More 70 than a quarter (26 percent) of adult Medicaid beneficiaries report that they never use a computer, 71 25 percent do not use the internet, and 40 percent do not use e-mail, which may pose a barrier to 72 gaining a job and complying with reporting requirements under state waivers, and 73 74 Whereas, an earlier analysis of potential nationwide reductions in Medicaid coverage if all 75 states implemented work requirements estimated that most disenrollment would be among 76 individuals who would remain eligible, but lose coverage due to new administrative burdens or red 77 tape, and only a minority would lose eligibility due to not meeting new work requirements, and 78 79 Whereas, work requirements may not result in increased employment or employer-based 80 health coverage. Arkansas enrollees reported that new work requirements did not provide an 81 additional incentive to work, beyond economic pressures to pay for food and other bills. Another 82 study found that work requirements in Arkansas did result in significant changes in employment. 83 Among individuals who may find work, low-income jobs are not likely to come with employer- 84 sponsored insurance (ESI). ESI offer rates are low among poor (below 100 percent FPL) and low- 85 income (between 100 and 250 percent FPL) workers who work full-time (25 percent and 42 percent, 86 respectively). Very few part-time workers, especially those with low-incomes, receive an employer- 87 sponsored offer of health benefits, and 88 89 Whereas, several state-adopted Medicaid work requirements have been challenged in court 90 including Michigan’s policy, and 91 92 Whereas, federal judges have blocked Medicaid work requirements in Arkansas, Kentucky, 93 New Hampshire, and, most recently, Michigan, further raising the question of whether the issue will 94 be taken up by the Supreme Court; therefore be it 95 96 RESOLVED: That MSMS continue to advocate for the elimination of Medicaid work 97 requirements, as well as other barriers to state Medicaid insurance plans. 98 99 100 WAYS AND MEANS COMMITTEE FISCAL NOTE: None

Relevant MSMS Policy:

Opposition to Medicaid Work Requirements MSMS opposes work requirements as a criterion for Medicaid eligibility. (Res22-19)

Relevant AMA Policy:

Opposition to Medicaid Work Requirements H-290.961 Our AMA opposes work requirements as a criterion for Medicaid eligibility. Sources: 1. Michigan House Fiscal Agency, “Legislative Analysis on Healthy Michigan Work Requirements and Premium Payment Requirements,” June 6, 2018, http://www.legislature.mi.gov/documents/2017- 2018/billanalysis/House/pdf/2017-HLA-0897-5CEEF80A.pdf. 2. Source: Kaiser Family foundation analysis of March 2018 Current Population Survey 3. Center for Health and Research Transformation, Ann Arbor MI 4. Kaiser Family Foundations: https://www.kff.org/medicaid/issue-brief/implications-of-a-medicaid-work- requirement-national-estimates-of-potential-coverage-losses/ 1 RESOLUTION 18-20 2 3 Title: Medicaid Expansion 4 5 Introduced by: Richard Burney, MD, for the Washtenaw County Delegation 6 7 Original Author: Richard Burney, MD 8 9 Referred To: Reaffirmation Calendar 10 11 House Action: 12 13 14 Whereas, the Affordable Care Act, which beneficially expanded health insurance coverage in 15 the United States, allowed states to determine if they wished to enact Medicaid Expansion, and 16 17 Whereas, lack of insurance coverage has devastating effects on the health of all persons, 18 affecting them, their families, and society in general, and 19 20 Whereas, Medicaid expansion in the states in which it has been enacted has been 21 demonstrated to have beneficial effects on the health status of enrollees and to save money; 22 therefore be it 23 24 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 25 our AMA to advocate strongly for expansion of the Medicaid program to all states; and be it further 26 27 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 28 our AMA to produce informational brochures and other communications that can be distributed by 29 health care providers to inform the public of the importance of expanded health insurance 30 coverage to all. 31 32 33 WAYS AND MEANS COMMITTEE FISCAL NOTE: Name

Relevant MSMS Policy:

Medicaid Expansion MSMS supports the expansion of Medicaid under the Affordable Care Act.

Relevant AMA Policy:

Affordable Care Act Medicaid Expansion H-290.965 1. Our AMA encourages state medical associations to participate in the development of their state's Medicaid access monitoring review plan and provide ongoing feedback regarding barriers to access. 2. Our AMA will continue to advocate that Medicaid access monitoring review plans be required for services provided by managed care organizations and state waiver programs, as well as by state Medicaid fee-for- service models. 3. Our AMA supports efforts to monitor the progress of the Centers for Medicare and Medicaid Services (CMS) on implementing the 2014 Office of Inspector General's recommendations to improve access to care for Medicaid beneficiaries. 4. Our AMA will advocate that CMS ensure that mechanisms are in place to provide robust access to specialty care for all Medicaid beneficiaries, including children and adolescents. 5. Our AMA supports independent researchers performing longitudinal and risk-adjusted research to assess the impact of Medicaid expansion programs on quality of care. 6. Our AMA supports adequate physician payment as an explicit objective of state Medicaid expansion programs. 7. Our AMA supports increasing physician payment rates in any redistribution of funds in Medicaid expansion states experiencing budget savings to encourage physician participation and increase patient access to care. 8. Our AMA will continue to advocate that CMS provide strict oversight to ensure that states are setting and maintaining their Medicaid rate structures at levels to ensure there is sufficient physician participation so that Medicaid patients can have equal access to necessary services. 9. Our AMA will continue to advocate that CMS develop a mechanism for physicians to challenge payment rates directly to CMS. 10. Our AMA supports extending to states the three years of 100 percent federal funding for Medicaid expansions that are implemented beyond 2016. 11. Our AMA supports maintenance of federal funding for Medicaid expansion populations at 90 percent beyond 2020 as long as the Affordable Care Act's Medicaid expansion exists. 12. Our AMA supports improved communication among states to share successes and challenges of their respective Medicaid expansion approaches. 13. Our AMA supports the use of emergency department (ED) best practices that are evidenced-based to reduce avoidable ED visits.

Medicaid Expansion D-290.979 Our AMA, at the invitation of state medical societies, will work with state and specialty medical societies in advocating at the state level to expand Medicaid eligibility to 133% (138% FPL including the income disregard) of the Federal Poverty Level as authorized by the ACA and will advocate for an increase in Medicaid payments to physicians and improvements and innovations in Medicaid that will reduce administrative burdens and deliver healthcare services more effectively, even as coverage is expanded.

Medicaid Expansion Options and Alternatives H-290.966 1. Our AMA encourages policymakers at all levels to focus their efforts on working together to identify realistic coverage options for adults currently in the coverage gap. 2. Our AMA encourages states that are not participating in the Medicaid expansion to develop waivers that support expansion plans that best meet the needs and priorities of their low income adult populations. 3. Our AMA encourages the Centers for Medicare & Medicaid Services to review Medicaid expansion waiver requests in a timely manner, and to exercise broad authority in approving such waivers, provided that the waivers are consistent with the goals and spirit of expanding health insurance coverage and eliminating the coverage gap for low-income adults. 4. Our AMA advocates that states be required to develop a transparent process for monitoring and evaluating the effects of their Medicaid expansion plans on health insurance coverage levels and access to care, and to report the results annually on the state Medicaid web site. 1 RESOLUTION 27-20 2 3 Title: “Red Flag” Law to Enhance Safe Gun Ownership 4 5 Introduced by: John Pelachyk, MD, for the St. Clair County Delegation 6 7 Original Author: Raj Makim, MD 8 9 Referred To: Reaffirmation Calendar 10 11 House Action: 12 13 14 Whereas, in the United States, a “red flag” law is a gun control law that permits family 15 members, law enforcement, and sometimes others relevant in the circle of the person in question, 16 to petition a state court to order the temporary removal (of up to 12 months) of firearms from a 17 person who may present a danger to themselves or others, and 18 19 Whereas, “red flag” laws have been passed in 17 other states and the District of Columbia 20 and pending legislation for “red flag” laws are being considered in four more states, and 21 22 Whereas, research has shown “red flag” laws can affect a significant mitigation of the risk 23 posed by that small proportion of legal gun owners who may pose a threat to themselves or 24 others, and 25 26 Whereas, in an Annals of Internal Medicine 2019 study, a case series indicated that 27 California's “red flag” law has been found to be a factor in efforts to prevent mass shootings, and 28 29 Whereas, suicides accounted for 62 percent of U.S. gun deaths from 2008 to 2017, which 30 implies that “red flag” laws may have significant value in preventing some of these deaths, and 31 32 Whereas, Everytown for Gun Safety conducted a nationwide study showing that the 33 perpetrators of mass shootings showed warning signs before the event 42 percent of the time, and 34 35 Whereas, an April 2018 poll found that 85 percent of registered voters support laws that 36 would "allow the police to take guns away from people who have been found by a judge to be a 37 danger to themselves or others" (71 percent "strongly supported" while 14 percent "somewhat 38 supported" such laws); therefore be it 39 40 RESOLVED: That MSMS advocate for and recommend the adoption of “red flag” legislation 41 to enhance safe gun ownership in Michigan. 42 43 44 WAYS AND MEANS COMMITTEE FISCAL NOTE: None

Relevant MSMS Policy:

Firearm Regulations MSMS opposes the liberalization of concealed gun laws and efforts to weaken current laws regarding the manufacture, importation, and/or ownership of assault weapons and/or handguns. MSMS supports policies that 1) prohibit acquisition of firearms by high-risk persons; 2) require firearm owners to have firearm safety certification which includes but is not limited to basic education in the care and handling of firearms; 3) limit ownership and use of assault weapons; and, 4) ban the sale of assault weapons and large-capacity ammunition magazines.

Relevant AMA Policy:

Firearm Availability H-145.996 1. Our AMA: (a) advocates a waiting period and background check for all firearm purchasers; (b) encourages legislation that enforces a waiting period and background check for all firearm purchasers; and (c) urges legislation to prohibit the manufacture, sale or import of lethal and non-lethal guns made of plastic, ceramics, or other non-metallic materials that cannot be detected by airport and weapon detection devices. 2. Our AMA supports requiring the licensing/permitting of firearms-owners and purchasers, including the completion of a required safety course, and registration of all firearms. 3. Our AMA supports “gun violence restraining orders” for individuals arrested or convicted of domestic violence or stalking, and supports extreme risk protection orders, commonly known as “red-flag” laws, for individuals who have demonstrated significant signs of potential violence. In supporting restraining orders and “red-flag” laws, we also support the importance of due process so that individuals can petition for their rights to be restored.

Sources: 1. Swanson, J. W., Norko, M., Lin, H-J., Alanis-Hirsch, K., Frisman, L., Baranoski, M., Easter, M., Robertson, A. G., Swartz, M., Bonnie, R. J., Implementation and Effectiveness of Connecticut's Risk-Based Gun Removal Law: Does It Prevent Suicides?, 80 Law and Contemporary Problems, pp. 179-208 (August 2016). 2. Garen J. Wintemute, Veronica A. Pear, Julia P. Schleimer, Rocco Pallin, Sydney Sohl, Nicole Kravitz-Wirtz, Elizabeth A. Tomsich, Extreme Risk Protection Orders Intended to Prevent Mass Shootings: A Case Series, Annals of Internal Medicine (August 20, 2019), doi:10.7326/M19-2162. 3. Warren Fiske, Miyares Gun-Suicide Claim Rates "Mostly True", PolitiFact Virginia (August 20, 2019) 4. Michael Livingston, More States Approving 'Red Flag' Laws to Keep Guns Away from People Perceived as Threats, Los Angeles Times (May 14, 2018). 5. Washington Post-ABC News Poll, April 8-11, 2018. 6. Emily Guskin & Scott Clement, Has Parkland changed Americans' views on guns?, Washington Post (April 20, 2018). 1 RESOLUTION 30-20 2 3 Title: Promote NBPAS as Board Recertification in Michigan 4 5 Introduced by: Rose Ramirez, MD, for the Kent County Delegation 6 7 Original Author: Rose Ramirez, MD 8 9 Referred To: Reaffirmation Calendar 10 11 House Action: 12 13 14 Whereas, the American Board of Medical Specialties (ABMS) holds monopoly power over 15 physician board recertification in Michigan and the United States, and 16 17 Whereas, ABMS recertification is an expensive, time consuming, high cost requirement to 18 maintain board certification (MOC), and 19 20 Whereas, the requirements of the ABMS are often irrelevant to a particular physician’s 21 practice, and 22 23 Whereas, the National Board of Physicians and Surgeons (NBPAS) is committed to providing 24 certification that ensures physician compliance with national standards and promotes lifelong 25 learning, and 26 27 Whereas, NBPAS will provide recertification in the event that previous certification was 28 obtained through an ABMS or American Osteopathic Association member board, and 29 30 Whereas, the NBPAS is relevant, lower cost, and does not require many extra hours of time 31 beyond continuing medical education already obtained; therefore be it 32 33 RESOLVED: That MSMS actively lobby hospitals and insurers about the rational approach to 34 board recertification that National Board of Physicians and Surgeons can provide for maintenance 35 of certification. 36 37 38 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 39 $25,000+

Relevant MSMS Policy:

Review Board Recertification and Maintenance of Certification Process MSMS supports Maintenance of Certification (MOC) only under all of the following circumstances: 1. MOC must be voluntary 2. MOC must not be a condition of licensure, hospital privileges, health plan participation, or any other function unrelated to the specialty board requiring MOC 3. MOC should not be the monopoly of any single entity. Physicians should be able to access a range of alternatives from different entities. 4. The status of MOC should be revisited by MSMS if it is identified that the continuous review of physician competency is objectively determined to be a benefit for patients. If that benefit is determined to be present by objective data regarding value and efficacy, then MSMS should support the adoption of an evidence based process that serves only to improve patient care. (Res73-15) - Reaffirmed (Res10-19)

Relevant AMA Policy:

Continuing Board Certification D-275.954 Our AMA will: 1. Continue to monitor the evolution of Continuing Board Certification (CBC), continue its active engagement in discussions regarding their implementation, encourage specialty boards to investigate and/or establish alternative approaches for CBC, and prepare a yearly report to the House of Delegates regarding the CBC process. 2. Continue to review, through its Council on Medical Education, published literature and emerging data as part of the Council’s ongoing efforts to critically review CBC issues. 3. Continue to monitor the progress by the American Board of Medical Specialties (ABMS) and its member boards on implementation of CBC, and encourage the ABMS to report its research findings on the issues surrounding certification and CBC on a periodic basis. 4. Encourage the ABMS and its member boards to continue to explore other ways to measure the ability of physicians to access and apply knowledge to care for patients, and to continue to examine the evidence supporting the value of specialty board certification and CBC. 5. Work with the ABMS to streamline and improve the Cognitive Expertise (Part III) component of CBC, including the exploration of alternative formats, in ways that effectively evaluate acquisition of new knowledge while reducing or eliminating the burden of a high-stakes examination. 6. Work with interested parties to ensure that CBC uses more than one pathway to assess accurately the competence of practicing physicians, to monitor for exam relevance and to ensure that CBC does not lead to unintended economic hardship such as hospital de-credentialing of practicing physicians. 7. Recommend that the ABMS not introduce additional assessment modalities that have not been validated to show improvement in physician performance and/or patient safety. 8. Work with the ABMS to eliminate practice performance assessment modules, as currently written, from CBC requirements. 9. Encourage the ABMS to ensure that all ABMS member boards provide full transparency related to the costs of preparing, administering, scoring and reporting CBC and certifying examinations. 10. Encourage the ABMS to ensure that CBC and certifying examinations do not result in substantial financial gain to ABMS member boards, and advocate that the ABMS develop fiduciary standards for its member boards that are consistent with this principle. 11. Work with the ABMS to lessen the burden of CBC on physicians with multiple board certifications, particularly to ensure that CBC is specifically relevant to the physician’s current practice. 12. Work with key stakeholders to (a) support ongoing ABMS member board efforts to allow multiple and diverse physician educational and quality improvement activities to qualify for CBC; (b) support ABMS member board activities in facilitating the use of CBC quality improvement activities to count for other accountability requirements or programs, such as pay for quality/performance or PQRS reimbursement; (c) encourage ABMS member boards to enhance the consistency of quality improvement programs across all boards; and (d) work with specialty societies and ABMS member boards to develop tools and services that help physicians meet CBC requirements. 13. Work with the ABMS and its member boards to collect data on why physicians choose to maintain or discontinue their board certification. 14. Work with the ABMS to study whether CBC is an important factor in a physician’s decision to retire and to determine its impact on the US physician workforce. 15. Encourage the ABMS to use data from CBC to track whether physicians are maintaining certification and share this data with the AMA. 16. Encourage AMA members to be proactive in shaping CBC by seeking leadership positions on the ABMS member boards, American Osteopathic Association (AOA) specialty certifying boards, and CBC Committees. 17. Continue to monitor the actions of professional societies regarding recommendations for modification of CBC. 18. Encourage medical specialty societies’ leadership to work with the ABMS, and its member boards, to identify those specialty organizations that have developed an appropriate and relevant CBC process for its members. 19. Continue to work with the ABMS to ensure that physicians are clearly informed of the CBC requirements for their specific board and the timelines for accomplishing those requirements. 20. Encourage the ABMS and its member boards to develop a system to actively alert physicians of the due dates of the multi-stage requirements of continuous professional development and performance in practice, thereby assisting them with maintaining their board certification. 21. Recommend to the ABMS that all physician members of those boards governing the CBC process be required to participate in CBC. 22. Continue to participate in the National Alliance for Physician Competence forums. 23. Encourage the PCPI Foundation, the ABMS, and the Council of Medical Specialty Societies to work together toward utilizing Consortium performance measures in Part IV of CBC. 24. Continue to assist physicians in practice performance improvement. 25. Encourage all specialty societies to grant certified CME credit for activities that they offer to fulfill requirements of their respective specialty board’s CBC and associated processes. 26. Support the American College of Physicians as well as other professional societies in their efforts to work with the American Board of Internal Medicine (ABIM) to improve the CBC program. 27. Oppose those maintenance of certification programs administered by the specialty boards of the ABMS, or of any other similar physician certifying organization, which do not appropriately adhere to the principles codified as AMA Policy on Continuing Board Certification. 28. Ask the ABMS to encourage its member boards to review their maintenance of certification policies regarding the requirements for maintaining underlying primary or initial specialty board certification in addition to subspecialty board certification, if they have not yet done so, to allow physicians the option to focus on continuing board certification activities relevant to their practice. 29. Call for the immediate end of any mandatory, secured recertifying examination by the ABMS or other certifying organizations as part of the recertification process for all those specialties that still require a secure, high-stakes recertification examination. 30. Support a recertification process based on high quality, appropriate Continuing Medical Education (CME) material directed by the AMA recognized specialty societies covering the physician’s practice area, in cooperation with other willing stakeholders, that would be completed on a regular basis as determined by the individual medical specialty, to ensure lifelong learning. 31. Continue to work with the ABMS to encourage the development by and the sharing between specialty boards of alternative ways to assess medical knowledge other than by a secure high stakes exam. 32. Continue to support the requirement of CME and ongoing, quality assessments of physicians, where such CME is proven to be cost-effective and shown by evidence to improve quality of care for patients. 33. Through legislative, regulatory, or collaborative efforts, will work with interested state medical societies and other interested parties by creating model state legislation and model medical staff bylaws while advocating that Continuing Board Certification not be a requirement for: (a) medical staff membership, privileging, credentialing, or recredentialing; (b) insurance panel participation; or (c) state medical licensure. 34. Increase its efforts to work with the insurance industry to ensure that continuing board certification does not become a requirement for insurance panel participation. 35. Advocate that physicians who participate in programs related to quality improvement and/or patient safety receive credit for CBC Part IV. 36. Continue to work with the medical societies and the American Board of Medical Specialties (ABMS) member boards that have not yet moved to a process to improve the Part III secure, high-stakes examination to encourage them to do so. 37. Our AMA will, through its Council on Medical Education, continue to work with the American Board of Medical Specialties (ABMS), ABMS Committee on Continuing Certification (3C), and ABMS Stakeholder Council to pursue opportunities to implement the recommendations of the Continuing Board Certification: Vision for the Future Commission and AMA policies related to continuing board certification.

1 RESOLUTION 39-20 2 3 Title: End Time Limited Board Certification 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Authors: Megan Edison, MD, and David Whalen, MD 8 9 Referred To: Reaffirmation Calendar 10 11 House Action: 12 13 14 Whereas, achievement of initial board certification status after residency or fellowship is 15 widely regarded as a marker of academic competency in a medical or surgical specialty, and 16 17 Whereas, initial board certification is all that is required of time-unlimited, or 18 "grandfathered," physicians to be board-certified without any concerns about their competence or 19 professionalism, and 20 21 Whereas, time-unlimited physicians have the option to participate and purchase the 22 maintenance of certification (MOC) educational product, but they do not lose initial board 23 certification if they choose not to participate, and 24 25 Whereas, time-limited physicians must continually participate and purchase MOC, or they 26 will lose initial board certification and be erased from publicly available certification websites if they 27 do not comply with the MOC process, and 28 29 Whereas, continuing medical education (CME) from a robust competitive CME marketplace 30 is widely regarded as the physician pathway to staying current and up to date in a specialty and is 31 therefore required by most states for medical licensure and renewal, and 32 33 Whereas, the proprietary MOC educational products from the American Board of Medical 34 Specialties (ABMS) or the American Osteopathic Association (AOA) have no proven academic 35 benefit over other forms of CME to improve quality of care and patient outcomes, and 36 37 Whereas, robust local accountability systems throughout our profession (including direct 38 observation through our work together as fellow colleagues, employer peer review, hospital peer 39 review, and review by state Boards of Medicine) exist and assure professionalism, discipline, and 40 self-regulation of our profession locally, and 41 42 Whereas, private medical specialty boards (e.g., ABMS, AOA) have little to no jurisdiction to 43 ensure discipline, accountability, and professionalism of physicians, and 44 45 Whereas, the MOC product is not academically superior to other forms of CME in terms of 46 patient outcomes and is jurisdictionally inferior to local forms of professional accountability and 47 discipline, rendering it a duplicative burden upon younger physicians, at best, and 48 49 Whereas, loss of initial board certification status for not participating and purchasing the 50 MOC product results in significant financial and professional harm to time-limited physicians as 51 they are removed from insurance panels and hospitals; thereby, forcing many physicians to comply 52 with MOC, and 53 54 Whereas, all good faith efforts by organized medicine asking ABMS and AOA to limit the 55 cost, burden, and stress of forced MOC have been ignored, resulting in ongoing harm to 56 physicians, and 57 58 Whereas, all good faith efforts by organized medicine asking that MOC not be tied to 59 insurance reimbursement and hospital privileges have been ignored, and 60 61 Whereas, it is time to stop this nonsense and the harm forced MOC is causing physicians; 62 therefore be it 63 64 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 65 our AMA to call for an end to time-limited American Board of Medical Specialties and American 66 Osteopathic Association board certification; thereby, ending discrimination against time-limited 67 board-certified physicians, and 68 69 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 70 our AMA to allow the purchase and participation of any proprietary continuing board certification 71 or maintenance of certification or osteopathic continuous certification product to be a voluntary 72 process for all board-certified physicians; and be it further 73 74 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 75 our AMA to call on the American Board of Medical Specialties and the American Osteopathic 76 Association to make continuing board certification or maintenance of certification or osteopathic 77 continuous certification a voluntary process separate from initial certification; and be it further 78 79 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) work 80 with the American Board of Medical Specialties and the American Osteopathic Association to 81 ensure that initial board certification remain as a time-unlimited, earned marker of academic 82 competency, and should not be nullified for not participating in or purchasing the maintenance of 83 certification product. 84 85 86 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 87 or AMA policy - $500

Relevant MSMS Policy:

Review Board Recertification and Maintenance of Certification Process MSMS supports Maintenance of Certification (MOC) only under all of the following circumstances: 1. MOC must be voluntary. 2. MOC must not be a condition of licensure, hospital privileges, health plan participation, or any other function unrelated to the specialty board requiring MOC. 3. MOC should not be the monopoly of any single entity. Physicians should be able to access a range of alternatives from different entities. 4. The status of MOC should be revisited by MSMS if it is identified that the continuous review of physician competency is objectively determined to be a benefit for patients. If that benefit is determined to be present by objective data regarding value and efficacy, then MSMS should support the adoption of an evidence based process that serves only to improve patient care.

Relevant AMA Policy:

1 RESOLUTION 49-20 2 3 Title: Long-Acting Reversible Contraception Access in Michigan 4 5 Introduced by: Mara Darian, for the Medical Student Section 6 7 Original Authors: John Dewey, Megan Sandberg, Emma Swayze, and Alangoya Tezel 8 9 Referred To: Reaffirmation Calendar 10 11 House Action: 12 13 14 Whereas, Long-Acting Reversible Contraceptives (LARCs) have been demonstrated to be a 15 highly effective method of birth control, with failure rates as low as 0.05 percent, and 16 17 Whereas, LARCs have a very limited and safe adverse event profile, and 18 19 Whereas, LARCs are available in a variety of forms, allowing patients to choose a method 20 that works best for them, and 21 22 Whereas, LARCs are designed to be functional for months to years at a time with little to no 23 maintenance, which reduces the error introduced by reliance on consistent adherence to 24 medication regimens, and 25 26 Whereas, a program that provided LARCs and relevant provider training to Title X clinics at 27 a reduced cost has been established in Colorado, known as the Colorado Family Planning Initiative 28 (CFPI), and 29 30 Whereas, the CFPI resulted in more than 36,000 LARCs being administered from 2009 to 31 2015, with a majority of those recipients being in the age bracket of 15-24, and 32 33 Whereas, during the course of the CFPI, unintended pregnancy rates among 15-19 year olds 34 in the state of Colorado went from 35 percent in 2009 to 21 percent in 2014, and 35 36 Whereas, during the course of the CFPI, abortion rates decreased almost 50 percent in the 37 age group of 15-19, and decreased by 18 percent in the age group of 20-24, and 38 39 Whereas, the CFPI contributed toward an increase in the average age of first pregnancy by 40 1.2 years between 2009 and 2014, and 41 42 Whereas, an increase in age of first pregnancy is associated with better outcomes for the 43 mother and the child, and 44 45 Whereas, rapid repeat births are here defined as a childbirth that takes place less than 24 46 months postpartum, and 47 48 Whereas, rapid repeat births are associated with worse perinatal health outcomes, and 49 50 Whereas, the CFPI contributed to a reduction in rapid repeat births by 12 percent between 51 2009 and 2014, and 52 53 Whereas, the CFPI resulted in an estimated avoidance in federal and state costs of between 54 $66.1 and $69.6 million for women aged 15 to 24, off of an initial $27.3 million investment; 55 therefore be it 56 57 RESOLVED: That MSMS support legislation that increases access to Long-Acting Reversible 58 Contraceptives for populations with barriers to contraceptive access and is consistent with the 59 clinical management guidelines provided by the American College of Obstetricians and 60 Gynecologists. 61 62 63 WAYS AND MEANS COMMITTEE FISCAL NOTE: None

Relevant MSMS Policy:

Coverage and Billing of Postpartum LARC Services MSMS supports AMA policy H-75.984, Increasing Availability and Coverage for Immediate Postpartum Long- Acting Reversible Contraceptive Placement, in effect on April 29, 2018, which recognizes efficacy of postpartum long-acting reversible contraceptives placement as a way of reducing future unintended pregnancies and the need to increase availability and coverage by Medicaid, Medicare, and private insurers, as well as to bill and pay these devices separately from the obstetrical global fee.

Family Planning Services MSMS supports the concept that family planning services are a basic health service and funds should be earmarked to support those services. Universal family planning is an essential element of responsible parenthood, stable family life and social harmony. The very personal nature of advice and counseling in family planning makes it mandatory that consideration be given to the patient’s wishes and desires, and to ethnic and religious background. The professional must be prepared to counsel on all aspects of family planning, either in assisting a couple to have a family, or postponing additions to their family. Expert counseling in all techniques, such as rhythm, barrier, hormone or tubal ligation must be available. Consistent with responsible preventive medicine and in the interest of reducing the incidence of teenage pregnancy, the following is recommended: a. The teenage minor whose sexual behavior exposes her to possible conception should have access to medical consultation and the most effective contraceptive advice and methods consistent with her physical and emotional needs. b. The physician so consulted should be free to prescribe or withhold contraceptive advice in accordance with his or her best medical judgment in the best interests of the patient.

Preserve Access to Contraceptives MSMS supports the preservation of access to contraceptive services, including through Title X funds.

Relevant AMA Policy:

Increasing Availability and Coverage for Immediate Postpartum Long-Acting Reversible Contraceptive Placement H-75.984 1. Our AMA: (a) recognizes the practice of immediate postpartum and post pregnancy long-acting reversible contraception placement to be a safe and cost effective way of reducing future unintended pregnancies; and (b) supports the coverage by Medicaid, Medicare, and private insurers for immediate postpartum long-acting reversible contraception devices and placement, and that these be billed separately from the obstetrical global fee. 2. Our AMA encourages relevant specialty organizations to provide training for physicians regarding (a) patients who are eligible for immediate postpartum long-acting reversible contraception, and (b) immediate postpartum long-acting reversible contraception placement protocols and procedures.

Sources: 1. Stoddard, A., McNicholas, C., & Peipert, J. F. (2011). Efficacy and safety of long-acting reversible contraception. Drugs, 71(8), 969-980. 2. Brache, V., Faundes, A., Alvarez, F., & Cochon, L. (2002). Nonmenstrual adverse events during use of implantable contraceptives for women: data from clinical trials. Contraception, 65(1), 63-74. 3. Bosco-Lévy, P., Gouverneur, A., Langlade, C., Miremont, G., & Pariente, A. (2019). Safety of levonorgestrel 52 mg intrauterine system compared to copper intrauterine device: a population-based cohort study. Contraception, 99(6), 345-349. 4. https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins/Committee-on-Practice- Bulletins-Gynecology/Long-Acting-Reversible-Contraception-Implants-and-Intrauterine- Devices?IsMobileSet=false 5. Programme, U. N. D., Fund, U. N. P., Bank, W., of Research, S. P., & World Health Organization. (1997). Long-term reversible contraception: twelve years of experience with the TCu380A and TCu220C. Contraception, 56(6), 341-352. 6. CFPI Report, Page viii, https://www.colorado.gov/pacific/cdphe/cfpi-report a. Adapted from: Ricketts, S., Klingler, G., & Schwalberg, R. (2014). Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspectives on sexual and reproductive health, 46(3), 125-132. 7. CFPI Report, Page 19 8. CFPI Report, Page 26 9. CFPI Report, Page 25 10. CFPI Report, Page 30 11. Fraser, A. M., Brockert, J. E., & Ward, R. H. (1995). Association of young maternal age with adverse reproductive outcomes. New England journal of medicine, 332(17), 1113-1118. 12. Cooper, L. G., Leland, N. L., & Alexander, G. (1995). Effect of maternal age on birth outcomes among young adolescents. Social biology, 42(1-2), 22-35. 13. Zhu, B. P., Rolfs, R. T., Nangle, B. E., & Horan, J. M. (1999). Effect of the interval between pregnancies on perinatal outcomes. New England journal of medicine, 340(8), 589-594. 14. Klerman, L. V., Cliver, S. P., & Goldenberg, R. L. (1998). The impact of short interpregnancy intervals on pregnancy outcomes in a low-income population. American Journal of Public Health, 88(8), 1182-1185. 15. CFPI Report, Page 34 16. CFPI Report, Page 47

1 RESOLUTION 59-20 2 3 Title: Interest-Based Debt Burden on Medical Students and Residents 4 5 Introduced by: Mara Darian, for the Medical Student Section 6 7 Original Author: Eric James 8 9 Referred To: Reaffirmation Calendar 10 11 House Action: 12 13 14 Whereas, 73 percent of medical students graduated with debt in 2017, and 15 16 Whereas, in the United States, the average medical school loan debt in 2017 was $192,000, 17 as opposed to $50,000 in 1992, representing a 220 percent increase in debt, and 18 19 Whereas, subsidized, interest free loans were previously available prior to the 2011-2012 20 academic year for up to $34,000 dollars, but are no longer available to medical students, and 21 22 Whereas, Stafford unsubsidized loans prior to 2006 had an interest rate of 1.87 percent 23 while in medical school to a current fixed and capitalizing rate of 6.8 percent, and 24 25 Whereas, the current interest rate on Graduate Plus Loans, used to supplement the cost of 26 medical education outside the Stafford loan has a fixed interest rate of 7.9 percent, and 27 28 Whereas, medical school debt is negatively associated with mental well-being, and 29 academic outcomes, as well as an association with seeking higher paying specialties as opposed to 30 primary care, and 31 32 Whereas, the American Medical Association (AMA) recognizes the shortage of physicians 33 across specialties, including primary care, and to explore other innovative solutions to the 34 recognized shortage, and 35 36 Whereas, the funding for graduate medical education has not increased consistent with the 37 number of medical school graduates, creating further financial risk for medical students, and 38 39 Whereas, MSMS policy dictates the pursing of immediate debt relief for medical students 40 and the analysis of novel solutions to the medical student debt crisis, and 41 42 Whereas, the bipartisan H.R. 1554, “The Resident Education Deferred Interest Act,” currently 43 in the United States House of Representatives Education and Labor Committee aims to make 44 interest free deferment on loans during medical or dental internships or residency, and 45 46 Whereas, AMA policy supports advocacy for legislation and regulation that would lead to 47 more favorable terms and conditions for borrowing and loan repayment, as well as the self- 48 managed low interest loan programs, and 49 50 Whereas, the AMA supports taking an active role in the reauthorization of the Higher 51 Education Act, and similar legislations to expanding loan deferment and other concerns regarding 52 medical school debt, and

53 Whereas, AMA policy states the AMA will collaborate to advocate for reduction of Stafford 54 and Graduate Plus Loan program interest rates; therefore be it 55 56 RESOLVED: That MSMS advocate for the passage of the bipartisan Resident Education 57 Deferred Interest Act, H.R. 1554; and be it further 58 59 RESOLVED: That Michigan Delegation to the American Medical Association (AMA) ask our 60 AMA to strongly advocate for the passage of the bipartisan Resident Education Deferred Interest 61 Act, H.R. 1554 and adoption of an amendment to include conversion of currently unsubsidized 62 Stafford and Graduate Plus loans to interest free status for the duration of undergraduate medical 63 education. 64 65 66 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 67 $25,000+

Relevant MSMS Policy:

Medical School Debt Forgiveness MSMS supports the principle of debt forgiveness for students of Michigan medical schools in return for service in primary care in the state of Michigan.

Financial Aid for Medical Students Adequate financial aid systems should be available for financially needy medical students.

Resolution 46-08 RESOLVED: That MSMS pursue immediate debt relief for medical students at the statewide level by advocating for tuition freezes upon matriculation at state medical schools, pursuing scholarship and loan repayment options for students who stay to train and practice in the state, and continue to advocate at the state and national level for medical student debt relief; and be it further RESOLVED: That the Michigan Delegation to the AMA ask the AMA to pursue long-term solutions to the student debt crisis by hiring an economic consulting firm to analyze the feasibility of novel solutions1 including; 1) competency-based curriculums that shorten the length of undergraduate education and medical school, 2) work-study opportunities, 3) paid rotating internships for fourth-year students who have passed initial licensing exams and have the training equivalents of mid-level providers, 4) financial investment funds that match parental savings, 5) relief for dual degrees not covered by the National Institute of Health, 6) pursuit of government Medicare funding for undergraduate medical education funding, and 7) implementing international medical student tuition models, among other viable options.

Relevant AMA Policy:

Reduction in Student Loan Interest Rates D-305.984 1. Our AMA will actively lobby for legislation aimed at establishing an affordable student loan structure with a variable interest rate capped at no more than 5.0%. 2. Our AMA will work in collaboration with other health profession organizations to advocate for a reduction of the fixed interest rate of the Stafford student loan program and the Graduate PLUS loan program. 3. Our AMA will consider the total cost of loans including loan origination fees and benefits of federal loans such as tax deductibility or loan forgiveness when advocating for a reduction in student loan interest rates. 4. Our AMA will advocate for policies which lead to equal or less expensive loans (in terms of loan benefits, origination fees, and interest rates) for Grad-PLUS loans as this would change the status quo of high- borrowers paying higher interest rates and fees in addition to having a higher overall loan burden. 5. Our AMA will work with appropriate organizations, such as the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges, to collect data and report on student indebtedness that includes total loan costs at completion of graduate medical education training.

Principles of and Actions to Address Medical Education Costs and Student Debt H-305.925 The costs of medical education should never be a barrier to the pursuit of a career in medicine nor to the decision to practice in a given specialty. To help address this issue, our American Medical Association (AMA) will: 1. Collaborate with members of the Federation and the medical education community, and with other interested organizations, to address the cost of medical education and medical student debt through public- and private-sector advocacy. 2. Vigorously advocate for and support expansion of and adequate funding for federal scholarship and loan repayment programs--such as those from the National Health Service Corps, Indian Health Service, Armed Forces, and Department of Veterans Affairs, and for comparable programs from states and the private sector- -to promote practice in underserved areas, the military, and academic medicine or clinical research. 3. Encourage the expansion of National Institutes of Health programs that provide loan repayment in exchange for a commitment to conduct targeted research. 4. Advocate for increased funding for the National Health Service Corps Loan Repayment Program to assure adequate funding of primary care within the National Health Service Corps, as well as to permit: (a) inclusion of all medical specialties in need, and (b) service in clinical settings that care for the underserved but are not necessarily located in health professions shortage areas. 5. Encourage the National Health Service Corps to have repayment policies that are consistent with other federal loan forgiveness programs, thereby decreasing the amount of loans in default and increasing the number of physicians practicing in underserved areas. 6. Work to reinstate the economic hardship deferment qualification criterion known as the “20/220 pathway,” and support alternate mechanisms that better address the financial needs of trainees with educational debt. 7. Advocate for federal legislation to support the creation of student loan savings accounts that allow for pre- tax dollars to be used to pay for student loans. 8. Work with other concerned organizations to advocate for legislation and regulation that would result in favorable terms and conditions for borrowing and for loan repayment, and would permit 100% tax deductibility of interest on student loans and elimination of taxes on aid from service-based programs. 9. Encourage the creation of private-sector financial aid programs with favorable interest rates or service obligations (such as community- or institution-based loan repayment programs or state medical society loan programs). 10. Support stable funding for medical education programs to limit excessive tuition increases, and collect and disseminate information on medical school programs that cap medical education debt, including the types of debt management education that are provided. 11. Work with state medical societies to advocate for the creation of either tuition caps or, if caps are not feasible, pre-defined tuition increases, so that medical students will be aware of their tuition and fee costs for the total period of their enrollment. 12. Encourage medical schools to (a) Study the costs and benefits associated with non-traditional instructional formats (such as online and distance learning, and combined baccalaureate/MD or DO programs) to determine if cost savings to medical schools and to medical students could be realized without jeopardizing the quality of medical education; (b) Engage in fundraising activities to increase the availability of scholarship support, with the support of the Federation, medical schools, and state and specialty medical societies, and develop or enhance financial aid opportunities for medical students, such as self-managed, low-interest loan programs; (c) Cooperate with postsecondary institutions to establish collaborative debt counseling for entering first-year medical students; (d) Allow for flexible scheduling for medical students who encounter financial difficulties that can be remedied only by employment, and consider creating opportunities for paid employment for medical students; (e) Counsel individual medical student borrowers on the status of their indebtedness and payment schedules prior to their graduation; (f) Inform students of all government loan opportunities and disclose the reasons that preferred lenders were chosen; (g) Ensure that all medical student fees are earmarked for specific and well-defined purposes, and avoid charging any overly broad and ill-defined fees, such as but not limited to professional fees; (h) Use their collective purchasing power to obtain discounts for their students on necessary medical equipment, textbooks, and other educational supplies; (i) Work to ensure stable funding, to eliminate the need for increases in tuition and fees to compensate for unanticipated decreases in other sources of revenue; mid-year and retroactive tuition increases should be opposed. 13. Support and encourage state medical societies to support further expansion of state loan repayment programs, particularly those that encompass physicians in non-primary care specialties. 14. Take an active advocacy role during reauthorization of the Higher Education Act and similar legislation, to achieve the following goals: (a) Eliminating the single holder rule; (b) Making the availability of loan deferment more flexible, including broadening the definition of economic hardship and expanding the period for loan deferment to include the entire length of residency and fellowship training; (c) Retaining the option of loan forbearance for residents ineligible for loan deferment; (d) Including, explicitly, dependent care expenses in the definition of the “cost of attendance”; (e) Including room and board expenses in the definition of tax-exempt scholarship income; (f) Continuing the federal Direct Loan Consolidation program, including the ability to “lock in” a fixed interest rate, and giving consideration to grace periods in renewals of federal loan programs; (g) Adding the ability to refinance Federal Consolidation Loans; (h) Eliminating the cap on the student loan interest deduction; (i) Increasing the income limits for taking the interest deduction; (j) Making permanent the education tax incentives that our AMA successfully lobbied for as part of Economic Growth and Tax Relief Reconciliation Act of 2001; (k) Ensuring that loan repayment programs do not place greater burdens upon married couples than for similarly situated couples who are cohabitating; (l) Increasing efforts to collect overdue debts from the present medical student loan programs in a manner that would not interfere with the provision of future loan funds to medical students. 15. Continue to work with state and county medical societies to advocate for adequate levels of medical school funding and to oppose legislative or regulatory provisions that would result in significant or unplanned tuition increases. 16. Continue to study medical education financing, so as to identify long-term strategies to mitigate the debt burden of medical students, and monitor the short-and long-term impact of the economic environment on the availability of institutional and external sources of financial aid for medical students, as well as on choice of specialty and practice location. 17. Collect and disseminate information on successful strategies used by medical schools to cap or reduce tuition. 18. Continue to monitor the availability of and encourage medical schools and residency/fellowship programs to (a) provide financial aid opportunities and financial planning/debt management counseling to medical students and resident/fellow physicians; (b) work with key stakeholders to develop and disseminate standardized information on these topics for use by medical students, resident/fellow physicians, and young physicians; and (c) share innovative approaches with the medical education community. 19. Seek federal legislation or rule changes that would stop Medicare and Medicaid decertification of physicians due to unpaid student loan debt. The AMA believes that it is improper for physicians not to repay their educational loans, but assistance should be available to those physicians who are experiencing hardship in meeting their obligations. 20. Related to the Public Service Loan Forgiveness (PSLF) Program, our AMA supports increased medical student and physician benefits the program, and will: (a) Advocate that all resident/fellow physicians have access to PSLF during their training years; (b) Advocate against a monetary cap on PSLF and other federal loan forgiveness programs; (c) Work with the United States Department of Education to ensure that any cap on loan forgiveness under PSLF be at least equal to the principal amount borrowed; (d) Ask the United States Department of Education to include all terms of PSLF in the contractual obligations of the Master Promissory Note; (e) Encourage the Accreditation Council for Graduate Medical Education (ACGME) to require residency/fellowship programs to include within the terms, conditions, and benefits of program appointment information on the PSLF program qualifying status of the employer; (f) Advocate that the profit status of a physicians training institution not be a factor for PSLF eligibility; (g) Encourage medical school financial advisors to counsel wise borrowing by medical students, in the event that the PSLF program is eliminated or severely curtailed; (h) Encourage medical school financial advisors to increase medical student engagement in service-based loan repayment options, and other federal and military programs, as an attractive alternative to the PSLF in terms of financial prospects as well as providing the opportunity to provide care in medically underserved areas; (i) Strongly advocate that the terms of the PSLF that existed at the time of the agreement remain unchanged for any program participant in the event of any future restrictive changes. 21. Advocate for continued funding of programs including Income-Driven Repayment plans for the benefit of reducing medical student load burden. 22. Formulate a task force to look at undergraduate medical education training as it relates to career choice, and develop new polices and novel approaches to prevent debt from influencing specialty and subspecialty choice.

Sources: 1. Youngclaus J. An Exploration of the Recent Decline in the Percentage of U.S. Medical School Graduates with Education Debt. AAMC Anal Br. 2018;1(4). 2. Pisaniello MS, Asahina AT, Bacchi S, et al. Effect of medical student debt on mental health, academic performance and specialty choice: A systematic review. BMJ Open. 2019;9(7):1-15. doi:10.1136/bmjopen-2019-029980 3. Craft JA, Craft TP. Rising medical education debt a mounting concern. Graduates also face less favorable repayment terms, shortage of training positions. Mo Med. 2012. 4. Babin B, Harris A, Posey B, Gosar P, Stivers S. Resident Education Deffered Interest Act. Washington D.C.: United States House of Representatives; 2019. https://www.congress.gov/bill/116th- congress/house-bill/1554/all-info. 1 RESOLUTION 01-21 2 3 Title: Stop Continuous CME Mandates 4 5 Introduced by: Martha Gray, MD, for the Washtenaw County Delegation 6 7 Original Author: Martha Gray, MD 8 9 Referred To: Reaffirmation Calendar 10 11 House Action: 12 13 14 Whereas, the definition of continuing medical education (CME) is “the process by which 15 physicians and other health professionals engage in activities designed to support their continuing 16 professional development,” and 17 18 Whereas, all physicians must adhere to multiple educational credentialing mandates 19 through their specialty boards and societies, and 20 21 Whereas, all physicians must meet state board of medicine requirements to maintain a 22 license to practice in Michigan, and 23 24 Whereas, Michigan has one of the highest CME requirements compared to other states in 25 our country, and 26 27 Whereas, the state and payers continue to add new mandates regarding CME for physicians 28 poorly correlative with value to patient care by physicians, and 29 30 Whereas, Blue Cross Blue Shield of Michigan added a required implicit bias training 31 mandate in 2020 for primary care physicians connected to loss of reimbursement if not fulfilled, 32 and 33 34 Whereas, this was done in response to unequal societal COVID-19 disease effect but after 35 state law that uncoupled maintenance of certification with payor credentialling and reimbursement, 36 and 37 38 Whereas, MSMS has developed CME opportunities and educational training on implicit bias 39 and racial inequities, and 40 41 Whereas, new CME mandates arising now are adding to the clinical burden of caring for 42 patients and to the current economic struggle of clinical practice in the time of the COVID-19 43 pandemic, and 44 45 Whereas, MSMS and the AMA are here to support patient care such that physicians are not 46 overburdened by credentialing criteria and MSMS readily responds to changes in the educational 47 needs of its physicians as challenges and new credentialing needs arise; therefore be it

48 RESOLVED: That MSMS work with the Michigan Board of Medicine and Board of 49 Osteopathic Medicine to stop CME mandates by Michigan legislators and payers such that the 50 physicians are able to self-credential and focus on caring for patients. 51 52 53 WAYS AND MEANS COMMITTEE FISCAL NOTE: None

STATEMENT OF URGENCY: New CME requirements have come out during COVID-19, time is of the essence.

Relevant MSMS Policy:

Opposition to Compulsory Content of Mandated Continuing Medical Education MSMS opposes any attempt to introduce compulsory content of mandated Continuing Medical Education (CME) in the state of Michigan. (Res67-07A) - Reaffirmed (Sunset Report 2020)

Relevant AMA Policy: None

Sources: 1. https://www.aafp.org/about/policies/all/continuing-medical-education-definition.html 2. https://www.fsmb.org/siteassets/advocacy/key-issues/continuing-medical-education-by-state.pdf 3. https://www.msms.org/About-MSMS/News-Media/what-to-expect-from-governor-whitmers-implicit- bias-training-directive 1 RESOLUTION 06-21 2 3 Title: Maternal Levels of Care Standards of Practice 4 5 Introduced by: Federico G. Mariona, MD, MBA, FACOG, FACS, for the Wayne County 6 Delegation 7 8 Original Authors: Federico Mariona, MD, and Brianna Sohl 9 10 Referred To: Reaffirmation Calendar 11 12 House Action: 13 14 15 Whereas, severe maternal morbidity and maternal-infant mortality continue to be a serious 16 national public health and physicians’ concern, and 17 18 Whereas, in the last five years the Centers for Disease Control and Prevention (CDC), the 19 American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal Fetal 20 Medicine (SMFM) and the Joint Commission, supported by other national professional 21 organizations, have recommended the implementation of initiatives to reduce severe maternal 22 morbidity and avoid preventable pregnancy-related maternal deaths, and 23 24 Whereas, several states and specific geographic areas where maternal care is provided have 25 implemented collaborative programs to ensure optimal care to pregnant women and decrease or 26 avoid inequality in maternal care, an issue that more severely affects minorities, and 27 28 Whereas, maternity care with standardized and established levels of care appears conducive 29 to provide optimal obstetrical and perinatal care and improve clinical outcomes, and 30 31 Whereas, due to the increasing demand in clinical care added by the coronavirus 19 32 (COVID-19) pandemic this resolution requires urgent attention; therefore be it 33 34 RESOLVED: That MSMS support statewide initiatives to help improve maternal care in the 35 state of Michigan; and be it further 36 37 RESOLVED: That MSMS advocate for the implementation of standards consistent with the 38 Maternal Levels of Care at all birthing centers in the state; and be it further 39 40 RESOLVED: That the Michigan Delegation to the American Medical Association ask our 41 AMA to support national standards of practice to help improve maternal health at birthing centers 42 across the country. 43 44 45 WAYS AND MEANS COMMITTEE FISCAL NOTE:

Relevant MSMS Policy:

Michigan Maternal Health Safety and Quality Care Initiative – Resolution 24-14 RESOLVED: That MSMS join efforts with the Michigan Department of Community Health, the Michigan Section of the ACOG, the Keystone OB initiative, and all professional societies in the state involved in the care of pregnant women by advocating for the implementation of a standard risk assessment clinical protocol for the identification and standardized treatment of postpartum hemorrhage in all Michigan institutions that offer maternity services.

Relevant AMA Policy:

Disparities in Maternal Mortality D-420.993 Our AMA: (1) will ask the Commission to End Health Care Disparities to evaluate the issue of health disparities in maternal mortality and offer recommendations to address existing disparities in the rates of maternal mortality in the United States; (2) will work with the CDC, HHS, state and county health departments to decrease maternal mortality rates in the US; (3) encourages and promotes to all state and county health departments to develop a maternal mortality surveillance system; and (4) will work with stakeholders to encourage research on identifying barriers and developing strategies toward the implementation of evidence-based practices to prevent disease conditions that contribute to poor obstetric outcomes, maternal morbidity and maternal mortality in racial and ethnic minorities.

Infant Mortality D-245.994 1. Our AMA will work with appropriate agencies and organizations towards reducing infant mortality by providing information on safe sleep positions and preterm birth risk factors to physicians, other health professionals, parents, and child care givers. 2. Our AMA will work with Congress and the Department of Health and Human Services to improve maternal outcomes through: (a) maternal/infant health research at the NIH to reduce the prevalence of premature births and to focus on obesity research, treatment and prevention; (b) maternal/infant health research and surveillance at the CDC to assist states in setting up maternal mortality reviews; modernize state birth and death records systems to the 2003-recommended guidelines; and improve the Safe Motherhood Program; (c) maternal/infant health programs at HRSA to improve the Maternal Child Health Block grant; (d) comparative effectiveness research into the interventions for preterm birth; (e) disparities research into maternal outcomes, preterm birth and pregnancy-related depression; and (f) the development, testing and implementation of quality improvement measures and initiatives.

Maternal and Child Health Care H-420.986 The AMA opposes any further decreases in funding levels for maternal and child health programs; encourages more efficient use of existing resources for maternal and child health programs; encourages the federal government to allocate additional resources for increased health planning and program evaluation within Maternal and Child Health Block Grants; and urges increased participation of physicians through advice and involvement in the implementation of block grants.

Sources: 1. Moaddab A, Dildy GA, et al. Obstet Gynecol. 2018. Apr, 131(4) 707-712. Health Care Disparity and Pregnancy-Related mortality in the United States, 2005-2014 2. Lazariu V, Nguyen T, et al. PLos One. 2017 August 7;12(8). Severe maternal morbidity: a population-based study of an expanded measure and associated factors. Severe maternal morbidity: screening and review. Obstetric Care Consensus #5. ACOG-SMFM. 2016 3. Main EK et al. Am J Obstet Gynecol 2016.214. 643. Measuring severe maternal morbidity; validation of potential measures. 4. Robertson T et al. BMC Public Health 2017 Nov 7;17. Suppl 4. All things to all people: tradeoffs in pursuit of an ideal modeling tool for maternal and child health Levels of maternal care. Obstetric care consensus # 9. ACOG-SMFM August 2019. Obstet Gynecol. Vol 134 (2) 5. Catalano A et al. Implementing CDC’s level of care assessment tool (LOCATe). A national collaboration to improve maternal and child health. J Women’s Health. 2017 Dec 26 (12) 1265-1269 6. Zahn CM et al. Levels of maternal care verification pilot: translating guidance into practice, Obstet Gynecol 2018. Dec. 132 (6) 1401-1406 7. Dalton ME et al. Am J Obst Gynecol 2019. October. 221(4) 311-317 Putting the “M” back in maternal fetal medicine: a 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States. 8. Brantley MD, et al. Perinatal regionalization: a geospatial view of perinatal critical care, United States, 2010- 2013. Am J Obstet Gynecol. 2017 Feb. 216(2). 9. Arizona perinatal trust voluntary certification program. https://azperinatal.org/certification. 10. Georgia General Assembly.2017-2018 regular session-HB 909:health;designation of perinatal facilities; provisions. http://www.legis.ga.gov/Legislation/en-US/display/20172018/HB/909 11. Indiana General Assembly 2018 session. SenateBill360. https://iga.in.gov/legislative/2018/bills/senate/360 12. Texas Office of the Secretary of State, Department of state Health Services. Texas administrative code; Title 25, part 1, Chapter 133, subchapter K. https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=25&pt=1&ch=133&sch=K&rl= Y 13. Executive Summary: Reproductive services for women at high risk for maternal mortality workshop. February 11-12, 2019, Las Vegas. Am J Obstet Gynecol October 2019, 221(4) B2-5 . Kramer M R et al. Changing the conversation: applying a health equity framework to maternal mortality reviews. Am J Obstet Gynecol. December 2019. 609-616

1 RESOLUTION 08-21 2 3 Title: Prohibit Persons from Carrying Firearms and Explosive Devices in Public 4 Spaces 5 6 Introduced by: Robert Sain, MD, for the Washtenaw County Delegation 7 8 Original Author: Robert Sain, MD 9 10 Referred To: Reaffirmation Calendar 11 12 House Action: 13 14 15 Whereas, Michigan citizens experienced the deliberate lethal threat against our neighbors 16 and public officials by persons carrying firearms and/or explosive devices in the Michigan State 17 Capitol on April 30, 2020, and in various instances since, and 18 19 Whereas, members of the group(s) who invaded Michigan’s Capitol in April and threatened 20 our elected officials and public servants were among those who went on to threaten to kidnap and 21 harm various elected leaders, including Governor Gretchen Whitmer and Attorney General Dana 22 Nessel, and 23 24 Whereas, private unauthorized militias are illegal in Michigan, and 25 26 Whereas, the Armed Conflict Location & Event Data Project states that far-right groups 27 have taken an increasing part in demonstrations against the election result, demonstrations are 28 more likely to turn violent if militia members are present, and these groups have not just started 29 attending more protests, they are also ramping up training and recruitment events, and 30 31 Whereas, members of Michigan militant groups are known to have participated in the 32 insurrection attempt at the U.S. Capitol in Washington, DC on January 6, 2021, making it clear that 33 violence against the U.S., its people, and its institutions may just be beginning, and 34 35 Whereas, the act of threatening and intimidating with firearms, and/or explosive devices 36 through open carry in the Michigan State Capitol only became expressly prohibited in January 37 2021, but concealed carry is still permissible, and 38 39 Whereas, there is increasing bipartisan support from lawmakers on banning the open carry 40 of firearms in the Michigan legislature, and 41 42 Whereas, the latest U.S. public opinion on carrying firearms in public places from the 43 American Journal of Public Health shows that fewer than one in three U.S. adults supported gun 44 carrying in any of the specified venues, and support for carrying in public was lowest for schools 45 (19%; 95% confidence interval [CI] = 16.7, 21.1), bars (18%; 95% CI = 15.9, 20.6), and sports 46 stadiums (17%; 95% CI = 15.0, 19.5), and

47 Whereas, carrying firearms has been used to threaten individuals and impose physiologic 48 and psychological harm to persons exposed making this a medical issue worthy of consideration by 49 our medical societies, and 50 51 Whereas, in Michigan, those who carry firearms and explosive devices in public incite 52 unnecessary fear, stress, and safety risks to fellow citizens and public officials; therefore be it 53 54 RESOLVED: That MSMS advocate that firearms and explosive devices of all kinds, with a 55 carry exception for law enforcement officials, be prohibited from state government buildings and 56 public spaces. 57 58 59 WAYS AND MEANS COMMITTEE FISCAL NOTE: None

STATEMENT OF URGENCY: Gun violence is a daily epidemic and there was increased unrest and violence in 2020-2021 in Michigan and Washington.

Relevant MSMS Policy:

Address Gun Violence Using a Public Health Approach MSMS supports physicians working with local and state public health agencies, law enforcement agencies, and other community organizations and leaders to identify, develop and evaluate strategies to increase firearm safety and prevent firearm injury and death.

Firearm-Related Injury and Death: Adopt A Call to Action MSMS endorses the specific recommendations made in the publication “Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association,” which is aimed at reducing the health and public health consequences of firearms.

Handgun Control and Education MSMS recommends effective controls on the assembly, manufacture, distribution and possession of handguns.

MSMS supports distribution of educational materials to firearm purchasers. The materials should address the use of lock boxes, trigger locks, childproof safety catches and loading indicators.

Oppose Imposition of Penalties on Local Units of Government and/or Officials and Staff MSMS opposes the prohibition of local units of government and/or their elected or appointed officials or staff from imposing restrictions on the ownership, registration, purchase, sale, transfer, transportation, or possession of guns within their area of jurisdiction and/or punishment for the imposition of such restrictions.

Relevant AMA Policy:

AMA Campaign to Reduce Firearm Deaths H-145.988 The AMA supports educating the public regarding methods to reduce death and injury due to keeping guns, ammunition and other explosives in the home.

Firearm Related Injury and Death: Adopt a Call to Action H-145.973 Our AMA endorses the specific recommendations made by an interdisciplinary, inter-professional group of leaders from the American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, American College of Obstetricians and Gynecologists, American College of Physicians, American College of Surgeons, American Psychiatric Association, American Public Health Association, and the American Bar Association in the publication "Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association," which is aimed at reducing the health and public health consequences of firearms and lobby for their adoption.

Firearms as a Public Health Problem in the United States - Injuries and Death H-145.997 1. Our AMA recognizes that uncontrolled ownership and use of firearms, especially handguns, is a serious threat to the public's health inasmuch as the weapons are one of the main causes of intentional and unintentional injuries and deaths.

Therefore, the AMA: (A) encourages and endorses the development and presentation of safety education programs that will engender more responsible use and storage of firearms; (B) urges that government agencies, the CDC in particular, enlarge their efforts in the study of firearm-related injuries and in the development of ways and means of reducing such injuries and deaths; (C) urges Congress to enact needed legislation to regulate more effectively the importation and interstate traffic of all handguns; (D) urges the Congress to support recent legislative efforts to ban the manufacture and importation of nonmetallic, not readily detectable weapons, which also resemble toy guns; (5) encourages the improvement or modification of firearms so as to make them as safe as humanly possible; (E) encourages nongovernmental organizations to develop and test new, less hazardous designs for firearms; (F) urges that a significant portion of any funds recovered from firearms manufacturers and dealers through legal proceedings be used for gun safety education and gun-violence prevention; and (G) strongly urges US legislators to fund further research into the epidemiology of risks related to gun violence on a national level.

2. Our AMA will advocate for firearm safety features, including but not limited to mechanical or smart technology, to reduce accidental discharge of a firearm or misappropriation of the weapon by a non- registered user; and support legislation and regulation to standardize the use of these firearm safety features on weapons sold for non-military and non-peace officer use within the U.S.; with the aim of establishing manufacturer liability for the absence of safety features on newly manufactured firearms.

Sources: 1. https://www.nytimes.com/2021/01/09/us/politics/michigan-state-capitol.html 2. https://www.nytimes.com/2020/10/08/us/gretchen-whitmer-michigan-militia.html 3. https://www.law.georgetown.edu/icap/wp- content/uploads/sites/32/2020/09/Michigan.pdf?fbclid=IwAR0IaVjyucWn93MRZj-MJfTfkO- vzLehfIBqK7ZLG8jhezk8qNvfVWJYT4M 4. https://www.bbc.com/news/world-us-canada-55638579 5. https://www.bbc.com/news/world-us-canada-56174168 6. https://www.detroitnews.com/story/news/local/michigan/2021/01/11/commission-consider-open-carry- ban-state-capitol/6620997002/ 7. https://www.detroitnews.com/story/news/politics/2021/01/07/michigan-capitol-temporarily-closed- because-a-threat/6578215002/ 8. https://ajph.aphapublications.org/doi/10.2105/AJPH.2017.303712 9. https://www.drsforamerica.org/issues/gun-violence-prevention/ 10. https://giffords.org/lawcenter/gun-laws/policy-areas/guns-in-public/open-carry/ 1 RESOLUTION 36-21 2 3 Title: Insurance Coverage of Adverse Childhood Experiences Screening 4 5 Introduced by: Laura Carravallah, MD 6 7 Original Authors: Elizabeth Anteau, Aleena Hajek, Rachel Hollander, and Laura Carravallah, MD 8 9 Referred To: Reaffirmation Calendar 10 11 House Action: 12 13 14 Whereas, adverse childhood experiences (ACEs) are events in childhood that are potentially 15 stressful and traumatic, such as experiencing abuse or neglect, witnessing violence, or being in a 16 household with substance abuse or instability, and 17 18 Whereas, ACEs have been proven to negatively impact health outcomes and have lasting 19 effects associated with injuries, mental health, maternal health, infectious disease, chronic disease, 20 risky behaviors, and social opportunities, and 21 22 Whereas, of those investigated in the Kaiser ACEs study, approximately two-thirds reported 23 one or more ACEs, and more than 20 percent reported experiencing more than three, and 24 25 Whereas, early detection of ACEs can help to decrease their negative health effects by 26 providing earlier intervention and increasing access to resources, and 27 28 Whereas, existing MSMS policy on Routine ACE Screening in Pediatric Appointments states, 29 “That MSMS supports screening for adverse childhood experiences in annual pediatric 30 appointments and shall advocate for such screening,” and 31 32 Whereas, a 2016 study found that physicians listed “inadequate reimbursement” as a 33 moderate/severe barrier to ACEs screening, and 34 35 Whereas, in October 2019, the California Department of Health Care Services and California 36 Office of the Surgeon General adopted the goal of reducing ACEs and “toxic stress by half in one 37 generation,” and 38 39 Whereas, California has recently adopted a reimbursement plan via Medi-cal of $29 per 40 ACEs screening for primary care physicians in order to accomplish the previously stated goal; 41 therefore be it 42 43 RESOLVED: That MSMS support and advocate for insurance reimbursement for Adverse 44 Childhood Events (ACEs) screening of the pediatric population. 45 46 47 WAYS AND MEANS COMMITTEE FISCAL NOTE: None

Relevant MSMS Policy:

Routine ACE Screening in Pediatric Appointments MSMS supports screening for adverse childhood experiences in annual pediatric appointments. (Board Action Report #2, 2019 HOD, re Res29-18)

Relevant AMA Policy:

Adverse Childhood Experiences and Trauma-Informed Care H-515.952 1. Our AMA recognizes trauma-informed care as a practice that recognizes the widespread impact of trauma on patients, identifies the signs and symptoms of trauma, and treats patients by fully integrating knowledge about trauma into policies, procedures, and practices and seeking to avoid re-traumatization. 2. Our AMA supports: a. evidence-based primary prevention strategies for Adverse Childhood Experiences (ACEs); b. evidence-based trauma-informed care in all medical settings that focuses on the prevention of poor health and life outcomes after ACEs or other trauma at any time in life occurs; c. efforts for data collection, research and evaluation of cost-effective ACEs screening tools without additional burden for physicians; d. efforts to educate physicians about the facilitators, barriers and best practices for providers implementing ACEs screening and trauma-informed care approaches into a clinical setting; and e. funding for schools, behavioral and mental health services, professional groups, community and government agencies to support patients with ACEs or trauma at any time in life.

Sources: 1. Preventing adverse childhood experiences. (2020, April 03). Retrieved February 08, 2021, from https://www.cdc.gov/violenceprevention/aces/fastfact.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.g ov%2Fviolenceprevention%2Facestudy%2Ffastfact.html 2. About the CDC-Kaiser ACE Study. (2020, April 13). Retrieved February 08, 2021, from https://www.cdc.gov/violenceprevention/aces/about.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.go v%2Fviolenceprevention%2Facestudy%2Fabout.html 3. CA launches First-of-its-kind aces Initiative; Beginning Jan. 1, 2020, Medi-cal will begin paying for ACEs screenings. (2019, December 10). Retrieved February 08, 2021, from https://www.cmadocs.org/newsroom/news/view/ArticleId/28226/California-launches-first-of-its-kind- ACEs-initiative-Beginning-Jan-1-2020-Medi-Cal-providers-can-be-paid-for-ACEs-screenings 4. Szilagyi, M., MD, PhD. (2016). Pediatricians' perceived barriers to addressing early brain and child development and inquiring about child/parent adverse childhood experiences. Retrieved February 08, 2021, from https://www.aap.org/en-us/professional-resources/Research/research- findings/Pages/Pediatricians-Perceived-Barriers-to-Addressing-Early-Brain-and-Child-Development-and- Inquiring.aspx 5. Trauma screenings and Trauma-Informed care Provider Trainings. Retrieved February 08, 2021, from https://www.dhcs.ca.gov/provgovpart/Pages/TraumaCare.aspx#:~:text=Detecting%20ACEs%20early%20a nd%20connecting,adults%20with%20Medi%2DCal%20coverage MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES

RESOLUTIONS BY COMMITTEE

REFERENCE COMMITTEE A – MEDICAL CARE DELIVERY

RESOLUTION DESCRIPTION 31-20 Bring Insurance Credentialing into Legal Compliance on Maintenance of Certification 10-21 Financial Impact and Fiscal Transparency of the American Medical Association Current Procedural Terminology Program 16-21 Medicaid Dialysis Policy for Undocumented Patients 18-21 Medical and Dental Care for Prisoners 21-21 Address Adolescent Telehealth Confidentiality Concerns

1 RESOLUTION 31-20 2 3 Title: Bring Insurance Credentialing into Legal Compliance on Maintenance of 4 Certification 5 6 Introduced by: David Whalen, MD, for the Kent County Delegation 7 8 Original Author: Megan Edison, MD 9 10 Referred To: Reference Committee A 11 12 House Action: 13 14 15 Whereas, Public Act 487 of 2018 became law on December 27, 2018, and 16 17 Whereas, this law was a direct result of resolutions adopted by the MSMS House of 18 Delegates to end insurance company mandates to participate in or purchase maintenance of 19 certification products in order to be accepted as an in-network provider eligible to care for 20 patients, and 21 22 Whereas, the law states, "an insurer that delivers, issues for delivery, or renews in this state a 23 health insurance policy issued under chapter 34 or a health maintenance organization that issues a 24 health maintenance contract under chapter 35 shall not require as the sole condition precedent to 25 the payment or reimbursement of a claim under the policy or contract that an allopathic or 26 osteopathic physician in the medical specialties of family practice, internal medicine, or pediatrics 27 maintain a national or regional certification not otherwise specifically required for licensure under 28 article of the public health code, 1978 PA 368, MCL 333.16101 to 333.18838," and 29 30 Whereas, despite passage of this law over two years ago, there are insurance companies in 31 Michigan ignoring the law by not changing credentialing policy and continuing to reject physicians 32 solely for not maintaining American Board of Medical Specialties or the American Osteopathic 33 Association board certification; therefore be it 34 35 RESOLVED: That MSMS work with Michigan health insurance companies to change 36 credentialing requirements to be in compliance with Public Act 487 of 2018, by requiring only initial 37 board certification for the credentialing of in-network physicians specializing in family medicine, 38 internal medicine, and pediatrics; and be it further 39 40 RESOLVED: That MSMS pursue legal action against Michigan health insurance companies 41 that refuse to work with MSMS to bring the health insurance company’s credentialing requirements 42 into legal compliance with Public Act 487 of 2018 and continue to discriminate against family 43 medicine, internal medicine, and pediatric physicians for not participating in or purchasing a 44 maintenance of certification product. 45 46 47 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions calling for legal intervention - 48 $100,000+

Relevant MSMS Policy:

Review Board Recertification and Maintenance of Certification Process MSMS supports Maintenance of Certification (MOC) only under all of the following circumstances: 1. MOC must be voluntary. 2. MOC must not be a condition of licensure, hospital privileges, health plan participation, or any other function unrelated to the specialty board requiring MOC. 3. MOC should not be the monopoly of any single entity. Physicians should be able to access a range of alternatives from different entities. 4. The status of MOC should be revisited by MSMS if it is identified that the continuous review of physician competency is objectively determined to be a benefit for patients. If that benefit is determined to be present by objective data regarding value and efficacy, then MSMS should support the adoption of an evidence based process that serves only to improve patient care.

Relevant AMA Policy:

1 RESOLUTION 10-21 2 3 Title: Financial Impact and Fiscal Transparency of the American Medical 4 Association Current Procedural Terminology Program 5 6 Introduced by: David Whalen, MD, for the Kent County Delegation 7 8 Original Authors: Patrick Droste, MD, and Megan Edison, MD 9 10 Referred To: Reference Committee A 11 12 House Action: 13 14 15 Whereas, the 2020 COVID-19 pandemic and restrictions brought unprecedented financial 16 strain upon physicians, with the most recent Physician Foundation survey showing 12 percent of 17 physicians either closing or planning to close their practice within the next year (75 percent of 18 those physicians are in private practice), and nearly 75 percent of physicians reported lost income, 19 and 20 21 Whereas, in the middle of this crisis, the new AMA Current Procedural Terminology® 22 (CPT®) Evaluation and Management coding system went live on January 1, 2021, completely 23 changing the Evaluation and Management (E&M) coding system and reimbursement for the first 24 time in 24 years, and 25 26 Whereas, the timing of this change could not have come at a worse time for physicians still 27 reeling from the pandemic and new insurance contracts not yet negotiated, and 28 29 Whereas, each patient encounter and experience is unique, and attempts to create a system 30 to accurately reflect the care given within hundreds of specialties and thousands of patient visits is 31 very difficult and likely to be inadequate, and 32 33 Whereas, failure to account for all patient interactions and care within a medical coding 34 system will financially harm physicians in these overlooked areas of medicine, and 35 36 Whereas, the adverse consequences of the new CPT® system have not been studied, but 37 early feedback among physicians shows this new CPT® system focuses on chronic care, thereby 38 excluding nearly every pediatric diagnosis, and 39 40 Whereas, the new CPT® system rewards ordering prescriptions, lab tests, and studies, 41 rather than watchful waiting and counseling, and 42 43 Whereas, the new CPT® system prevents private practice physicians from counting in- 44 house labs and studies towards the complexity of care, but allows hospital employed physicians to 45 do so, and 46 47 Whereas, the new CPT® system awards higher levels of reimbursement for curb siding a 48 specialist, thereby encouraging and codifying a system of uncompensated care by specialists, and

49 Whereas, while the intent of this coding change may have been noble, the fallout and 50 failures need to be studied and modified to create a fair system among private and employed 51 physicians, reflective of the complexity of care within all specialties, and respectful of 52 uncompensated care by our specialist colleagues, and 53 54 Whereas, the physicians in this country deserve to know the finances behind the AMA CPT® 55 coding system that we are required to participate in; therefore be it 56 57 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) 58 request that our AMA study and report the financial impact of the new 2021 CPT® Evaluation and 59 Management coding system upon physicians, among all specialties, in private and employed 60 practices; and be it further 61 62 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 63 our AMA to publicly disclose all revenue generated by the proprietary CPT® program in a 64 transparent fashion, including but not limited to licensing fees, royalties, electronic health record 65 fees, government and institutional licensing fees, handbooks, training programs, coding apps, and 66 print-based coding resources in a yearly report. 67 68 69 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 70 or AMA policy - $500

STATEMENT OF URGENCY: The 2021 American Medical Association (AMA) Current Procedural Terminology® (CPT®) Evaluation and Management went live on January 1, 2021. It is currently affecting physician reimbursement. Failure to address any potential harm in a timely manner will result in more practice closures and worsen patient access to physicians. This resolution asks the AMA to study and provide fiscal transparency on an issue that is very pertinent to practicing physicians right now.

Relevant MSMS Policy: None

Relevant AMA Policy:

AMA CPT Editorial Panel and Process H-70.973 The AMA will continue (1) to work to improve the CPT process by encouraging specialty societies to participate fully in the CPT process; (2) to enhance communications with specialty societies concerning the CPT process and subsequent appeals process; and (3) to assist specialty societies, as requested, in the education of their members concerning CPT coding issues.

Preservation of Evaluation/Management CPT Codes H-70.985 It is the policy of the AMA to (1) oppose the bundling of procedure and laboratory services within the current CPT Evaluation/Management (E/M) services; (2) oppose the compression of E/M codes and support efforts to better define and delineate such services and their codes; (3) seek feedback from its members on insurance practices that advocate bundling of procedures and laboratory services with or the compression of codes in the CPT E/M codes, and express its views to such companies on behalf of its members; (4) continue to work with the PPRC and all other appropriate organizations to insure that any modifications of CPT E/M codes are appropriate, clinically meaningful, and reflective of the considered views of organized medicine; and (5) work to ensure that physicians have the continued opportunity to use CPT as a coding system that is maintained by the medical profession.

Use of CPT Editorial Panel Process H-70.919 Our AMA reinforces that the CPT Editorial Panel is the proper forum for addressing CPT code set maintenance issues and all interested stakeholders should avail themselves of the well-established and documented CPT Editorial Panel process for the development of new and revised CPT codes, descriptors, guidelines, parenthetic statements and modifiers.

CPT Coding System H-70.974 1. The AMA supports the use of CPT by all third party payers and urges them to implement yearly changes to CPT on a timely basis. 2. Our AMA will work to ensure recognition of and payment for all CPT codes approved by the Centers for Medicare & Medicaid Services (CMS) retroactive to the date of their CMS approval, when the service is covered by a patient's insurance.

Physicians' Current Procedural Terminology H-70.972 The AMA (1) continues to seek ways to increase its efforts to communicate with specialty societies and state medical associations concerning the actions and deliberations of the CPT Maintenance process; (2) urges the national medical specialty societies to ensure that their representatives to the CPT process are fully informed as to their association's policies and coding preferences; and (3) urges those specialty societies that have not nominated individuals to serve on the CPT Advisory Committee to do so.

Source: http://physiciansfoundation.org/wp-content/uploads/2020/08/20-1278-Merritt-Hawkins-2020-Physicians- Foundation-Survey.6.pdf

1 RESOLUTION 16-21 2 3 Title: Medicaid Dialysis Policy for Undocumented Patients 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Authors: Michelle Condon, MD, FACP, and David Whalen, MD 8 9 Referred To: Reference Committee A 10 11 House Action: 12 13 14 Whereas, in most states undocumented migrants with end stage kidney disease (ESKD) are 15 ineligible for public assistance and rely on sessions of emergency dialysis when symptoms become 16 intolerable, and 17 18 Whereas, in most states, undocumented migrants access to care is limited to safety-net 19 providers, including hospital Emergency Departments (EDs) that are required to provide emergency 20 care under federal Emergency Medical Treatment and Labor Act (EMTALA), and then have to wait 21 until their symptoms qualify for ED admission for care to be reimbursed by emergency Medicaid 22 program funding, and 23 24 Whereas, the five year mortality rate on emergency dialysis is 14 times higher than standard 25 care, and costs up to $400,000 per patient annually compared to $100,000 in the outpatient setting, 26 and 27 28 Whereas, undocumented ESKD patients are often younger with fewer comorbidities than 29 other ESKD patients, making them often ideal candidates for transplantation, but usually they 30 cannot qualify due to lack of insurance to cover the high cost of immunosuppressive therapy, and 31 32 Whereas, caring for these patients exerts a toll on physicians resulting in signs of burnout 33 stemming from the feeling that they were being forced to provide substandard care, and 34 35 Whereas, undocumented patients can purchase commercial plans at full price due to a 36 provision in the Affordable Care Act (ACA) forbidding companies from denying coverage based on 37 preexisting conditions, and 38 39 Whereas, some states have allowed patients to automatically qualify for outpatient dialysis 40 care after presenting to a hospital; therefore be it 41 42 RESOLVED: That MSMS ask the State of Michigan to develop a dialysis policy for 43 undocumented patients with end stage kidney disease as an emergency condition covered under 44 Medicaid; and be it further 45 46 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 47 the AMA to work with the Center for Medicare and Medicaid Services and other state Medicaid 48 programs to develop a dialysis policy for undocumented patients with end stage kidney disease as 49 an emergency condition covered under Medicaid. 50 51 52 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 53 $25,000+

STATEMENT OF URGENCY: This is a timely issue that should be addressed promptly for physicians and underserved, low-income patients. It is an access-to-care issue for many patients.

Relevant MSMS Policy: None

Relevant AMA Policy: None 1 RESOLUTION 18-21 2 3 Title: Medical and Dental Care for Prisoners 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Author: Patrick J. Droste, MS, MD 8 9 Referred To: Reference Committee A 10 11 House Action: 12 13 14 Whereas, prisoners in correctional facilities have the right to receive timely medical and 15 dental care, and 16 17 Whereas, prisoners in correctional facilities frequently have medical and dental problems 18 that are not addressed by prison authorities, and 19 20 Whereas, prisoners do not have internal prison advocates to support their quest for medical 21 and/or dental care, and 22 23 Whereas, prisoners get charged for each request of medical or dental service and may not 24 have the funds to pay for such visits, and 25 26 Whereas, prisoners have no recourse to request second opinion or specialty evaluation for 27 unresolved medical or dental concerns, and 28 29 Whereas, family members of prisoners, serving as an advocate, find it difficult to facilitate 30 appropriate medical care or obtain information regarding a prisoner’s condition(s), and 31 32 Whereas, prisoners are frequently transferred to multiple prison facilities throughout their 33 sentence, which leads to lack of continuity of care; therefore be it 34 35 RESOLVED: That MSMS work with the Michigan Department of Corrections to establish 36 viable and effective protocols to allow prisoners to present their medical concerns and receive 37 timely responses to their request for medical and dental care; and be it further 38 39 RESOLVED: That MSMS support the development of a Review Board, composed of 40 correctional officials, medical professionals such as physicians, nurses, or physician assistants and 41 prisoners, to review inmates concerns regarding medical and dental diagnosis and treatment. 42 43 44 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 45 $25,000+

STATEMENT OF URGENCY: We feel that the MSMS-HOD should hear and act on this resolution in 2021 and give it highest consideration, because prisoners are being denied timely and affordable medical and dental care during their period of confinement. This neglect of care makes it more difficult for them to rehabilitate both inside the correction facilities and after their discharge.

Relevant MSMS Policy: None

Relevant AMA Policy: None

Source: Kimberly Norris, MD, of Barry County 1 RESOLUTION 21-21 2 3 Title: Address Adolescent Telehealth Confidentiality Concerns 4 5 Introduced by: Mara Darian, for the Medical Student Section 6 7 Original Authors: Meredith Hengy, Aayush Mittal, and Samantha Rea 8 9 Referred To: Reference Committee A 10 11 House Action: 12 13 14 Whereas, adolescents believe that all health care should be confidential and report it as one 15 of the most important aspects of their health care, yet many express concerns regarding privacy 16 and worry that their providers will tell parents about their conversations, and 17 18 Whereas, the Academy of Pediatrics recommends providing confidential and private health 19 care to adolescents by allowing sufficient opportunities for adolescents to discuss sensitive issues 20 with physicians without a parent present, and 21 22 Whereas, the COVID-19 pandemic has not affected adolescents' needs for confidential 23 services, and the early shift from in-person visits to telehealth visits demonstrated that 85 percent 24 of adolescent primary care visits occurred for sensitive issues including sexual and reproductive 25 health, eating disorders, and substance use, and 26 27 Whereas, recent studies report that only 38 percent of adolescents spent any time alone 28 with a provider within the last year, yet adolescents who experience portions of their visits 29 unaccompanied by a parent are more likely to discuss sensitive topics such as sexual and 30 reproductive health, and 31 32 Whereas, only 27 percent of adolescents reported that they had any alone time with their 33 provider during recent telehealth visits, potentially limiting access to confidential services, and 34 35 Whereas, a unique challenge of providing confidential care over telehealth includes finding 36 quiet and private spaces in adolescents' homes that are separate from other household members 37 to discuss sensitive topics without fear of the conversation being overheard, and 38 39 Whereas, the American Academy of Pediatrics, Pediatric Health Network, Michigan 40 Medicine, and other organizations have developed frameworks recommending that physicians 41 continue providing confidential and private care to adolescents through telehealth, and 42 43 Whereas, the organizations above provide recommendations unique to telehealth to ensure 44 private and confidential visits, including asking the parent to leave for part of the visit and gaining 45 parent buy-in regarding the importance of this privacy, and 46 47 Whereas, additional suggestions to provide confidential care to adolescents through 48 telehealth include asking the adolescent to move to a more private area of the home, providing 49 suggestions on unique areas that patients may go to ensure privacy, the use of headphones and 50 chat features, the use of yes or no answers, asking the adolescent for a 360 degree video view to 51 understand who is in the room, and having the parent and adolescent call from separate devices to 52 easily facilitate the transition to confidential discussions, and 53 54 Whereas, AMA Policies H-60.938 and H-60.965 recommend providing confidential care to 55 adolescent patients, but do not address the unique confidentiality concerns of adolescents and 56 their parents accessing telehealth, nor the challenges associated with finding private spaces in an 57 adolescents' home; therefore be it 58 59 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 60 our AMA to amend AMA policy H-60.965 by addition to read as follows: 61 62 Confidential Health Services for Adolescents H-60.965 63 Our AMA: 64 (1) reaffirms that confidential care for adolescents is critical to improving their health; 65 (2) encourages physicians to allow emancipated and mature minors to give informed 66 consent for medical, psychiatric, and surgical care without parental consent and notification, 67 in conformity with state and federal law; 68 (3) encourages physicians to involve parents in the medical care of the adolescent patient, 69 when it would be in the best interest of the adolescent. When, in the opinion of the 70 physician, parental involvement would not be beneficial, parental consent or notification 71 should not be a barrier to care; 72 (4) urges physicians to discuss their policies about confidentiality with parents and the 73 adolescent patient, as well as conditions under which confidentiality would be abrogated. 74 This discussion should include possible arrangements for the adolescent to have 75 independent access to health care (including financial arrangements); 76 (5) encourages physicians to offer adolescents an opportunity for examination and 77 counseling apart from parent. The same confidentiality will be preserved between the 78 adolescent patient and physician as between the parent (or responsible adult) and the 79 physician; 80 (6) encourages state and county medical societies to become aware of the nature and effect 81 of laws and regulations regarding confidential health services for adolescents in their 82 respective jurisdictions. State medical societies should provide this information to 83 physicians to clarify services that may be legally provided on a confidential basis; 84 (7) urges undergraduate and graduate medical education programs and continuing 85 education programs to inform physicians about issues surrounding minors' consent and 86 confidential care, including relevant law and implementation into practice; 87 (8) encourages health care payers to develop a method of listing of services which preserves 88 confidentiality for adolescents; and 89 (9) encourages medical societies to evaluate laws on consent and confidential care for 90 adolescents and to help eliminate laws which restrict the availability of confidential care; 91 and 92 (10) encourages physicians to recognize the unique confidentiality concerns of 93 adolescents' and their parents associated with telehealth visits; and 94 (11) encourages physicians in a telehealth setting to offer examination and counseling 95 apart from others in the home and to ensure that the adolescent is in a private space. 96 97 98 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 99 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy: See above.

Sources: 1. Daley AM, Polifroni EC, Sadler LS. The Essential Elements of Adolescent-friendly Care in School-based Health Centers: A Mixed Methods Study of the Perspectives of Nurse Practitioners and Adolescents. J Pediatr Nurs. 2019 Jul-Aug;47:7-17. doi: 10.1016/j.pedn.2019.03.005. Epub 2019 Apr 11. PMID: 30981090. 2. Zucker NA, Schmitt C, DeJonckheere MJ, Nichols LP, Plegue MA, Chang T. Confidentiality in the Doctor- Patient Relationship: Perspectives of Youth Ages 14-24 Years. J Pediatr. 2019 Oct;213:196-202. doi: 10.1016/j.jpeds.2019.05.056. Epub 2019 Jun 21. PMID: 31230890. 3. Fuzzell L, Fedesco HN, Alexander SC, Fortenberry JD, Shields CG. "I just think that doctors need to ask more questions": Sexual minority and majority adolescents' experiences talking about sexuality with healthcare providers. Patient Educ Couns. 2016 Sep;99(9):1467-72. doi: 10.1016/j.pec.2016.06.004. Epub 2016 Jun 14. PMID: 27345252. 4. Fuentes L, Ingerick M, Jones R, Lindberg L. Adolescents' and Young Adults' Reports of Barriers to Confidential Health Care and Receipt of Contraceptive Services. J Adolesc Health. 2018 Jan;62(1):36-43. doi: 10.1016/j.jadohealth.2017.10.011. Epub 2017 Nov 20. PMID: 29157859; PMCID: PMC5953199. 5. Pampati S, Liddon N, Dittus PJ, Adkins SH, Steiner RJ. Confidentiality Matters but How Do We Improve Implementation in Adolescent Sexual and Reproductive Health Care? J Adolesc Health. 2019 Sep;65(3):315-322. doi: 10.1016/j.jadohealth.2019.03.021. Epub 2019 Jun 18. PMID: 31227388. 6. Marcell, A. V., Burstein, G. R., & Adolescence, C. O. (2017). Sexual and Reproductive Health Care Services in the Pediatric Setting. Pediatrics, 140(5). https://doi.org/10.1542/peds.2017-2858 7. Wood SM, White K, Peebles R, Pickel J, Alausa M, Mehringer J, Dowshen N. Outcomes of a Rapid Adolescent Telehealth Scale-Up During the COVID-19 Pandemic. J Adolesc Health. 2020 Aug;67(2):172- 178. doi: 10.1016/j.jadohealth.2020.05.025. Epub 2020 Jun 28. PMID: 32611509; PMCID: PMC7321038. 8. Copen, C. E., Dittus, P. J., & Leichliter, J. S. (2016). Confidentiality Concerns and Sexual and Reproductive Health Care Among Adolescents and Young Adults Aged 15-25. NCHS data brief, (266), 1-8. 9. Allison, B.A., Rea, S., Mikesell, L., et al. "Perceptions of the Provider-Patient Relationship Following the COVID Transition to Telehealth Visits." Poster presentation at: Academic Pediatric Association Region IV Meeting. Virtual. 10. Barney A, Buckelew S, Mesheriakova V, Raymond-Flesch M. The COVID-19 Pandemic and Rapid Implementation of Adolescent and Young Adult Telemedicine: Challenges and Opportunities for Innovation. J Adolesc Health. 2020 Aug;67(2):164-171. doi: 10.1016/j.jadohealth.2020.05.006. Epub 2020 May 14. PMID: 32410810; PMCID: PMC7221366. 11. Evans YN, Golub S, Sequeira GM, Eisenstein E, North S. Using Telemedicine to Reach Adolescents During the COVID-19 Pandemic. J Adolesc Health. 2020 Oct;67(4):469-471. doi: 10.1016/j.jadohealth.2020.07.015. Epub 2020 Aug 5. PMID: 32768330; PMCID: PMC7403159. 12. Providing Adolescent-Centered Virtual Care (2020). Adolescent Health Initiative, Michigan Medicine. Retrieved on 2/5/21 from https://www.umhs-adolescenthealth.org/wp-content/uploads/2020/07/virtual- care-starter-guide.pdf 13. Teens and Telehealth: Consent & Confidentiality. (2020). Pediatric Health Network. Retrieved on 2/5/21 from https://pediatrichealthnetwork.org/wp-content/uploads/2020/04/4.9.202-Teens-and-Telehealth- Consent-Confidentiality.pdf 14. American Academy of Pediatrics. Guidance on the Necessary Use of Telehealth During the COVID-19 Pandemic. Published 2020. Accessed on 2/20/21. https://services.aap.org/en/pages/2019-novel- coronavirus-covid-19-infections/clinical-guidance/guidance-on-the-necessary-use-of-telehealth-during- the-covid-19-pandemic/ 15. Carlson JL, Goldstein R. Using the Electronic Health Record to Conduct Adolescent Telehealth Visits in the Time of COVID-19. J Adolesc Health. 2020 Aug;67(2):157-158. doi: 10.1016/j.jadohealth.2020.05.022. Epub 2020 Jun 6. PMID: 32517972; PMCID: PMC7275171. 16. S. North. Telemedicine in the time of coronavirus disease and beyond. J Adolesc Health, 67 (2020), pp. 145-146 MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES

RESOLUTIONS BY COMMITTEE

REFERENCE COMMITTEE B – LEGISLATION

RESOLUTION DESCRIPTION 09-20 Medication-Assisted Treatment in Physician Health Programs 54-20 Resentencing for Individuals Convicted of Marijuana-Based Offenses 03-21 Oppose Routine Use of Gonad Shields 15-21 Electronic Prescribing Waiver for Michigan’s Free Clinics 22-21 Expanding Access to Medication for the Treatment of Opioid Use Disorder 26-21 Decarceration During an Infectious Disease Pandemic

BOARD ACTION DESCRIPTION REPORT #1-21 Resolution 50-20 – “Remove Clinic-Specific Caps on Buprenorphine”

1 RESOLUTION 09-20 2 3 Title: Medication-Assisted Treatment in Physician Health Programs 4 5 Introduced by: Clara Hwang, MD, for the Wayne County Delegation 6 7 Original Authors: Clara Hwang, MD, and Tabitha Moses, MS 8 9 Referred To: Reference Committee B 10 11 House Action: 12 13 14 Whereas, Physician Health Programs (PHPs) are designed to allow physicians with 15 potentially impairing conditions who either come forward or are referred to be given the 16 opportunity for evaluation, rehabilitation, treatment, and monitoring without disciplinary action in 17 an anonymous, confidential, and respectful manner, and 18 19 Whereas, the PHP model is intended to ensure participants receive effective clinical care for 20 mental, physical, and substance abuse disorders and access to a variety of clinical interventions and 21 support, and 22 23 Whereas, currently, almost all of the physicians referred to PHPs who are diagnosed with 24 substance use disorder (SUD) involving monitoring or sanctions are also subjected to punitive 25 action by their respective licensing boards, and 26 27 Whereas, the majority of state PHP treatment programs adhere to abstinence only policies 28 for physicians diagnosed with a SUD and will not refer physicians to addiction treatment programs 29 that include medications for addiction treatment (MAT) as part of their program, and 30 31 Whereas, other treatment modalities used for SUDs include neuro-psychiatric testing and 32 behavioral counseling, and 33 34 Whereas, FDA-approved MAT for SUD includes the opioid agonists buprenorphine, 35 buprenorphine-naloxone combination products, and methadone, and the opioid antagonist 36 naltrexone, and 37 38 Whereas, MAT has been proven to help maintain recovery and prevent death in patients 39 with opioid use disorder (OUD), being referred to as the "gold standard" of treatment for OUD in 40 the U.S. Surgeon General's "Spotlight on Opioids" report, and 41 42 Whereas, it is reported that patients who use MAT to treat their OUD remain in therapy 43 longer than those who do not, and are less likely to use illicit opioids, and 44 45 Whereas, patients with OUD who receive the gold-standard MAT have significantly lower 46 rates of relapse than those who do not have access to these treatments, and 47 48 Whereas, for physicians with SUD who are denied MAT, relapses and recurrences are 49 common, and 50 51 Whereas, a 2019 report from the National Academies of Sciences, Engineering, and Medicine 52 stated that “there is no scientific evidence that justifies withholding medications from OUD patients 53 in any setting” and that such practices amount to “denying appropriate medical treatment,” and 54 that such practices amount to “denying appropriate medical treatment”, and 55 56 Whereas, physicians with SUD should have access to all the same evidenced-based 57 treatment provided to patients which includes the use of counseling and MAT when medically 58 indicated, and 59 60 Whereas, these outcomes are critical to ensuring a pathway to recovery and continuation of 61 clinical practice in a safe and ethical manner with patient protection at the forefront, and 62 63 Whereas, there is no evidence to suggest that physicians maintained on therapeutic doses 64 of MAT pose an increased risk to patient safety, and 65 66 Whereas, on August 29, 2019, the New England Journal of Medicine printed a perspective 67 titled, “Practicing What We Preach- Ending Physician Health Program Bans on OPIOID-Agonist 68 Therapy,” by Leo Beletsky,JD; Sarah Wakeman, MD; and Kevin Fiscella, MD, MPH; therefore be it 69 70 RESOLVED: That MSMS work with the Michigan Legislature, the Michigan Department of 71 Licensing and Regulatory Affairs, and the Michigan Boards of Medicine and Osteopathic Medicine 72 and Surgery to direct Michigan’s Health Professional Recovery Programs to adopt policy that 73 permit physicians diagnosed with substance use disorder to receive both counseling and 74 medications for addiction treatment, including agonist medications, as a means to ensure they 75 receive effective clinical care to aid in their recovery and safe and ethical return to clinical practice; 76 and be it further 77 78 RESOLVED: That the Michigan Delegation to our American Medical Association (AMA) 79 encourage the AMA to work with stakeholders including the Federation of State Medical Boards 80 and the Federation of State Physician Health Programs to develop guidelines supporting the 81 adoption of policies by state- based Physician Health Programs to permit physicians diagnosed 82 with substance use disorder to receive both counseling and medications for addiction treatment, 83 including agonist medications, to ensure physicians receive effective clinical care to aid in their 84 recovery and safe and ethical return to clinical practice; and be it further 85 86 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 87 our AMA to work with stakeholders including the Federation of State Medical Boards and the 88 Federation of State Physician Health Programs to develop model legislation permitting state 89 Boards of Medicine and Osteopathic Medicine to waive punitive sanctions for physicians who 90 voluntarily self-report their physical, mental, and substance use disorders by engaging with a 91 Physician Health Program and who successfully complete the terms of participation. 92 93 94 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 95 $25,000+

Relevant MSMS Policy:

Physician Health Program Programs for physicians whose capacity to function professionally has been impaired by addictive, psychiatric, medical, behavioral or other potentially impairing conditions should be motivated by humanitarian concerns for the public and the impaired physician.

All actions with regard to physician health programs should be intended to be in the best interest of the physician and the public. They should not be designed to be punitive in nature since the best current evidence indicates none of these conditions are voluntarily acquired or “self-inflicted.” Physician health programs should enable effective clinical care for mental, physical and substance use disorders, including easy access to a variety of clinical interventions and treatment programs.

Relevant AMA Policy:

Support the Elimination of Barriers to Medication-Assisted Treatment for Substance Use Disorder D- 95.968 1. Our AMA will: (a) advocate for legislation that eliminates barriers to, increases funding for, and requires access to all appropriate FDA-approved medications or therapies used by licensed drug treatment clinics or facilities; and (b) develop a public awareness campaign to increase awareness that medical treatment of substance use disorder with medication-assisted treatment is a first-line treatment for this chronic medical disease. 2. Our AMA supports further research into how primary care practices can implement medication-assisted treatment (MAT) into their practices and disseminate such research in coordination with primary care specialties. 3. The AMA Opioid Task Force will increase its evidence-based educational resources focused on methadone maintenance therapy (MMT) and publicize those resources to the Federation.

Educating Physicians About Physician Health Programs and Advocating for Standards D-405.990 Our AMA will: (1) work closely with the Federation of State Physician Health Programs (FSPHP) to educate our members as to the availability and services of state physician health programs to continue to create opportunities to help ensure physicians and medical students are fully knowledgeable about the purpose of physician health programs and the relationship that exists between the physician health program and the licensing authority in their state or territory; (2) continue to collaborate with relevant organizations on activities that address physician health and wellness; (3) in conjunction with the FSPHP, develop state legislative guidelines addressing the design and implementation of physician health programs; (4) work with FSPHP to develop messaging for all Federation members to consider regarding elimination of stigmatization of mental illness and illness in general in physicians and physicians in training; (5) continue to work with and support FSPHP efforts already underway to design and implement the physician health program review process, Performance Enhancement and Effectiveness Review (PEER™), to improve accountability, consistency and excellence among its state member PHPs. The AMA will partner with the FSPHP to help advocate for additional national sponsors for this project; and (6) continue to work with the FSPHP and other appropriate stakeholders on issues of affordability, cost effectiveness, and diversity of treatment options. 1 RESOLUTION 54-20 2 3 Title: Resentencing for Individuals Convicted of Marijuana-Based Offenses 4 5 Introduced by: Mara Darian, for the Medical Student Section 6 7 Original Authors: Mara Darian, Vikas Kanneganti, Tabitha Moses, Jaya Parulekar, Siri Sarvepalli, 8 and Brianna Sohl 9 10 Referred To: Reference Committee B 11 12 House Action: 13 14 15 Whereas, from 2016 to 2017, more than 20,000 arrests involving marijuana charges were 16 made in Michigan, which accounted for about eight percent of all arrests in the state and about 10 17 percent of all drug-related arrests; of these marijuana-related arrests, 87 percent were for 18 possession and 13 percent were for sales/distribution with 90 percent of possession arrests 19 accounting for one ounce or less of marijuana, and 20 21 Whereas, the Michigan Department of Corrections spent approximately $214,900,160 in 22 2017 to jail individuals for marijuana-related offenses; however, a 2014 report by the National 23 Research Council found that mandatory minimum sentences for drug offenders “have few, if any, 24 deterrent effects,” and 25 26 Whereas, incarceration is a key issue under the domain of Social and Community Context in 27 the Social Determinants of Health topic area of Healthy People 2020 due to numerous disparities in 28 inmate mental and physical health compared to the population, as well as the increased rate of 29 mental health disorders in the children of incarcerated parents, and 30 31 Whereas, there is a clear link between incarceration and health, with incarcerated individuals 32 showing higher risk of chronic conditions such as cardiovascular disease, hypertension, and cancer 33 compared to the general population; a study in March 2013 found that each additional year an 34 individual spends in prison corresponds with a decline in life expectancy by two years, and 35 36 Whereas, incarcerated populations are particularly vulnerable to the coronavirus disease 37 2019 (COVID-19) given the demographics of those experiencing incarceration in addition to the 38 inability to properly "social distance", high population turnover, unsanitary living conditions, poor 39 ventilation systems, inability or inadequacy to properly test and track COVID-19 cases and exposure 40 which have led to an estimated 113,664 COVID-19 cases and 887 related deaths among 41 incarcerated people as of August 2020, and 42 43 Whereas, arrests for marijuana possession, regardless of whether the person was later 44 convicted on these charges, have been shown to negatively impact opportunities such as finding 45 employment, housing, and obtaining student loans, which can lead to widespread and 46 multifactorial individual health consequences; furthermore, criminalization of drug use is associated 47 with increased stigma and discrimination of drug users and that stigma and discrimination is also a 48 causal factor for decreased mental and physical health, and 49 50 Whereas, nationally, African Americans are three times more likely to be arrested for 51 marijuana possession than Whites, a difference mirrored in Michigan where African Americans are 52 2.6 times more likely to be arrested, a finding that cannot be explained by differences in use, and 53 54 Whereas, fifteen states have legalized the use of recreational and medicinal marijuana, and 55 in the past four years, 23 states have passed laws addressing expungement of certain marijuana 56 convictions, pairing these laws with other policies to its decriminalization or legalization, and 57 58 Whereas, in 2018, California became the first state to enact legislation ordering its 59 Department of Justice to conduct a review of criminal records and identify past convictions eligible 60 for sentence dismissal or re-designation in accordance with the Adult Use of Marijuana Act; the 61 outcomes of this legislation showed that reductions in criminal penalties for drug possession 62 reduce racial and ethnic disparities in the criminal justice system, allowing for improvements in 63 health inequalities linked to social determinants of health, and 64 65 Whereas, Illinois passed a bill in May 2019, to expunge convictions for non-violent crimes of 66 possession, manufacturing, and distribution of up to 30 grams and possession up to 500 grams, 67 and Colorado and Massachusetts have approved legislation allowing individuals convicted for 68 possession to petition to seal criminal records of misdemeanor offenses that are no longer 69 considered crimes, and 70 71 Whereas, a recent study examining the impact of this type of expungement found that 72 those who do obtain expungement have extremely low subsequent crime rates and experience a 73 significant increase in their wage and employment trajectories and an overall positive impact on 74 the lives of those affected; however, of those legally eligible for expungement, only 6.5 percent 75 obtain it within five years of eligibility, findings that support the development of “automatic” 76 expungement procedures, and 77 78 Whereas, those who have received resentencing for past offenses, including decriminalized 79 marijuana-based charges, have experienced an increase of 22 percent in wages on average within 80 one year of resentencing as well as lower subsequent crime rates that compare favorably to the 81 general population, and 82 83 Whereas, our American Medical Association supports public health-based strategies, rather 84 than incarceration, in the handling of individuals possessing cannabis for personal use; encourages 85 research on the impact of legalization and decriminalization of cannabis in an effort to promote 86 public health and public safety (H-95.924), and 87 88 Whereas, during the 2018 elections, Michigan voters passed Proposal 1 to legalize the 89 recreational use and possession of marijuana for individuals 21 years of age or older, since then 90 Macomb and Oakland County Prosecutors have already begun dismissing low-level marijuana 91 criminal charges, the city of Detroit has hired attorneys to help individuals with expungement cases, 92 and a bill was introduced by state Representative Sheldon Neeley of Flint to require judges to 93 review requests of people convicted of low-level marijuana crimes, and 94 95 Whereas, efforts to set up expungement laws for marijuana-based offenses have come 96 through Bills 4890-85 and 5120 in the Michigan House of Representatives which passed with 97 bipartisan support in November 2019, these bills are currently under review by the Senate 98 Committee on Judiciary and Public Safety and a Senate Bill to this same end (SB-416) is still 99 pending; and 100 101 Whereas, in October 2020, Governor Gretchen Whitmer signed a bill to expand 102 expungement of misdemeanor marijuana charges that would not be considered crimes after 103 legalization of recreational marijuana; and, 104 105 Whereas, at the federal level, the Marijuana Opportunity Reinvestment and Expungement 106 (MORE) Act asks that marijuana be removed from the Controlled Substances Act and create an 107 opportunity for individuals with marijuana law convictions to petition for expungement and 108 resentencing; this act was passed in the House in December 2020 (H.R. 3884) and is also under 109 consideration by the Senate (S. 2227); and 110 111 Whereas, The Marijuana Opportunity Reinvestment and Expungement Act defines “eligible 112 State of Locality” as a “State or locality that has taken steps to— (i) create an automatic process, at 113 no cost to the individual, for the expungement, destruction, or sealing of criminal records for 114 cannabis offenses; and (ii) eliminate violations or other penalties for persons under parole, 115 probation, pre-trial, or other State or local criminal supervision for a cannabis offense”; therefore be 116 it 117 118 RESOLVED: That MSMS support legislative initiatives that support the creation of an 119 automatic process, at no cost to the individual, for the expungement, destruction, or sealing of 120 criminal records for marijuana offenses that would now be considered legal under Michigan’s 121 adult-use marijuana law; and be it further 122 123 RESOLVED: That MSMS support legislative initiatives that support the elimination of 124 violations or other penalties for persons under parole, probation, pre-trial, or criminal supervision 125 for marijuana offenses that would now be considered legal under Michigan’s adult-use marijuana 126 law; and be it further 127 128 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 129 our AMA to work with states that have legalized marijuana to develop model legislation to create 130 an automatic process, at no cost to the individual, for the expungement, destruction, or sealing of 131 criminal records for marijuana offenses that would now be considered legal; and be it further 132 133 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 134 our AMA to work with states that have legalized marijuana to develop model legislation to 135 eliminate violations or other penalties for persons under parole, probation, pre-trial, or other State 136 or local criminal supervision for a marijuana offense that would now be considered legal. 137 138 139 WAYS AND MEANS COMMITTEE FISCAL NOTE: $16,000-$32,000 for legislative advocacy.

Relevant MSMS Policy:

43-19 - Resentencing for People Convicted of Marijuana-Based Offenses - DISAPPROVE Rationale: The Committee agreed with the underlying intent to decriminalize low-level offenses associated with marijuana possession; however, Committee members determined that the resolution entails a complex legal matter and not within the purview of MSMS.

Relevant AMA Policy:

Cannabis Legalization for Adult Use (commonly referred to as recreational use) H-95.924 Our AMA: (1) believes that cannabis is a dangerous drug and as such is a serious public health concern; (2) believes that the sale of cannabis for adult use should not be legalized (with adult defined for these purposes as age 21 and older); (3) discourages cannabis use, especially by persons vulnerable to the drug's effects and in high-risk populations such as youth, pregnant women, and women who are breastfeeding; (4) believes states that have already legalized cannabis (for medical or adult use or both) should be required to take steps to regulate the product effectively in order to protect public health and safety including but not limited to: regulating retail sales, marketing, and promotion intended to encourage use; limiting the potency of cannabis extracts and concentrates; requiring packaging to convey meaningful and easily understood units of consumption, and requiring that for commercially available edibles, packaging must be child-resistant and come with messaging about the hazards about unintentional ingestion in children and youth; (5) laws and regulations related to legalized cannabis use should consistently be evaluated to determine their effectiveness; (6) encourages local, state, and federal public health agencies to improve surveillance efforts to ensure data is available on the short- and long-term health effects of cannabis, especially emergency department visits and hospitalizations, impaired driving, workplace impairment and worker-related injury and safety, and prevalence of psychiatric and addictive disorders, including cannabis use disorder; (7) supports public health based strategies, rather than incarceration, in the handling of individuals possessing cannabis for personal use; (8) encourages research on the impact of legalization and decriminalization of cannabis in an effort to promote public health and public safety; (9) encourages dissemination of information on the public health impact of legalization and decriminalization of cannabis; (10) will advocate for stronger public health messaging on the health effects of cannabis and cannabinoid inhalation and ingestion, with an emphasis on reducing initiation and frequency of cannabis use among adolescents, especially high potency products; use among women who are pregnant or contemplating pregnancy; and avoiding cannabis- impaired driving; (11) supports social equity programs to address the impacts of cannabis prohibition and enforcement policies that have disproportionately impacted marginalized and minoritized communities; and (12) will coordinate with other health organizations to develop resources on the impact of cannabis on human health and on methods for counseling and educating patients on the use cannabis and cannabinoids.

Sources: 1. J. Mack, “See data on 2017 marijuana arrests in your Michigan city or township,” MLive, 2018. [Online]. Available: https://www.mlive.com/news/index.ssf/2018/10/see_the_number_of_2017_marijua.html. [Accessed: 20-Jan-2019]. 2. J. Hovey, “New Analysis Shows Vast Majority of Michigan Marijuana Arrests Are for Petty Possession,” 2018. [Online]. Available: https://www.regulatemi.org/press/2018/10/10/new-analysis-shows-vast- majority-of-michigan-marijuana-arrests-are-for-petty-possession/. [Accessed: 20-Jan-2019]. 3. N. R. Council, The Growth of Incarceration in the United States. Washington, D.C.: National Academies Press, 2014. 4. P. Trust, “More Imprisonment Does Not Reduce State Drug Problems,” 2018. 5. R. Snyder and J. J. Walsh, “EXECUTIVE BUDGET STATE OF MICHIGAN.” 6. J. Mack, “Marijuana is 9% of all Michigan arrests, and other facts on marijuana arrests,” M-Live, 2017. [Online]. Available: https://www.mlive.com/news/2017/07/marijuana_is_9_of_all_michigan.html. [Accessed: 28-Feb-2019]. 7. “Incarceration | Healthy People 2020.” [Online]. Available: https://www.healthypeople.gov/2020/topics- objectives/topic/social-determinants-health/interventions-resources/incarceration. [Accessed: 31-Jan- 2020]. 8. N. Freudenberg, “Jails, prisons, and the health of urban populations: A review of the impact of the correctional system on community health,” Journal of Urban Health, vol. 78, no. 2. pp. 214-235, 2001, doi: 10.1093/jurban/78.2.214. 9. E. J. Patterson, “The dose-response of time served in prison on mortality: New York State, 1989-2003,” Am. J. Public Health, vol. 103, no. 3, pp. 523-528, Mar. 2013, doi: 10.2105/AJPH.2012.301148. 10. M. Massoglia and B. Remster, “Linkages Between Incarceration and Health.” Public Health Rep., vol. 134, no. 1_suppl, pp. 8S-14S, doi: 10.1177/0033354919826563. 11. C. Strassle et al., "Covid-19 Vaccine Trials and Incarcerated People â€” The Ethics of Inclusion," N. Engl. J. Med., vol. 383, no. 20, pp. 1897-1899, Nov. 2020, doi: 10.1056/nejmp2025955. 12. C. Franco-Paredes et al., "Decarceration and community re-entry in the COVID-19 era," The Lancet Infectious Diseases, vol. 21, no. 1. Lancet Publishing Group, pp. e11-16, 01-Jan-2021, doi: 10.1016/S1473-3099(20)30730-1. 13. S. Burris, “Disease Stigma in U.S. Public Health Law,” J. Law, Med. Ethics, vol. 30, no. 2, pp. 179-190, Jun. 2002, doi: 10.1111/j.1748-720X.2002.tb00385.x. 14. J. Ahern, J. Stuber, and S. Galea, Stigma, discrimination and the health of illicit drug users,” Drug Alcohol Depend., vol. 88, no. 2-3, pp. 188-196, May 2007, doi: 10.1016/J.DRUGALCDEP.2006.10.014. 15. G. Taras, “High Time for Change: How Legalizing Marijuana Could Help Narrow the Racial Divide in the United States,” Comp. L., vol. 24, pp. 565-598, 2016, doi: 10.3868/s050-004-015-0003-8. 16. D. J. Roelfs, E. Shor, K. W. Davidson, and J. E. Schwartz, “Losing life and livelihood: A systematic review and meta-analysis of unemployment and all-cause mortality,” Soc. Sci. Med., vol. 72, no. 6, pp. 840-854, Mar. 2011, doi: 10.1016/j.socscimed.2011.01.005. 17. B. Graetz, “Health consequences of employment and unemployment: Longitudinal evidence for young men and women,” Soc. Sci. Med., vol. 36, no. 6, pp. 715-724, Mar. 1993, doi: 10.1016/0277- 9536(93)90032-Y. 18. National Conference of State Legislatures, “Marijuana Overview,” 2018. 19. D. Schlussel, "Marijuana expungement accelerates across the country," Collateral Consequences of Criminal Conviction and Restoration of Rights, 20-Nov-2020. 20. S. Rense, "15 States, D.C. Legalized Weed U.S. - Where Is Marijuana Legal 2020?," Esquire, 04-Nov- 2020. 21. A. C. Mooney et al., “Racial/Ethnic Disparities in Arrests for Drug Possession After California Proposition 47, 2011-2016,” Am. J. Public Health, vol. 108, no. 8, pp. 987-993, Aug. 2018, doi: 10.2105/AJPH.2018.304445. 22. A. Bonta, S. Skinner, S. Wiener, A. Gonzalez Fletcher, and A. Quirk, An act to add Section 11361.9 to the Health and Safety Code, relating to cannabis. California Secretary of State, 2018. 23. Illinois, HB1438: Adult Use Cannabis Summary. 2019, pp. 1-14. 24. R. Beggin, “Michigan House considers expungement of many marijuana, traffic convictions,” 2019. 25. J. J. Prescott and S. B. Starr, “Expungement of Criminal Convictions: An Empirical Study,” SSRN Electron. J., Mar. 2019, doi: 10.2139/ssrn.3353620. 26. Neeley et al., House Bill No. 6227. Michigan House of Delegates, 2018, p. 10. 27. K. Grey, “Expunging marijuana convictions wouldn’t be automatic,” Detroit Free Press, Detroit, MI, 10- Sep-2019. 28. K. Grey, :”Michigan marijuana legalization date set for Dec. 6,” Detroit Free Press, Detroit, MI, 26-Nov- 2018. 29. ] K. Grey, "Michigan marijuana legalization date set for Dec. 6," Detroit Free Press, Detroit, MI, 26-Nov- 2018. 30. S. Stutzky et al., “Ballot Proposal 1 of 2018.” 31. K. Grey, “Marijuana bill passes in Michigan: What you need to know,” Detroit, MI, 07-Nov-2018. 32. Representative Isaac Robinson, Michigan Legislature - House Bill 5120 . 2019. 33. Representative Eric Leutheuser, Michigan Legislature - House Bill 4980 . 2019. 34. A. Jackson, "Historic' Michigan expungement bills signed into law," Detroit Free Press, Detroit, 12-Oct- 2020. 35. A. Knopf, “Legalization of marijuana takes another step forward,” Alcohol. Drug Abus. Wkly., vol. 31, no. 45, pp. 5-6, Nov. 2019, doi: 10.1002/adaw.32550. 36. Harris, Booker, Merkley, Wyden, and Warren, S. 2227: MORE Act of 2019 (Introduced version). 2019. 37. Congressional Research Service, “The MORE Act: House Plans Historic Vote on Federal Marijuana Legalization,” Nov. 2020.

1 RESOLUTION 03-21 2 3 Title: Oppose Routine Use of Gonad Shields 4 5 Introduced by: Aparna Joshi, MD, and Gunjan Malhotra, MD 6 7 Original Authors: Aparna Joshi, MD, and Gunjan Malhotra, MD 8 9 Referred To: Reference Committee B 10 11 House Action: 12 13 14 Whereas, the Image Gently Alliance was formed in late 2006 led by the Society of Pediatric 15 Radiology (SPR) with the goal of “changing practice by raising awareness of the opportunities to 16 lower radiation dose in the imaging of children,” and 17 18 Whereas, the SPR recruited other organizations/members of the imaging team into the 19 alliance in 2007 including the American College of Radiology (ACR), American Association of 20 Physicists in Medicine (AAPM), and American Society of Radiologic Technologists (ASRT), and 21 22 Whereas, the practice of shielding reproductive organs and in utero fetuses began about 70 23 years ago in the 1950s in response to potential concerns about the long term effects of radiation 24 and the potential for passing on genetic mutations through genetic inheritance, and 25 26 Whereas, in response to these concerns, regulation by entities such as the FDA and 27 legislation at the state and federal level exist requiring the use of gonad shields in medical imaging 28 studies, and 29 30 Whereas, through technological advances, medical physicists estimate the dose from 31 routine diagnostic imaging to reproductive organs has reduced by 95 percent without 32 compromising diagnostic quality, and 33 34 Whereas, technological advances and optimization have resulted in marginal hereditary risk 35 reduction from gonad shielding ranging from 1x10-6 in women and 5x10-6 in men, and 36 37 Whereas, research on radiation dosing has shown that routine diagnostic imaging does not 38 produce harmful levels of radiation to patients and fetuses, and 39 40 Whereas, technological advances such as automatic exposure control (AEC) (meant to 41 optimize imaging parameters) are negatively affected by shielding, and 42 43 Whereas, the gonad shield results in decreased activity on the detector triggering AEC to 44 increase the radiation tube to increase output, exposure, and patient dose and also degrades 45 image quality, and 46 47 Whereas, the gonad shield produces artifacts and can obscure relevant anatomy and 48 diagnostic information, and

49 Whereas, non-diagnostic or obscured images may need to be repeated increasing patient 50 dose when shields are used, and 51 52 Whereas, the gonad surface shield is ineffective at reducing internal scatter, and 53 54 Whereas, studies have shown that gonad shields are incorrectly placed for females in 91 55 percent of radiographs and for males in 66 percent of radiographs, rendering them ineffective, and 56 57 Whereas, on January 12, 2021, the National Council on Radiation Protection and 58 Measurements issued a statement that the risks of utilizing gonad shields far outweigh the 59 negligible benefits to reproductive organs and therefore they should not be routinely used, and 60 61 Whereas, similar statements opposing routine or mandatory use of gonadal shields were 62 released by the ACR and the AAPM in 2019 and by the ASRT in 2021; therefore be it 63 64 RESOLVED: That MSMS advocate for state legislation and regulatory changes to oppose 65 mandatory use of gonad shields in medical imaging; and be it further 66 67 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 68 our AMA to advocate that the FDA amend the code of federal regulations to oppose the routine 69 use of gonad shields in medical imaging; and be it further 70 71 RESOLVED: That the Michigan Delegation to the AMA in conjunction with state medical 72 societies, develop model state and national legislation to oppose mandatory use of gonadal shields 73 in medical imaging. 74 75 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - $25,000+

STATEMENT OF URGENCY: This resolution is urgent and time sensitive because recent research and statements from organizations that optimize radiation in imaging protocols have recommended legislative changes regarding the use of gonadal shields. We need urgent legislative and regulatory changes to decrease the radiation doses for medical imaging in children. Without these changes children are receiving unnecessary radiation and creating poor diagnostic quality images. The National Council on Radiation Protection and Measurements (NCRP) released a statement on this issue in January 2021.

Relevant MSMS Policy: None

Relevant AMA Policy: None

Sources: 1. https://www.imagegently.org/About-Us/Campaign-Overview 2. https://www.aappublications.org/news/2020/03/31/xrayshields040120 3. https://www.radiologyinfo.org/en/info.cfm?pg=safety-patient-shielding 4. https://www.ecfr.gov/cgi-bin/text- idx?SID=c6fd98dfc8955d41420798f3e5357c66&mc=true&node=se21.8.1000_150&rgn=div8 5. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=1000.50 6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7005227/ 7. https://www.aapm.org/org/policies/details.asp?id=468&type=PP%C2%A4t=true 8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3292647/ 9. https://pubmed.ncbi.nlm.nih.gov/28437549/ 10. https://ncrponline.org/wp-content/themes/ncrp/PDFs/Statement13.pdf 11. https://www.acr.org/Advocacy-and-Economics/Advocacy-News/Advocacy-News-Issues/In-the-June-8- 2019-Issue/ACR-Endorses-AAPM-Position-on-Patient-Gonadal-and-Fetal-Shielding 12. https://www.asrt.org/main/news-publications/news/article/2021/01/12/asrt-statement-on-fetal-and- gonadal-shielding

1 RESOLUTION 15-21 2 3 Title: Electronic Prescribing Waiver for Michigan’s Free Clinics 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Author: Michelle M. Condon, MD, FACP 8 9 Referred To: Reference Committee B 10 11 House Action: 12 13 14 Whereas, there are 57 free clinics for patients who obtain medical care from non-profit 15 charitable medical clinics mostly because they do not have health insurance in Michigan, and 16 17 Whereas, approximately one-third of these clinics, have not had sufficient funds to switch to 18 electronic medical records, and 19 20 Whereas, these clinics are largely run with all volunteer personnel and are financed by 21 donations and the occasional grant, and 22 23 Whereas, many clinics are open less than 25 hours per week, and 24 25 Whereas, some volunteer retired physician personnel have resigned from these clinics 26 rather than learn a (or another) medical records system, and 27 28 Whereas, patients generally shop multiple pharmacies to find the least expensive source for 29 their medications thus requiring additional valuable staff time to discontinue electronic 30 prescriptions sent to pharmacies in order to support patients’ efforts to source their medication at 31 a lower price, perhaps having found it at an alternative pharmacy; therefore be it 32 33 RESOLVED: That MSMS supports the Free Clinics of Michigan in asking the Michigan 34 Department of Licensing and Regulatory Affairs (LARA) and the Michigan Board of Pharmacy to 35 change the initial proposed language of Michigan Administrative Code Section R, 338.3162a 36 (5)(a)(v), not yet posted for public comment, to allow a waiver for non-profit charitable medical 37 clinics excusing them from being required to submit all prescriptions to pharmacies in electronic 38 form. 39 40 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - $25,000+

STATEMENT OF URGENCY: The business of the MSMS HOD addresses issues of physicians from all over Michigan, in a timely fashion, to improve the delivery of care, patient care issues and important policy and legislative issues affecting our members. Listening to the voice of physicians is paramount in organized medicine and is why many of our members participate at the county and state levels. Physician authors have taken the time during this busy and stressful time to articulate the issues. It is time to get back to the business of medicine for the sake of over-stressed colleagues and their patients to address what is important to them, our members. The result can be improved transparency, updated physicians, or improved issues that affect patients in Michigan and/or across the country.

Relevant MSMS Policy: None

Relevant AMA Policy: None

1 RESOLUTION 22-21 2 3 Title: Expanding Access to Medication for the Treatment of Opioid Use Disorder 4 5 Introduced by: Mara Darian, for the Medical Student Section 6 7 Original Authors: May Chammaa and Brianna Sohl 8 9 Referred To: Reference Committee B 10 11 House Action: 12 13 14 Whereas, in 2017, there were 21.2 opioid overdose deaths per 100,000 persons in Michigan, 15 which is higher than the national rate of 14.6 deaths per 100,000 persons; nationally, more than 2 16 million people have an opioid use disorder (OUD) but fewer than 10 percent have accessed 17 treatment, and 18 19 Whereas, medications for opioid use disorder (MOUD), which includes the full agonist 20 methadone and the partial agonist buprenorphine, are evidence-based, gold standard, effective 21 treatments for OUD that lessen the harmful health and societal effects of such substance use 22 disorders, and 23 24 Whereas, opioid agonist treatment (OAT), such as buprenorphine, is well documented to 25 reduce rates of relapse, decrease self-reported opioid cravings, and increase opioid free urine 26 samples in clinical trials, and is being formulated into extended release and implantable drug 27 eluting systems to improve adherence, and 28 29 Whereas, the Drug Addiction Treatment Act of 2000 (DATA-2000) allows physicians to 30 obtain a waiver from the Narcotic Addict Treatment Act registration requirements to treat OUD 31 with Schedule III, IV, and V drugs or a combination of them (including buprenorphine); physicians 32 are eligible to prescribe buprenorphine-based medications if they pass an eight-hour course, and 33 after obtaining their current state medical license and a valid DEA registration number, they then 34 apply for a waiver, and 35 36 Whereas, the DATA-2000 law states that eligible physicians during their first year following 37 certification can treat at one time up to 30 patients, after which physicians may expand their patient 38 cap to 100, and one year thereafter physicians and qualifying other practitioners who meet certain 39 criteria can apply to increase their patient limit to 275, and 40 41 Whereas, between 2016 and 2018, there was a 175 percent increase in the number of 42 providers with buprenorphine waivers; however, as of 2018 there were still an estimated 47 percent 43 of counties in the U.S. lacking a physician with a buprenorphine waiver and physicians in the U.S. 44 cite regulations on buprenorphine prescribing as one of the barriers to their ability and willingness 45 to prescribe the medication, and 46 47 Whereas, implementing point of care initiation of buprenorphine treatment and referral 48 such as within the emergency department is hindered by factors including the buprenorphine 49 waiver and thus loses a significant setting for intervention that, when utilized, has shown to reduce 50 one-year mortality, and 51 52 Whereas, since 1995, France has allowed all registered medical doctors to prescribe 53 buprenorphine without any waivers, specific training, or licensure, and has since seen an 80 percent 54 reduction in opioid overdoses with no resultant difference in buprenorphine diversion rates 55 compared to the U.S., which has much more stringent buprenorphine prescribing policies, and 56 57 Whereas, a 2015 survey of 706 people who used opioids in San Francisco found that less 58 than one percent of those prescribed buprenorphine reported using it to get high, serving as 59 evidence of the low misuse potential of buprenorphine in the USA, and 60 61 Whereas, buprenorphine has a higher safety profile compared to commonly prescribed, full 62 opioid agonists, which physicians are able to prescribe to patients with no additional training and a 63 2015 survey of 706 people who used opioids in San Francisco found that less than one percent of 64 those prescribed buprenorphine reported using it to get high, serving as evidence of the low 65 misuse potential of buprenorphine in the U.S., and 66 67 Whereas, one-third of counties within the state of Michigan have no medication treatment 68 programs - including opioid treatment programs, buprenorphine, and naltrexone - for substance 69 use disorder available, and only 18 percent of counties in Michigan have access to OAT programs, 70 and 71 72 Whereas, as of September 2019, 2,756 Michigan practitioners - including MDs, DOs, APRNs, 73 and PAs - have obtained a waiver to prescribe buprenorphine but only 54 percent of counties in 74 Michigan had access to buprenorphine prescribers, and 75 76 Whereas, in an effort to increase treatment availability, the U.S. Department of Health and 77 Human Services (HHS) announced new guidelines in January 2021, to exempt DEA-registered 78 physicians from the waiver requirements; however, these new guidelines were rapidly halted, and 79 80 Whereas, many medical organizations including the AMA supported the new HHS 81 guidelines, and Patrice Harris, MD, Chair of the AMA's Opioid Task Force and Immediate Past 82 President, stated: "With this change, office-based physicians and physician-led teams working with 83 patients to manage their other medical conditions can also treat them for their opioid use disorder 84 without being subjected to a separate and burdensome regulatory regime," and 85 86 Whereas, experts believe that the X-waiver will continue to overregulate buprenorphine, a 87 medication with a high safety profile and low misuse potential, continue to discourage physicians 88 from prescribing it even in the midst of a worsening opioid epidemic, and continue to stigmatize 89 OUDs and disregard them as chronic medical conditions which needs evidence based medication 90 treatment, and 91 92 Whereas, in light of current legislation discussions, it is vital that all medical organizations 93 and societies have explicit policy and advocacy regarding education requirements for treatments 94 for OUD; our AMA has policy (D-95.972) that explicitly calls for the elimination of the waiver to 95 prescribe buprenorphine for the treatment of OUD but MSMS has no such policy; therefore be it

96 RESOLVED: That MSMS advocates for the elimination of the requirement for obtaining a 97 waiver to prescribe buprenorphine for the treatment of opioid use disorder; and be it further 98 99 RESOLVED: That MSMS oppose all non-evidence based barriers to the prescription of 100 medications for the treatment of opioid use disorder; and be it further 101 102 RESOLVED: That MSMS encourages all undergraduate medical institutions to incorporate 103 into their curricula education on prescribing medications to treat opioid use disorders. 104 105 106 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 107 $25,000+

Relevant MSMS Policy: None

Relevant AMA Policy:

Expanding Access to Buprenorphine for the Treatment of Opioid Use Disorder D-95.972 1. Our AMA’s Opioid Task Force will publicize existing resources that provide advice on overcoming barriers and implementing solutions for prescribing buprenorphine for treatment of Opioid Use Disorder. 2. Our AMA supports eliminating the requirement for obtaining a waiver to prescribe buprenorphine for the treatment of opioid use disorder.

Sources: 1. Center for Behavioral Health Statistics, "Results from the 2017 national survey on drug use and health: detailed tables," Rockville, MD, 2018 2. "Michigan Opioid Summary | National Institute on Drug Abuse (NIDA)." [Online]. Available: https://www.drugabuse.gov/opioid-summaries-by-state/michigan-opioid-summary [Accessed: 06-Jan- 2020] 3. A. W. Dick et al., "Growth In Buprenorphine Waivers For Physicians Increased Potential Access To Opioid Agonist Treatment, 2002-11," Health Aff., vol. 34, no. 6, pp. 1028-1034, Jun. 2015, doi: 10.1377/hlthaff.2014.1205 4. A. L. Stotts, C. L. Dodrill, and T. R. Kosten, "Opioid dependence treatment: Options in pharmacotherapy," Expert Opinion on Pharmacotherapy, vol. 10, no. 11. pp. 1727-1740, Aug-2009, doi: 10.1517/14656560903037168 5. J. D. Lee et al., "Comparative effectiveness of extended-release naltrexone versus buprenorphine- naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial," Lancet, vol. 391, no. 10118, pp. 309-318, Jan. 2018, doi: 10.1016/S0140-6736(17)32812-X 6. M. R. Lofwall et al., "Weekly and monthly subcutaneous buprenorphine depot formulations vs daily sublingual buprenorphine with naloxone for treatment of opioid use disorder a randomized clinical trial," JAMA Intern. Med., vol. 178, no. 6, pp. 764-773, Jun. 2018, doi: 10.1001/jamainternmed.2018.1052 7. R. N. Rosenthal, M. R. Lofwall, S. Kim, M. Chen, K. L. Beebe, and F. J. Vocci, "Effect of buprenorphine implants on illicit opioid use among abstinent adults with opioid dependence treated with sublingual buprenorphine a randomized clinical trial," JAMA - J. Am. Med. Assoc., vol. 316, no. 3, pp. 282-290, Jul. 2016, doi: 10.1001/jama.2016.9382 8. "MAT Statutes, Regulations, and Guidelines | SAMHSA - Substance Abuse and Mental Health Services Administration." [Online]. Available: https://www.samhsa.gov/medication-assisted-treatment/statutes- regulations-guidelines [Accessed: 06-Jan-2020] 9. "DATA-2000 law 30/100 patient limit on prescribing Suboxone (buprenorphine / naloxone) for the treatment of opioid addiction." [Online]. Available: https://www.naabt.org/30_patient_limit.cfm [Accessed: 06-Jan-2020] 10. R. L. Haffajee, A. S. B. Bohnert, and P. A. Lagisetty, "Policy Pathways to Address Provider Workforce Barriers to Buprenorphine Treatment," Am. J. Prev. Med., vol. 54, no. 6, pp. S230-S242, Jun. 2018, doi: 10.1016/j.amepre.2017.12.022 11. R. Ghertner, "U.S. trends in the supply of providers with a waiver to prescribe buprenorphine for opioid use disorder in 2016 and 2018," Drug Alcohol Depend., vol. 204, Nov. 2019, doi: 10.1016/j.drugalcdep.2019.06.029 12. W. Kissin, C. McLeod, J. Sonnefeld, and A. Stanton, "Experiences of a national sample of qualified addiction specialists who have and have not prescribed buprenorphine for opioid dependence," J. Addict. Dis., vol. 25, no. 4, pp. 91-103, Nov. 2006, doi: 10.1300/J069v25n04_09 13. G. D'Onofrio, A. Venkatesh, and K. Hawk, "The Adverse Impact of Covid-19 on Individuals with OUD Highlights the Urgent Need for Reform to Leverage Emergency Department-Based Treatment," NEJM Catal., 2020 14. M. Auriacombe, M. Fatséas, J. Dubernet, J. P. Daulouéde, and J. Tignol, "French Field Experience with Buprenorphine," American Journal on Addictions, vol. 13, no. SUPPL. 1. 2004, doi: 10.1080/10550490490440780 15. M. Fatseas and M. Auriacombe, "Why buprenorphine is so successful in treating opiate addiction in France," Current Psychiatry Reports, vol. 9, no. 5. pp. 358-364, Oct-2007, doi: 10.1007/s11920-007-0046-2 16. T. J. Cicero, PhD, H. L. Surratt, PhD, and J. Inciardi, PhD, "Use and misuse of buprenorphine in the management of opioid addiction," J. Opioid Manag., vol. 3, no. 6, p. 302, Nov. 2007, doi: 10.5055/jom.2007.0018 17. S. P. Novak, L. Wenger, J. Lorvick, and A. Kral, "The misuse, abuse and diversion of opioid replacement therapies among street abusers," Drug Alcohol Depend., vol. 146, p. e54, Jan. 2015, doi: 10.1016/j.drugalcdep.2014.09.517 18. K. Fiscella, S. E. Wakeman, and L. Beletsky, "Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder: X the X Waiver," JAMA Psychiatry, vol. 76, no. 3, pp. 229-230, Mar. 2019, doi: 10.1001/jamapsychiatry.2018.3685 19. A. Bohnert, J. Erb-Downward, and T. Ivacko, "OPIOID ADDICTION: MEETING THE NEED FOR TREATMENT IN MICHIGAN" 20. "Waiver Totals by State | SAMHSA - Substance Abuse and Mental Health Services Administration." [Online]. Available: https://www.samhsa.gov/medication-assisted-treatment/practitioner-program- data/certified-practitioners?field_bup_us_state_code_value=MI [Accessed: 06-Jan-2020] 21. D. Diamond and L. Bernstein, "Biden moving to nix Trump plan on opioid-treatment prescriptions," The Washington Post, 25-Jan-2021 22. U.S. Department of Health and Human Services, "HHS Expands Access to Treatment for Opioid Use Disorder," Jan. 2021 23. L. Kuntz, "Dropping the X-Waiver for Buprenorphine," Psychiatric Times, 18-Jan-2021

1 RESOLUTION 26-21 2 3 Title: Decarceration During an Infectious Disease Pandemic 4 5 Introduced by: Sanjay Das, for the Medical Student Section 6 7 Original Authors: Jennifer Byk, Arjun Chadha, Moustafa Hadi, Jessyca Judge, Man Yee Keung, 8 Remonda Khalil, Darian Mills, Chan Nguyen, Melanie Valentin, Will Vander 9 Pols, and Francis Yang 10 11 Referred To: Reference Committee B 12 13 House Action: 14 15 16 Whereas, the United States has the highest incarceration rate in the world, with nearly 700 17 prisoners per 100,000 people and Michigan has an incarceration rate of 641 per 100,000 people, 18 including prisons, jails, immigration detention, and juvenile justice facilities, and 19 20 Whereas, the 2018 Bureau of Justice Statistics estimates that of the number of people 21 incarcerated in local jails per 100,000 people in each racial or ethnic category, incarceration rates 22 are much higher in Black individuals (592) compared to other racial/ethnic categories: American 23 Indian (401), White (187), Hispanic (182), Other (50), and Asian (26), and 24 25 Whereas, the 2017 Bureau of Justice Statistics estimates that the pretrial jail population has 26 disproportionately affected Black and Hispanic populations and nearly doubled in the past 15 27 years, and 28 29 Whereas, as of December 2020, confirmed case rates of COVID-19 in United States prisons 30 were 3.7 times higher than the national confirmed case rate, and case fatality rate was double what 31 was expected given the age, gender, and race/ethnicity of the prison population, and 32 33 Whereas, 61 percent of Michigan's prison population has tested positive for COVID-19, 34 while only 6.2 percent of Michigan's general population has tested positive for COVID-19, and 35 36 Whereas, inmates are discouraged from reporting symptoms due to penal measures aimed 37 at limiting spread of infectious agents, thus contributing to further spread of infectious agents, and 38 39 Whereas, high rates of preexisting health conditions and limited access to quality health 40 care exacerbate the impact of COVID-19 in incarceration systems, and inability to social distance 41 due to crowding in prisons prevents compliance with infection prevention protocols, and 42 43 Whereas, as of May 1, 2020, Michigan prisons were operating at 94 percent capacity, 44 making it difficult for safety protocols to be followed, and 45 46 Whereas, a 2020 report from a consensus panel of the National Academy of Sciences, 47 Engineering, and Medicine recognized that reducing the size of the incarcerated population could 48 help increase the penetration and effectiveness of standard prevention measures in jails and 49 prisons, such as testing, quarantining, and medical isolation for those who remain, and 50 51 Whereas, decarceration is not associated with an increase in crime, as the states of New 52 York and Connecticut have cut their overall prison and jail populations in half since reaching their 53 peak population levels, and have since had crime rates below the national average, and 54 55 Whereas, nearly every major city in the United States which decreased jail population in 56 response to COVID-19 experienced no subsequent increase in crime, and 57 58 Whereas, individuals older than 55 years are at low risk of reincarceration and are at high 59 risk of severe complications and mortality due to COVID-19, and 60 61 Whereas, rates of incarceration have decreased approximately 11 percent as a result of 62 restricted admission and expedited release of pre-trial detainees to reduce overall prison capacity 63 in coordinated efforts to curb impact of COVID-19 on prison health systems, and 64 65 Whereas, compassionate release, a legal provision that allows people with terminal illnesses 66 to be released before their sentences have been served, could be a lever for protecting many high- 67 risk patients from harm, as clinicians can assist by providing medical attestations to the release of 68 individual patients during COVID-19 and future pandemics, and 69 70 Whereas, as recommended by the American Bar Association, directive MCL-801.51a allowed 71 the compassionate release of inmates in Michigan county jails; therefore be it 72 73 RESOLVED: That MSMS support reducing the incarcerated population during an infectious 74 disease pandemic by way of restricted admission of pre-trial detainees, expedited release of pre- 75 trial detainees, and compassionate release of individuals at low risk of reincarceration. 76 77 78 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 79 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy:

Compassionate Release for Incarcerated Patients H-430.980 Our AMA supports policies that facilitate compassionate release for incarcerated patients on the basis of serious medical conditions and advanced age; will collaborate with appropriate stakeholders to develop clear, evidence-based eligibility criteria for timely compassionate release; and promote transparent reporting of compassionate release statistics, including numbers and demographics of applicants, approvals, denials, and revocations, and justifications for decisions.

Support Public Health Approaches for the Prevention and Management of Contagious Diseases in Correctional and Detention Facilities H-430.979 1. Our AMA, in collaboration with state and national medical specialty societies and other relevant stakeholders, will advocate for the improvement of conditions of incarceration in all correctional and immigrant detention facilities to allow for the implementation of evidence-based COVID-19 infection prevention and control guidance. 2. Our AMA will advocate for adequate access to personal protective equipment and SARS-CoV-2 testing kits, sanitizing and disinfecting equipment for correctional and detention facilities. 3. Our AMA will advocate for humane and safe quarantine protocols for individuals who are incarcerated or detained that test positive for or are exposed to SARS-CoV-2, or other contagious respiratory pathogens. 4. Our AMA supports expanded data reporting, to include testing rates and demographic breakdown for SARS-CoV-2 and other contagious infectious disease cases and deaths in correctional and detention facilities. 5. Our AMA recognizes that detention center and correctional workers, incarcerated persons, and detained immigrants are at high-risk for COVID-19 infection and therefore should be prioritized in receiving access to safe, effective COVID-19 vaccine in the initial phases of distribution, and that this policy will be shared with the Advisory Committee on Immunization Practices for consideration in making their final recommendations on COVID-19 vaccine allocation.

Health Care While Incarcerated H-430.986 1. Our AMA advocates for adequate payment to health care providers, including primary care and mental health, and addiction treatment professionals, to encourage improved access to comprehensive physical and behavioral health care services to juveniles and adults throughout the incarceration process from intake to re-entry into the community. 2. Our AMA supports partnerships and information sharing between correctional systems, community health systems and state insurance programs to provide access to a continuum of health care services for juveniles and adults in the correctional system. 3. Our AMA encourages state Medicaid agencies to accept and process Medicaid applications from juveniles and adults who are incarcerated. 4. That our AMA encourage state Medicaid agencies to work with their local departments of corrections, prisons, and jails to assist incarcerated juveniles and adults who may not have been enrolled in Medicaid at the time of their incarceration to apply and receive an eligibility determination for Medicaid. 5. Our AMA encourages states to suspend rather than terminate Medicaid eligibility of juveniles and adults upon intake into the criminal justice system and throughout the incarceration process, and to reinstate coverage when the individual transitions back into the community. 6. Our AMA urges Congress, the Centers for Medicare & Medicaid Services (CMS), and state Medicaid agencies to provide Medicaid coverage for health care, care coordination activities and linkages to care delivered to patients up to 30 days before the anticipated release from adult and juvenile correctional facilities in order to help establish coverage effective upon release, assist with transition to care in the community, and help reduce recidivism. 7. Our AMA advocates for necessary programs and staff training to address the distinctive health care needs of incarcerated women and adolescent females, including gynecological care and obstetrics care for pregnant and postpartum women. 8. Our AMA will collaborate with state medical societies and federal regulators to emphasize the importance of hygiene and health literacy information sessions for both inmates and staff in correctional facilities. 9. Our AMA supports: (a) linkage of those incarcerated to community clinics upon release in order to accelerate access to comprehensive health care, including mental health and substance abuse disorder services, and improve health outcomes among this vulnerable patient population, as well as adequate funding; and (b) the collaboration of correctional health workers and community health care providers for those transitioning from a correctional institution to the community.

Sources: 1. The Sentencing Project. Criminal Justice Facts. https://www.sentencingproject.org/criminal-justice-facts/ Published September 2, 2020. Accessed February 12, 2021 2. Prison Policy Initiative. Michigan profile. https://www.prisonpolicy.org/profiles/MI.html Published 2021. Accessed February 12, 2021 3. Sawyer W. Visualizing the racial disparities in mass incarceration. Prison Policy Initiative. https://www.prisonpolicy.org/blog/2020/07/27/disparities/ Published July 27, 2020. Accessed February 12, 2021 4. Schnepel KT. COVID-19 in U.S. State and Federal Prisons. National Commission on Covid-19 and Criminal Justice. https://cdn.ymaws.com/counciloncj.org/resource/resmgr/covid_commission/COVID- 19_in_State_and_Federa.pdf Published December 2020. Accessed February 9, 2021 5. Michigan Department of Correction (MDOC) takes steps to prevent the spread of coronavirus (COVID- 19). MI Department of Correction. Medium. https://medium.com/@MichiganDOC/mdoc-takes-steps-to- prevent-spread-of-coronavirus-covid-19-250f43144337 Published February 12, 2021. Accessed February 14, 2021 6. Michigan Data - Coronavirus. State of Michigan. https://www.michigan.gov/coronavirus/0,9753,7-406- 98163_98173---,00.html Accessed February 14, 2021 7. Manson J. History Teaches Us That When Viruses Come to Prisons, Punishment Is Not the Answer. The Appeal. https://theappeal.org/coronavirus-prisons-punishment-solitary-confinement/ Published March 23, 2020. Accessed February 10, 2021 8. Henry BF. Social Distancing and Incarceration: Policy and Management Strategies to Reduce COVID-19 Transmission and Promote Health Equity Through Decarceration - Brandy F. Henry, 2020. SAGE Journals. https://journals.sagepub.com/doi/full/10.1177/1090198120927318 Published May 10, 2020. Accessed February 10, 2021 9. Prison Policy Initiative. Since you asked: Just how overcrowded were prisons before the pandemic, and at this time of social distancing, how overcrowded are they now? Prison Policy Initiative. https://www.prisonpolicy.org/blog/2020/12/21/overcrowding/ Accessed February 12, 2021 10 Wang EA, Western B, Berwick DM. COVID-19, Decarceration, and the Role of Clinicians, Health Systems, and Payers. JAMA. 2020;324(22):2257. doi:10.1001/jama.2020.22109 11. Franco-Paredes C, Ghandnoosh N, Latif H, et al. Decarceration and community re-entry in the COVID-19 era. The Lancet Infectious Diseases. 2021;21(1). doi:10.1016/s1473-3099(20)30730-1 12. ACLU News & Commentary. American Civil Liberties Union. https://www.aclu.org/news/smart- justice/decarceration-and-crime-during-covid-19/ Accessed February 12, 2021 13. Macmadu A, Berk J, Kaplowitz E, Mercedes M, Rich JD, Brinkley-Rubinstein L. COVID-19 and mass incarceration: a call for urgent action. The Lancet Public Health. 2020;5(11). doi:https://doi.org/10.1016/S2468-2667(20)30231-0 14. Emergency Release from Jails and Prisons during COVID-19 and Coronavirus. Springstead Bartish Borgula and Lynch. https://www.springsteadbartish.com/blog/emergency-release-from-jails-and-prisons-during- covid-19-and-coronavirus/ Published January 4, 2021. Accessed February 12, 2021 15. Federal Compassionate Release in the Era of COVID-19: Practice Tips. American Bar Association. https://www.americanbar.org/groups/litigation/committees/criminal/articles/2020/winter2021-federal- compassionate-release-in-the-era-of-covid-19-practice-tips/ Published December 11, 2020. Accessed February 12, 2021.

ACTION REPORT #01-21 OF THE BOARD OF DIRECTORS

SUBJECT: Resolution 50-20 Remove Clinic-Specific Caps on Buprenorphine

REFERRED TO: Reference Committee B

HOUSE ACTION:

RECOMMENDATION: That the 2021 House of Delegates approve Resolution 50-20, “Remove Clinic-Specific Caps on Buprenorphine,” as amended to read:

RESOLVED: That MSMS oppose state legislation that attempts to limit the prescription of medication for opioid use disorder beyond those regulations set forth by federal laws; and be it further

RESOLVED: That MSMS advocate the Michigan Bureau of Community and Health System Substance Use Disorder Service Programs Administrative Rules be amended to remove the cap on the number of patients receiving buprenorphine or naltrexone prescriptions from a single site or group practice as a condition of licensure and instead rely on appropriate federal guidelines for the safe and effective provision of Substance Use Disorder services.

Resolution 50-20 was referred to the MSMS Board of Directors for study. The Board referred the resolution to the Committee on State Legislation and Regulations for review and recommendation.

Resolution 50-20 asked that “MSMS oppose state legislation that attempts to limit the prescription of medication for opioid use disorder beyond those regulations set forth by federal laws; and that MSMS advocate the Michigan Bureau of Community and Health System Substance Use Disorder Service Programs Administrative Rules be amended to remove the cap on the number of patients receiving buprenorphine prescriptions from a single site or group practice as a condition of licensure.”

Resolution 50-20 was introduced in response to concerns regarding the adoption of Michigan Administrative Rules governing substance use disorder programs. Under these rules, individuals or individuals in group practices who provide buprenorphine or naltrexone treatment to more than 100 individuals at any one time at a specific property

(continued) Action Report #01-21, “Resolution 50-20” - 2

must apply for a substance use disorder service program license. Licensure triggers additional requirements under the rules that would be difficult to meet for most physician group practices. The authors of the Resolution argue the 100 individual cap or threshold is a deterrent to increased access to buprenorphine prescribing as medically necessary for persons diagnosed with opioid use disorder.

Therefore, Resolution 50-20 directs MSMS to 1) oppose any legislative attempts to impose limits on the prescription of medication for opioid use disorder beyond those regulations set forth by federal laws, and 2) to advocate for the removal of the 100 individual cap/threshold in the Administrative Rules so that medical practice groups can manage their patients in need of MAT without having to be licensed.

The Administrative Rule prompting the introduction of Resolution 50-20 is as follows:

R 325.1303 Application; licensing requirement; review process; licensure. Rule 1303. (1) As authorized in article 6 of the public health code and chapter 2a of the mental health code, MCL 330.1260 to 330.1287, an application for initial licensure or licensure change, including change in ownership, relocation of the program, addition or deletion of service levels, change in bed or RDT positions, shall be made on the most recent applicable form authorized and provided by the department. (2) A person offering substance use disorder services shall be licensed under article 6 of the public health code, except as provided in subrule (3) or (4) of this rule. (3) A substance use disorder services program license is not required for an individual licensed under article 15 of the public health code to provide psychological, medical, or social services if all of the following are met: (a) An individual is offering psychological, medical, or social services within the scope of his or her individual professional license and not under a group or organization offering substance use disorder services, unless exempt under subdivision (c) of this subrule. (b) An individual is offering psychological or medical services and not providing methadone treatment. Methadone treatment requires a license under article 6 of the public health code, for the group or organization, not for the individual licensed under article 15 of the public health code. (c) An individual, or individuals in a group practice, is offering psychological or medical services and does not provide buprenorphine or naltrexone treatment to more than 100 individuals at any 1 time at a specific property. As a result of not meeting subdivision (c) of this subrule, a license shall be maintained until the licensee can demonstrate to the satisfaction of the department that the specific property will only provide treatment equal to or less than 100 unique recipients at any 1 time for each of the next 2 consecutive calendar years.

(continued) Action Report #01-21, “Resolution 50-20” - 3

The Administrative Rules in question were updated by the Michigan Department of Licensing and Regulatory Affairs (LARA) a few years ago. LARA has acknowledged that the Rules have created some unintended consequences and intends to revise the rules.

In recommending referral to the Board of Directors, the Reference Committee indicated it was supportive of the intent of this resolution. However, the issues surrounding the administrative rules versus the legislation referred to in the first Resolved, as well as a discussion around removing or increasing the cap, led the Committee to decide additional expertise was needed. The MSMS Committee on State Legislation and Regulations considered Resolution 50-20 at its meeting on February 2, 2021. One of the Resolution’s authors was present and provided the Committee with the rationale for introduction and the related “asks” of MSMS. After much discussion, the Committee agreed the first Resolved should remain as currently written, but the second Resolved should be amended to clarify MSMS advocate Michigan’s Administrative Rules for substance use disorder programs should be consistent with federal guidelines.

The Committee on State Legislation and Regulations unanimously approved a motion to support Resolution 50-20, as amended

At its virtual meeting on Wednesday, March 31, 2021, the MSMS Board of Directors approved the recommendation of the Committee on State Legislation and Regulations to approve Resolution 50-20, as amended.

Attachment Resolution 50-20

(continued)

MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES

RESOLUTIONS BY COMMITTEE

REFERENCE COMMITTEE C – INTERNAL AFFAIRS AND BYLAWS

RESOLUTION DESCRIPTION 04-21 Dissemination of Information to County Medical Societies 13-21 Upholding the Integrity and Vitality of the State and County Medical Societies 20-21 Designated Directors Serving as Chair of the MSMS Board of Directors

BOARD ACTION DESCRIPTION REPORT #2-21 Revisions to the MSMS Policy Manual and the 2021 Sunset Policy

1 RESOLUTION 04-21 2 3 Title: Dissemination of Information to County Medical Societies 4 5 Introduced by: Joseph Wilhelm, MD, for the Ingham County Delegation, Christopher J. Allen, 6 MD, for the Saginaw County Medical Society, and Evelyn Eccles, MD, for the 7 Washtenaw County Delegation 8 9 Original Author: Christopher J. Allen, MD 10 11 Referred To: Reference Committee C 12 13 House Action: 14 15 16 Whereas, the County Medical Societies (CMS) are duly chartered component societies of 17 MSMS, and membership is required in CMS and MSMS, and 18 19 Whereas, over time, MSMS has retained the statewide database of members and 20 nonmembers (including nonpaid members, physicians who have moved, and the deceased) as it 21 hosts the online membership platform and database, CRM, and 22 23 Whereas, the CMS are tasked with maintaining a roster of members, but the majority of 24 CMS do not maintain an independent electronic database of members and nonmembers as MSMS 25 hosts a comprehensive, statewide version, and 26 27 Whereas, the CMS have previously used this shared information exclusively for official 28 membership business including the verification of membership and to aid MSMS in recruitment 29 and retention efforts, and 30 31 Whereas, CMS and MSMS work hand-in-hand in providing services to their physician and 32 medical student members, and 33 34 Whereas, MSMS ceased providing statewide membership information to CMS stating the 35 practice was not in compliance with MSMS Bylaws and policies beginning in October 2020, and 36 37 Whereas, MSMS began citing a Website Privacy Policy Information Sharing and Disclosure 38 policy in February 2021, noting the prohibition of the release of this information to CMSs moving 39 forward, and 40 41 Whereas, the Information and Sharing Disclosure states “the Michigan State Medical Society 42 is committed to protecting your personal information. We will not disclose your personally 43 identifiable information to third parties without your consent,” and

44 Whereas, the newly cited MSMS policy suggests CMS are “third parties” and not component 45 partners in unified membership efforts; therefore be it

46 RESOLVED: That MSMS amend its Website Privacy Policy Information Sharing and 47 Disclosure policy to affirm the County Medical Societies as component societies, and continue the 48 transparent process of providing member and nonmember information to the Secretary and 49 Executive Director/Administrator, if applicable, of the duly chartered County Medical Societies as 50 requested without regard to the members’ or nonmembers’ county of origin; and be it further 51 52 RESOLVED: That any membership or information sharing policy shall be discussed and 53 approved with the County Medical Societies and/or the House of Delegates before implementation 54 or finalization moving forward. 55 56 57 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 58 or AMA policy - $500

STATEMENT OF URGENCY: The Saginaw, Ingham, and Washtenaw County Medical Society Delegations and Boards of Directors affirm this resolution is important and needs immediate action by the House of Delegates. In order for the county medical societies to survive, thrive and serve their members, it is imperative the county medical societies receive the requested information from MSMS which has been available to the county medical societies in the past, but has been withheld by MSMS for various unsubstantiated reasons as dictated by MSMS. The county medical societies are trusted partners, not third parties, and work hand-in-hand with MSMS to provide services to our dual members. The requested information is also needed to maintain and ensure the integrity and transparency of both the county medical societies and MSMS. The 2018 and 2019 HOD voted to maintain unification of MSMS and the county medical societies, therefore, the HOD needs to address the issue of MSMS staff withholding necessary information from the counties which is needed to maintain that unification.

Relevant MSMS Policy: Over the past year, MSMS has deployed several strategies to address issues raised by county medical societies regarding state society operations and procedures relative to membership, advocacy, communications and the House of Delegates. Those strategies include weekly (spring 2020) and then bi- weekly (summer 2020) virtual meetings between the MSMS CEO and county society staff, monthly meetings between MSMS departmental heads and county society staff (which have been ongoing since 2010), and a facilitator-led series of meetings to research state and county perspectives and host a series of meetings to work through how various issues will be handled going forward. The consultant work is ongoing, and the topic raised in this resolution has been part of that process. In addition, county concerns have been discussed broadly at MSMS Board meetings, the Chair and Vice Chair hosted a virtual meeting with Regional Directors representing five counties raising concerns, and the MSMS Executive Committee has also met to support strategies to establish best practices between state and county going forward.

MSMS Website Privacy Policy: At the Michigan State Medical Society, we believe anyone who uses the Internet should be fully aware of how their information is used, and are committed to doing business with the highest ethical standards. The following Privacy Policy outlines how the Michigan State Medical Society gathers and utilizes various sources of information obtained during your visit to www.msms.org, and handles your data.

Definitions: "Non-Personal Information" is information that is in no way personally identifiable and that is obtained automatically through your use of the Site with a Web browser. "Personally Identifiable Information" is non-public information that is personally identifiable and obtained in connection with providing a product or service to you. It may include information such as name and address. Information collected: When you enter the Site, we collect Non-Personal Information, such as your browser type and IP address. Likewise, in order to offer you meaningful products and services and for other reasons, we may collect personally identifiable Information about you from the following sources: Information you give us on applications or other forms on the Site; or Information you send us via any medium, including, but not limited to email, telephone, and social media interaction. If you are a non-registered visitor to the Site, the only information we collect will be Non-Personal Information through the use of cookies and/or pixels. Information you provide to third-party websites is not within the control of the Michigan State Medical Society and you provide such information at your own risk. The terms and conditions of use and the privacy policies of those websites that you provide information to will govern their use of such information.

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Managing Cookies: Most browser software can be set to reject cookies. If you'd prefer to restrict, block or delete cookies from www.msms.org or any other website, you can use your browser to do this. Each browser is different; so check the 'Help' menu of your particular browser to learn how to change your Cookie preferences. Alternatively, you can opt out of a third-party vendor's use of cookies by visiting the Network Advertising Initiative opt-out page. Please keep in mind that if cookies aren’t enabled, certain functionality on the Site may not work properly and your experience may be limited.

Information Sharing And Disclosure: The Michigan State Medical Society is committed to protecting your personal information. We will not disclose your personally identifiable information to third parties without your consent.

Relevant AMA Policy: None

1 RESOLUTION 13-21 2 3 Title: Upholding the Integrity and Vitality of the State and County Medical 4 Societies 5 6 Introduced by: Narasimha Gundamraj, MD, for the Ingham County Delegation, Christopher 7 J. Allen, MD, for the Saginaw County Delegation, and Evelyn Eccles, MD, for 8 the Washtenaw County Delegation 9 10 Original Author: Evelyn Eccles, MD 11 12 Referred To: Reference Committee C 13 14 House Action: 15 16 17 Whereas, MSMS and county medical societies are and always have been interdependent, 18 but supported by separate dues structures, and 19 20 Whereas, the health of MSMS depends in large part on the health of the county medical 21 societies, which provide grassroots input, mentorship, coordination, education, leadership, and 22 23 Whereas, physician and medical student members are best served when linked to leaders 24 within their respective local, component society communities, and 25 26 Whereas, physicians that live in areas where there is no active, staffed county medical 27 society have been allowed to become members of MSMS, and 28 29 Whereas, this practice could create an incentive for physicians and/or medical students 30 and/or physician groups regardless of where they live or work to join unstaffed counties or 31 counties without membership dues to reduce their cost, and 32 33 Whereas, this option is potentially disruptive and harmful to the integrity and vitality of the 34 county medical societies and MSMS, and 35 36 Whereas, the 2019 MSMS House of Delegates overwhelmingly approved continued 37 membership unification between MSMS and the county medical societies via the amended Final 38 MSMS Organizational Remodeling Recommendations, as well as disapproval of Resolution 63-19, 39 and 40 41 Whereas, the MSMS Board of Directors considered and approved a motion at the October 42 2020, Board meeting interpreting the bylaws stating, “that the MSMS Board of Directors 43 acknowledge MSMS Legal Counsel’s interpretation that the MSMS Bylaws do not expressly require 44 a physician to live or work in a county in order to hold membership in that county medical society,” 45 and 46 47 Whereas, the county medical societies have become aware of physician(s) and/or physician 48 group(s) that belong to counties in which they potentially do not live and/or work prior to the 49 October 2020, MSMS Board or Directors motion and approval and subsequently since, and 50 51 Whereas, the county medical societies have requested and received membership roster(s) 52 within their districts and/or regions previously, but have been informed by MSMS that this is not in 53 accordance with MSMS Bylaws and policies since October 2020; therefore be it 54 55 RESOLVED: That the county medical societies and MSMS work as committed partners to 56 uphold the county medical societies and MSMS shared integrity and vitality, as previously approved 57 by the House of Delegates; and be it further 58 59 RESOLVED: That the current MSMS state-wide membership roster shall be audited and the 60 results shall be distributed to the county medical societies and the 2022 MSMS House of Delegates 61 to evaluate the extent of the October 2020 bylaws interpretation; and be it further 62 63 RESOLVED: That any recruitment and/or retention practice by MSMS, vendors and/or 64 support subsidiaries, and/or county medical societies supported by the October 2020 bylaws 65 interpretation that serves to undermine the integrity and vitality of the medical societies end; and 66 be it further 67 68 RESOLVED: That moving forward, all physician and medical student members join the 69 county where they live or work, unless there is written agreement due to mutually agreed upon 70 exception between the medical student, physician and/or physician group, MSMS, and the 71 respective county(ies). 72 73 74 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 75 or AMA policy - $500

STATEMENT OF URGENCY: The membership practice was considered and approved within the last year and the consequences are currently unknown. The HOD should review and remedy this practice before the 2022 membership dues cycle begins.

Advise Physicians Regarding the Importance of Organized Medicine MSMS advocates educating Michigan physicians regarding the value of membership in their respective county medical societies, MSMS and the AMA. (Res17-96A)

Relevant AMA Policy: None

Sources: 1. https://www.msms.org/About-MSMS/News-Media/overview-of-the-2019-msms-house-of-delegates 2. https://www.msms.org/hodresolutions/2019/63.pdf 3. Source: January 14, 2021 MSMS Board of Directors Meeting Packet

1 RESOLUTION 20-21 2 3 Title: Designated Directors Serving as Chair of the MSMS Board of Directors 4 5 Introduced by: Betty S. Chu, MD, MBA 6 7 Original Author: Betty S. Chu, MD, MBA 8 9 Referred To: Reference Committee C 10 11 House Action: 12 13 14 Whereas, the MSMS House of Delegates amended its bylaws in 2019 to create a new 15 category of representatives on the MSMS Board of Directors, titled Designated Directors, and 16 17 Whereas, the purpose of the Designated Director was to represent specific physician 18 constituencies and perspectives based on current physician demographics, and 19 20 Whereas, the House of Delegates overwhelmingly supported the addition of these seats to 21 complement the Regional Directors that constitute the vast majority of seats on the MSMS Board 22 of Directors, and 23 24 Whereas, the House of Delegates forms a Nominating Committee, composed of delegates 25 from each of the nine regions, to review candidates for each of the Designated Director categories 26 to ensure the candidates presented are the most qualified and reflect the diversity of the Society’s 27 membership, and 28 29 Whereas, the House of Delegates has the final authority to elect candidates for the 30 Designated Director, and 31 32 Whereas, the current Designated Directors approved by the House of Delegates include 33 representatives from a physician organization, health system, independent small practice, 34 government/public health, designated institutional officer/graduate medical education, and an 35 at-large member, and 36 37 Whereas, the contribution of these House-elected Designated Directors has already proven 38 to be beneficial to the work of the MSMS Board, and 39 40 Whereas, allowing Designated Directors to be candidates to chair MSMS Board Committees, 41 which are elected by the Board annually, would expand the choice of qualified candidates that 42 could serve in Board leadership; therefore be it 43 44 RESOLVED: That the MSMS Bylaws be amended as follows. Deletions are indicated by 45 strikethroughs, additions are indicated in bold type. 46 47 14.10 ORGANIZATION—The Board of Directors is the executive body of the Society. 48 Subject only to the following, it shall determine the times and places of its meetings. 49 At its first meeting immediately following the Annual Session of the House of 50 Delegates, the Board of Directors shall elect Secretary and Treasurer, who shall serve 51 for a term of office of one year or until a successor is elected and takes office. At 52 the same meeting, the Board of Directors shall elect a Chair, a Vice-Chair, a Chair of 53 the Finance Committee, a Chair of the Health Care Delivery Committee, a Chair of 54 the Legislative Policy Committee, and a Chair of the Scientific and Educational Affairs 55 Committee, who shall be duly elected Regional Directors or Designated Directors, 56 each to take office immediately and to serve for a term of one year or until a 57 successor is elected and takes office. 58 59 60 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 61 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy: None

ACTION REPORT #02-21 OF THE BOARD OF DIRECTORS

SUBJECT: Revisions to the MSMS Policy Manual and the 2021 Sunset Policy

REFERRED TO: Reference Committee C

HOUSE ACTION:

RECOMMENDATION: That the 2021 MSMS House of Delegates approve the additions to the MSMS Policy Manual and the 2021 Sunset report. Upon House approval, the updates will be placed in the Policy Manual on the MSMS website.

The MSMS Policy Manual Review Committee met virtually on February 15, 2021, to review existing policy slated for review pursuant to the MSMS sunset policy; reviewed the 2020 House of Delegates Resolutions and Board Action Reports, as well as the MSMS Board Actions from January through October 2020.

At its virtual meeting on Wednesday, March 31, 2021, the MSMS Board of Directors approved the revisions to the MSMS Policy Manual and the 2021 Sunset Report and that upon House approval the updates will be placed in the Policy Manual on the MSMS website.

Attachments MSMS Policy Manual Updates Addendum S 2021 Sunset Report

Policy Manual Addendum to the 2020 Edition

END OF LIFE CARE (See also: Long-Term Care; Pain Management) Hospice Care and the “Adult Failure to Thrive” Diagnosis MSMS endorses working with the Michigan Home Care and Hospice Association to broaden the diagnosis and/or hospice admission criteria to encourage more focus on the patient’s prognosis and decline in functional status rather than on the primary diagnosis. (Board Action Report #05, 2020 HOD, re Res68-19)

ETHICS (See also: Discrimination; End of Life Care) Bioethics Forced Organ Harvesting MSMS denounces the practice of forced organ harvesting and programs and policies that assist with the education and research of anyone who participates in organ transplant programs in a country where forced organ harvesting is practiced. (Board Action Report #02, 2020 HOD, re Res52-19)

HEALTH INFORMATION TECHNOLOGY Anonymous Prescribing Option for Expedited Partner Therapy MSMS recommends that electronic medical records have the capability of providing an anonymous prescribing option for the purpose of expedited partner therapy. (Res43-20)

MENTAL HEALTH (See also: Health Care Insurance; Managed Care; Medical Education and Training)) Inter-Facility Transfers of Patients with Serious Mental Illness MSMS believes community mental health agencies and hospital administrators should, at all times, respect the Emergency Medical Treatment and Labor Act regarding inter-facility transfers of patients with serious mental illness. (Res38-20) Involuntary Hospitalization MSMS supports appropriate modification of the Michigan Mental Health Code in order to make involuntary hospitalization more rapidly accessible for mentally ill persons requiring such intervention for the benefit of their safety and the safety of others. (Prior to 1990) -Reaffirmed Res38-20 Behavioral Health Integration Guiding Principles MSMS supports the Behavioral Health Integration Guiding Principles listed in Addendum S. (See Addendum S in website version) (Board-March2020)

QUALITY ASSURANCE AND PATIENT SAFETY

1 Oppose Criminalization of Physicians and Patients for Evidence Based Standard of Medical Care MSMS opposes the criminalization of a procedure and prosecution of physicians for delivering evidence-based standard of medical care, as well as for refusing to engage in care that is neither safe nor evidence based. (Res41-20)

SUBSTANCE USE AND ADDICTION Access to Opioid Agonist Treatment for Incarcerated Persons MSMS recommends the availability of all types of opioid agonist treatment for opioid use disorder, as well as a validated screening tool to identify withdrawal and determine potential need for treatment for opioid use disorder, for incarcerated persons in Michigan. (Res47-20)

2 Addendum S

Behavioral Health Integration Guiding Principles

MSMS supports the following Behavioral Health Integration Guiding Principles: 1. Whole-person collaborative care across all elements of the health care system is prioritized and supported by training, payment, and care delivery addressing physical, behavioral, and social health together. 2. Efforts to improve behavioral health services address stigma, cultural competency, and disparities. 3. Behavioral health integration efforts support improved patient care, improved patient experience, improved provider experience, and improved cost of care efficiencies. 4. People receive the care they need at the place and time that is right for them. 5. Behavioral health services are covered equally with physical health services. 6. Mental health (including substance use) early intervention is encouraged and routinely available to persons of all ages including, children and adolescents, prior to any functional decline. Screening using valid instruments is supported through outreach and education, availability of screening tools, reimbursement, and infrastructure supporting screening follow up. 7. Promotion of clinical models across the spectrum of symptoms and continuum of care that recognize the importance of: a. Physician leadership in team-based care. b. Integrating physical and behavioral health, such as that achieved by the collaborative care model. c. Access to outpatient and inpatient psychiatric services and related therapies. d. Clinician care delivery from primary care through behavioral health through enhanced communication and administrative simplification. e. Individualized care plans that identify and address both physical and behavioral health needs, as well as social determinants which may affect health outcomes. f. The role of telepsychiatry and telehealth. g. Eliminating fragmentation in funding and contracting for physical and behavioral health services. h. Acknowledging that patients move across the severity continuum. 8. Core components of effective clinical models include, but are not limited to, patient identification and engagement, patient education and self-management support, medication management and psychotherapy as clinically indicated, team-based care management, systematic follow-up, and effective consultation and supervision for patients who are not improving as expected. 9. Mental health (including substance use conditions), health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress- related physical symptoms, and ineffective patterns of health care utilization are recognized and addressed at all levels of care. 10. Treatment and services are consistent with standards of care and evidence-based when there is credible research evidence to support their efficacy . 11. Primary care provider (PCP) and Community Mental Health (CMH) Agency communication and collaboration on mutual patients recognizes the PCP to be central in the referral process for specialty or subspecialty mental health care through CMH and provides standing to appeal an adverse determination. 12. Specialty physicians, in coordination with primary care, have the ability to refer their patients for behavioral health care. 13. Governmental programs and all payers support interdepartmental coordination and shared accountability, as well as greater access to timely outpatient treatment, crisis intervention, specialty behavioral health services, inpatient psychiatric hospitalizations, and other medically necessary related therapies on par with non-psychiatric conditions. 14. Billing and coding policies enable physicians, psychiatrists regardless of setting, and other health care providers to be reimbursed for providing team-based integrated care that includes screening, case management, consultation, and other related care. Policies and procedures for referrals, consultations and follow-up are uniform regardless of whether related to physical or behavioral health concerns. 15. Payment for behavioral health care is reflective of the value of care delivered (e.g., total cost of care), not just the volume of care provided. 16. Workforce needs are identified across the continuum of care in order to develop policies and programs supporting team-based care based on individualized patient needs and choices. 17. The sharing of confidential, accurate and timely care documentation between health care providers is supported by useable and interoperable health information technology.

(Created by the MSMS Behavioral Health Integration Task Force and adopted by the MSMS Board of Directors on March 25, 2020.)

Sunset Report to 2021 MSMS House of Delegates

At its 2018 Annual Meeting, the Michigan State Medical Society (MSMS) House of Delegates (HOD) established a sunset mechanism for House policies (Resolution 14-18, “Sunset Mechanism MSMS Policy”). Pursuant to this mechanism, a policy established by the HOD ceases to be viable after 10 years unless action is taken by the HOD to retain it.

The objective of the sunset mechanism is to help ensure the MSMS Policy Manual is current, coherent, and relevant. By eliminating outmoded, duplicative, and inconsistent policies, the sunset mechanism contributes to the ability of MSMS to communicate and promote its policy positions, as well as contributes to the efficiency and effectiveness of HOD deliberations.

The MSMS Committee to Review the MSMS Policy Manual recommends that the House of Delegates policies listed in this report be acted upon in the manner indicated and the remainder of the report be filed.

Policy Year Recommendation Educational Activities Addressing Needs of the Elderly MSMS supports, through existing MSMS committees and Prior to 1990 Retain, policy is still relevant. programs, educational activities addressing the special medical, social and economic needs of the elderly. Improving Medical Care in Extended Care Facilities MSMS supports a requirement for a qualified medical director in every skilled nursing home facility and encourages physicians to Prior to 1990 Retain, policy is still relevant. continue the care of their patients either directly or by delegation following admission to long term care facilities. Prevention of Elderly Abuse Retain, policy is still relevant, and modify to read as follows: MSMS urges implementation of current statutes that require providers of health services to report cases of abuse, neglect or Prevention of Elderly Abuse exploitation of the elderly to the Michigan Department of Prior to 1990 MSMS supports mandatory reporting of cases of abuse, neglect, or Community Health, and urges the provision of appropriate exploitation of the elderly to the appropriate state department by providers immunity from legal action for those who report such cases in of health services. MSMS believes providers of health care who report such good faith.o cases in good faith should have appropriate immunity from legal action. Policy Year Recommendation Appropriate End of Life Therapy MSMS will continue to work at all levels for improved pain management and symptom control. MSMS will continue education on recognition of depression and its adequate therapy. Res94-97A Retain, policy is still relevant. MSMS will continue to promote advance directives. MSMS will continue support for hospice including education about hospice and the use of hospice care. Clergy Involvement with the Terminally Ill MSMS encourages the inclusion of the clergy in providing care for the terminally ill and in meetings and discussions throughout the Res82-93A Retain, policy is still relevant. state to elicit their views and recommendations on the ethical and practical issues of care of terminal patients. Compassionate Care and Comfort Guidelines MSMS adopts the Compassionate Care and Comfort Guidelines Res86-95A Retain, policy is still relevant. as being in compliance with the standards of care. (See Addendum A in website version) Death Notification MSMS supports and encourages appropriate death notification Board-July97 Retain, policy is still relevant. by health care facilities in a timely fashion. Death with Dignity Law An attending physician should be allowed legally to participate with the patient and/or the legally appointed agent in deciding the continuation of medical treatment when faced with terminal Prior to 1990 Retain, policy is still relevant. illness. MSMS will work with interested groups to resolve and clarify the legal and ethical dilemmas surrounding the withholding and withdrawal of life support therapy. Hospice Deaths as Crime Scenes Sunset policy. This policy is no longer necessary as Public Act 153 of MSMS opposes attempts by local law enforcement agencies to 2004 addressed this issue by revising the conditions under which an regard expected hospice deaths as crime scenes. Res45-03A investigation is required when an individual dies while under home MSMS opposes the routine deployment of criminal investigators hospice care. to expected hospice death scenes. Living Will MSMS recognizes the validity of Living Will/Durable Power of Res92-90A Retain, policy is still relevant. Attorney forms in Michigan.

Policy Year Recommendation Oppose Legislative Interference in Patient/Physician Relationship MSMS opposes any legislation passed in the area of assisted suicide that interferes with the proper patient/physician Res70-93A Retain, policy is still relevant. relationship, particularly as such legislation relates to pain control and the terminally ill, so that physicians may continue to provide compassionate care to their patients in accordance with principles of medical care and ethics. Physician Assisted Suicide Legislation MSMS supports legislation opposing physician assisted suicide, Res85-98A Retain, policy is still relevant. so long as such legislation includes safeguards to protect the legal and ethical rights of physicians and patients. Stem Cells MSMS respects the diversity of opinion amongst Michigan physicians regarding human embryonic stem cell research and Res28-08A Retain, policy is still relevant. adopts a neutral position regarding human embryonic stem cell research. Cloning Res60-03A MSMS supports laws and governmental policies that prohibit Reaffirmed Retain, policy is still relevant. human reproductive cloning. w/Res70-06A

Policy Year Recommendation “Baby Doe” and Other Handicapped Individuals Retain, policy is still relevant, and modify to read as follows: Handicapped individuals, if competent, have the right to choose among treatment alternatives. Incompetent individuals and those Medical Treatment Decisions and Persons with Disabilities unable to express their own opinions have the right to have Persons with disabilities, unless they are subject to a guardian or choices made for them. conservator, have the right to make their own medical decisions, including In these circumstances, families provided with comprehensive the choice of treatment alternatives. Persons with disabilities and if information regarding alternatives can best represent the necessary, a guardian, conservator, or patient advocate, are best served handicapped. when provided with comprehensive information to assist in making informed decisions. When questions with respect to the patient’s best interest are Prior to 1990 raised by the patient’s physician, or the hospital bioethics When questions with respect to the patient’s best interest are raised by the committee, protections provided by local agencies and courts patient’s physician, or the hospital bioethics committee, protections may be invoked to evaluate fair choices. provided by local agencies and courts may be invoked to evaluate fair choices. Physicians and hospitals can aid by: 1. Providing counsel to patients, families, physicians and Physicians and hospitals can aid by: agencies charged with individual decisions. 1. Providing counsel to patients, families, physicians, and agencies 2. Confidential review of decision-making experiences. charged with individual decisions. 3. Aiding in the development of guidelines regarding this 2. Confidential review of decision-making experiences. process. 3. Aiding in the development of guidelines regarding this process. Surrogate Parenting MSMS endorses the need to define and protect the legal status Prior to 1990 and rights of a child born as a result of surrogate parenting. Retain, policy is still relevant. Edited 1998 MSMS endorsement does not extend to the process of surrogate parenting. Standards for Due Process in Hospital Ethics Committees Retain, policy is still relevant, but modify to read as follows: MSMS will work with the Michigan Health and Hospital Association to create policy to ensure that the minimum Standards for Due Process in Hospital Ethics Committees standards for institutional Ethics Committees include input from Board-Jan09 MSMS believes hospitals should ensure that the minimum standards for the patient, and/or a representative chosen by the patient, and/or institutional Ethics Committees include input from the patient, and/or a a guardian ad litem for the patient to protect the patient’s best representative chosen by the patient, and/or a guardian ad litem for the interests. patient to protect the patient’s best interests. Do Not Compete Clauses Res30-98A It is unethical for a teaching institution to seek a non-competition Retain, policy is still relevant. Edited 2005 guarantee from its residents or trainees. Integrity and the Values and Principles Embedded in the Tradition of Medicine Board Action Retain, policy is still relevant. MSMS supports the 1996 House of Delegates resolution on Report #9-96 “Statement on Integrity and the Values and Principles Embedded 4

Policy Year Recommendation in the Tradition of Medicine.” (See Addendum E in website version) Physician’s Definition of Terminal Illness Sunset the policy. This policy is no longer necessary as the MSMS supports a treating physician defining a disease or Board-Jan99 identification of common terminal conditions, along with the condition as a terminal illness. relevant medical criteria indicative of advanced illness is customary. Physician’s Rights in Treatment Decisions Neither physicians, hospitals nor hospital personnel shall be required to perform any act that violates good medical judgment or is contrary to moral principles of the individual. In such Prior to 1990 Retain, policy is still relevant. circumstances, the physician or other professional may withdraw from the case as long as the withdrawal is consistent with good medical practice. Racism and Sexism in the Practice of Medicine Res113-99A Retain, policy is still relevant. MSMS opposes racism and sexism in our society. Sexual Harassment Guidelines Res12-93A MSMS advocates that guidelines for prevention of sexual Retain, policy is still relevant. Edited 1998 harassment be integrated into the medical work place. Commercial or Political Exploitation of Officer Titles Physicians who hold offices or have held offices in MSMS should guard against commercial or political exploitation of any position Prior to 1990 Retain, policy is still relevant. or title use in any manner that implies, directly or indirectly, endorsement of a commercial product or service by MSMS. Choice of Family Planning Method Everyone in consultation with a physician should be free to Prior to 1990 choose his or her own method of family limitation, including Edited 1998, Retain, policy is still relevant. sterilization. MSMS supports the policy of third party payment for 2005 elective sterilization. CMS Auditing of Medicare and Medicaid Res49-98A MSMS opposes arbitrary assessment of audit monies by the Retain, policy is still relevant. Edited 2005 Centers for Medicare & Medicaid Services (CMS). Excessive Medical Administrative Costs MSMS opposes additional regulatory requirements that place a Res81-90A Retain, policy is still relevant. financial burden on the physicians or hospitals without Edited 1998 compensation. Government Financed Health Care Prior to 1990 The only purpose of government medical care programs for Retain, policy is still relevant. Edited 1998 indigent patients is the delivery of needed quality health care. Limited Antitrust Exemption for Physicians Res51-07A Retain, policy is still relevant, but modify to read as follows:

Policy Year Recommendation MSMS supports a limited physician antitrust exemption modeled after the “Quality Health Care Coalition Action” physician Limited Antitrust Exemption for Physicians organization mechanisms to equilibrate the bargaining position MSMS supports a limited physician antitrust exemption to balance the between health care insurance companies and physicians. bargaining position between health care insurance companies and physicians and therefore enable fair negotiations. National Health Care MSMS supports voluntary, free-choice methods of medical and Prior to 1990 Retain, policy is still relevant. health care rather than a system dominated and controlled by the Edited 1998 federal government. Physician Input for National Health Care Programs MSMS supports physician input at all levels in the development Res131-93A Retain, policy is still relevant. of any national health care programs. Unauthorized Files and Investigations by the Bureau of Retain, policy is still relevant, but modify to read as follows: Occupational and Professional Regulations, Office of Health

Services Unauthorized Files and Investigations by the State Regulatory Agency MSMS is opposed to unauthorized investigations of physicians Res106-97A MSMS is opposed to unauthorized investigations of physicians and the and the unauthorized development of files against physicians by unauthorized development of files against physicians by the state agency the administration of Bureau of Occupational and Professional with licensing and regulatory oversight of physicians. Relations (BOPR), Office of Health Services. Use of Appropriate Terminology MSMS encourages federation publications to reverse the trend of using inappropriate terminology when referring to physicians as Res20-00A Retain, policy is still relevant. “providers,” patients as “clients” and medical practices as “businesses.” Retain, policy is still relevant, but modify to read as follows: Denial of Medical Care to Indigents Prior to 1990 Indigents should not be denied medical care that is available to Edited 1998 Denial of Medical Care the remainder of society. Persons who are indigent should not be denied necessary medical care. Direct Access to Specialists MSMS supports direct access to specialty physicians when the Board-July99 Retain, policy is still relevant. specialty physician acts as a primary care physician, such as pediatricians and obstetrician/gynecologists. Ob/Gyn as Primary Care Physician MSMS supports the designation of the obstetrician/gynecologist Res26-95A Retain, policy is still relevant. as a primary care physician. Universal Coverage MSMS supports comprehensive health system reform described Res81-06A Retain, policy is still relevant. in the MSMS Future of Medicine Report. (See Addendum P

Policy Year Recommendation “Guiding Principles for the Future of Medicine and Health Care” in website version) Physician Organization Networks MSMS supports formation of physician organizations (POs) and Res21-94A Retain, policy is still relevant. PO networks to facilitate the provision of high-quality, efficient care and the communication of information. CPT Coding Res46-92A MSMS supports uniform CPT coding for all medical services Reaffirmed Retain, policy is still relevant. provided within the state of Michigan. w/Res50-10A Domination of Health Care Delivery Market Prior to 1990 MSMS opposes any single organization dominating the health Retain, policy is still relevant. Edited 1998 care delivery market. Economic Aspects of Health Care Delivery System Statement of Principles and Recommendations re Physician Involvement with Economic Aspects of the Health Care Delivery System: Principles: 1. MSMS and its individual members share with the public a concern for the proper distribution, delivery and utilization of (Prior to 1990) Retain, policy is still relevant. health care. 2. MSMS has an enduring commitment to the delivery of health care in the most cost-effective manner. 3. MSMS believes that physicians have a moral and vital obligation to inform, advise, or assist third parties in deliberations concerning the quality of health care, its utilization and cost. Emergency Care for Office Based Procedures MSMS supports a requirement that a physician, who performs office based procedures, provide access to post-operative Res107-99A Retain, policy is still relevant. physician care consistent with appropriate standards of care (practice). Alternative Uses of Hospital Beds Prior to 1990 Retain, policy is still relevant. MSMS supports alternative uses of hospital beds and space. Edited 1998

Policy Year Recommendation Blue Cross Blue Shield of Michigan (BCBSM) Restrictions for Ambulatory Surgery Centers MSMS advocates for the elimination of Blue Cross Blue Shield of Res48-07A Retain, policy is still relevant. Michigan Evidence of Need criteria for ambulatory surgery centers and promotes the more generally accepted guidelines for certification of ambulatory surgery centers set forth by Medicare. Closing of Small Community Hospitals Res16-90A MSMS supports the reduction of financial constraints on small Retain, policy is still relevant. Edited 1998 rural hospitals in order to improve access to health care. Funding of County Medical Care Facilities Res43-91A MSMS opposes inappropriate reduction in funding for county Retain, policy is still relevant. Edited 1998 medical care facilities. Determination of Disability and Impairment MSMS encourages appropriate agencies adopt the “AMA Guides Res65-96A Retain, policy is still relevant. to the Evaluation of Permanent Impairment” for determining disability and impairment. Specialty Society Clinical Care Guidelines Res76-90A MSMS supports the implementation of clinical care guidelines 1990 Board developed by recognized national medical specialty societies to Retain, policy is still relevant. Annual Report enhance state-of-the-art, quality care for patients. (See Edited 1998 Addendum F in website version) Determination of Medical Necessity of Medical Case Management The treating physician shall be the sole determinant of medical Board Action case management and medical necessity. MSMS believes that an Report #14, insurer, a health care corporation or a government agency may Retain, policy is still relevant. 1994 HOD, re not interfere with the patient/physician relationship by Res121-93A determining medical necessity or medical case management without a fair and reasonable appeals process and independent binding arbitration in a timely fashion. Breast Thermography MSMS accepts the American College of Radiology position that ACR Res33-90 Retain, policy is still relevant. thermography has not been demonstrated to have value as a Edited 1998 screening, diagnostic, or adjunctive imaging tool. Physician Support of Statewide Breast and Cervical Cancer Res16-93A Retain, policy is still relevant. Control Program

Policy Year Recommendation MSMS supports and endorses the Breast and Cervical Cancer Control Program and urges members to refer eligible patients to the Program for screening as part of ongoing care. Support of Cholesterol Screening Programs Sunset policy. This policy is no longer necessary as the AMA Prior to 1990 MSMS supports the AMA cholesterol-screening program. cholesterol-screening program is no longer operational. Continuous Quality Improvement (CQI) Programs MSMS urges its members to participate in Continuous Quality Res111-95A Retain, policy is still relevant. Improvement (CQI) training programs. Collection and Use of Physician Specific Data Board-May94 MSMS supports the amended “Principles on the Release of Reaffirmed by Retain, policy is still relevant. Physician-Specific and Physician Group Data.” (See Addendum J Board-March07 in website version) Access to Psychiatrists MSMS supports requiring qualified health plans to provide access Res92-95A Retain, policy is still relevant. to psychiatrists. Automatic and Affordable Health Insurance Coverage for All MSMS supports affordable health insurance coverage for Res41-01A Retain, policy is still relevant. Americans. Childhood Obesity as a Covered Benefit MSMS supports the treatment of childhood obesity a benefit Res88-10A Retain, policy is still relevant. covered by health insurance plans. Children’s Preventive Care MSMS supports requiring insurance companies to cover well- Board-Nov93) Retain, policy is still relevant. baby check-ups, pediatric check-ups and child immunizations. Coverage of Immunization by Third Party Payers MSMS urges all third party payers, especially fee-for-service health plans, to provide coverage of immunizations recommended by national authorities. Res51-96A Retain, policy is still relevant. MSMS encourages fee-for-service health plans, large businesses and labor organizations in Michigan to include health insurance coverage of recommended immunizations. Discrimination by Health Insurance Carriers against Breast Retain, policy is still relevant, but modify to read as follows: Reconstruction MSMS supports the right for all women to have access to breast Access to Breast Reconstruction reconstruction after cancer surgery if they desire it, and that Res96-96A MSMS supports the right for all women to have access to breast access should be available regardless of timing in relationship to reconstruction after cancer surgery if they desire it, and that access should the onset of the deformity or absence of their breast. be available regardless of timing in relationship to the onset of the deformity or absence of their breast. 9

Policy Year Recommendation MSMS urges health insurance carriers to provide coverage of costs associated with all stages of the breast reconstruction. Retain, policy is still relevant, but modify to read as follows: Emotional Disorder as a Pre-existing Condition

MSMS believes no applicant should be denied an insurance Emotional or Behavioral Health Disorder as a Pre-existing Condition policy for health care, sickness and accident, and/or life because Res88-95A MSMS believes no applicant should be denied an insurance policy for health the applicant has been treated for any current or previous care, sickness and accident, and/or life because the applicant has been emotional disorder. treated for any current or previous emotional or behavioral health disorder. Evaluation of Health Plan Performance MSMS continues to evaluate overall performance of health insurance companies with particular emphasis on patient and Res28-95A Retain, policy is still relevant. provider satisfaction, as well as the proportion of premium dollars spent on administration. Gender Equity for Prescription Drug Coverage MSMS supports Michigan insurance carriers and employers to Res4-03A Retain, policy is still relevant. establish gender equity for prescription drug coverage, i.e. birth control pills. Retain, policy is still relevant, but modify to read as follows: Genetic Screening Affecting Insurance Policy Rates MSMS supports prohibiting the health insurance industry from Res36-95A Genetic Screening Affecting Insurance Policy Rates basing coverage and rates on knowledge of genetic risk. MSMS opposes the use of genetic information by health insurers to make coverage or rate decisions. Health Insurance for Adopted Children Res11-91A There should be no discrimination in health insurance benefits Retain, policy is still relevant. Edited 1998 between adopted and biological children. Retain, policy is still relevant, but modify as follows: Health Insurers: Domestic Assault Victims

MSMS supports the concept of prohibiting insurers, health Health Insurers: Domestic Assault Victims maintenance organizations and life insurers, from using a Board-July96 MSMS opposes the use of a person’s status as a victim of domestic assault person’s status as a victim of domestic assault to deny or cancel by insurers, health maintenance organizations, and life insurers to deny or coverage or charge special rates. cancel coverage or charge special rates. Insurance Coverage Prior to 1990 Medical insurance companies should make provision for Retain, policy is still relevant. Edited 1998 adequate coverage of abortions. Long-term Care Insurance MSMS supports the availability of insurance for long-term care Prior to 1990) Retain, policy is still relevant. for Michigan residents. Mental Health Insurance Benefits Prior to 1990 Retain, policy is still relevant.

Policy Year Recommendation Mental health benefits should be reimbursed on a par with other health care benefits. No-Fault Auto Insurance – Coordination of Benefits MSMS supports the requirement that automobile insurance policies with a coordination of benefits clause pay reasonable charges for products, services and accommodations incurred by Board-July97 Retain, policy is still relevant. the insured that are not covered by his/her primary health care policy, if the services are provided by a qualified health care professional. No-fault Health Insurance MSMS supports the concept that health insurance carriers cover Res60-95A Retain, policy is still relevant. the cost of treatment for illness or injury until the responsible payer is identified in order to ensure continuity of care. Over Utilization of Radiologic Studies MSMS recommends that insurers reimburse radiologic procedures fairly and equitably and that over utilization be Res67-94A Retain, policy is still relevant. addressed not by decreasing fees, but by recommending appropriate utilization of radiologic procedures and appropriate credentialing of physicians performing these procedures. Retain, policy is still relevant, but modify to read as follows: Patient Choice Between Vaginal Birth after Cesarean Section

(VBAC) and Repeat Cesarean Section Procedures Patient Informed Choice of Delivery Options MSMS believes that the choice between Vaginal Birth after MSMS believes that the choice between vaginal birth after cesarean (VBAC) Cesarean Section (VBAC) and repeat cesarean section should be a Res93-94A delivery and repeat cesarean sections should be a decision between the decision between the patient, her partner and her doctor. patient, her partner, and her doctor utilizing the latest relevant guidelines MSMS requests insurance companies to not withhold from the American College of Obstetricians and Gynecologists (AGOG). reimbursement for a repeat cesarean section if this alternative is Insurance companies should not withhold reimbursement for a repeat the patient’s informed decision. cesarean section if this alternative is the patient’s informed decision. Physician Penalties for Out-of-Network Services MSMS vehemently opposes any penalties implemented by Res25-07A Retain, policy is still relevant. insurance companies against physicians when patients independently choose to obtain out-of-network services. Pre-existing Conditions MSMS supports prohibiting health and disability insurers and Board-Nov93 Retain, policy is still relevant. HMOs from denying coverage and from refusing to issue or renew coverage because of pre-existing condition. Promotion and Sale of Medical and Disability Insurance Prior to 1990 Retain, policy is still relevant. Policies

Policy Year Recommendation Medical and/or disability insurance policies that contain deceptive exclusionary devices should not be promoted or sold. Prostate Cancer Screening MSMS supports third party coverage of prostate cancer Board-July97 Retain, policy is still relevant. screening. Second Opinion MSMS endorses the concept of “second opinion” when requested by the patient or his or her physician. Prior to 1990 Retain, policy is still relevant. Mandatory second surgical opinion programs are not in the best interest of the public. Tax Deductible Insurance Premiums Prior to 1990 Retain, policy is still relevant. All health insurance premiums should be tax deductible. Edited 1998 Uniform Claim Form Prior to 1990 MSMS supports implementation of a uniform claim form for all Retain, policy is still relevant. Edited 1998 third party payers. Waiting Period for Pre-existing Conditions MSMS supports coverage of pre-existing conditions by third Board-Nov97 Retain, policy is still relevant. party payers without a waiting period. Acupuncture: Licensure Res30-90A Retain, policy is still relevant. MSMS opposes the licensure of acupuncturists. Amended 1993 Evaluation of Allied Health Professionals MSMS supports the evaluation of allied health professional Prior to 1990 Retain, policy is still relevant. methods of practice. Medical Staff Privileges for Allied Health Professionals MSMS urges (1) Michigan physicians to examine the credentials and privileges of allied health professionals and (2) hospital Res26-94A Retain, policy is still relevant. medical staffs to periodically review their bylaws to ensure they include the appropriate language describing the credentialing of allied health professionals. Retain, policy is still relevant, but modify to read as follows: Midlevel Provider Use Rules Board Action MSMS supports daily physician supervision of all midlevel Non-Physician Practitioner Use Rules Report #7, 2011 providers who provide care to hospitalized patients as MSMS supports daily physician supervision of all non-physician HOD, Res74-10A documented by a signature. practitioners who provide care to hospitalized patients as documented by a signature. Midwifery: Protection from Unqualified Practitioners Prior to 1990 MSMS supports protection of Michigan women from unqualified Retain, policy is still relevant. Edited 1998 practitioners of obstetrics. 12

Policy Year Recommendation Nursing: Direct Reimbursement of Certified Nurse Midwives MSMS supports permitting direct reimbursement to certified nurse midwives if the regulations stipulate the following: • An expense-incurred, medical or surgical policy, conversion policy or indemnity policy, that provides coverage for maternity services, shall offer to provide coverage for such services whether performed by a physician or a nurse midwife acting within the scope of his or her license. A certified nurse midwife must include evidence of a collaborative relationship Board-Sept94 Retain, policy is still relevant. with a physician with obstetrical privileges at the same institution. • A group or non-group certificate or conversion certificate that provides coverage for maternity services, shall offer to provide or shall provide, coverage for such services whether performed by a physician or a nurse midwife acting within the scope of his or her license. A certified nurse midwife must include evident of a collaborative relationship with a physician with obstetrical privileges at the same institution. Nursing: Education Sunset policy. This policy is no longer timely as hospital-based Hospital nursing schools should not be “phased out.” The Prior to 1990 nursing degree programs are rare, with the majority of individuals integration of hospital nursing schools and community and state receiving their nursing degree at a college or university. colleges into a unified academic program should be considered. Optometry: Scope of Practice Expansion MSMS opposes allowing optometrists to expand their scope of practice to include the use of therapeutic drugs, and to expand Board-Jan93 Retain, policy is still relevant. the area that they may examine from the eyeball to the area surrounding the eye. Pharmacy: Cooperation to Insure Patient Medication Safety MSMS works with the Michigan Pharmacists Association to assure Res88-93A Retain, policy is still relevant. patient safety, confidentiality, and continuity of care. Pharmacy: Cooperation to Insure Patient Medication Safety MSMS works with the Michigan Pharmacists Association to assure patient safety, confidentiality, and continuity of care. (Res88-93A)Physician Assistants and Nursing: Prescription Board-July95 Retain, policy is still relevant. Drugs MSMS supports the concept of permitting physician assistants and registered nurses to order, receive and dispense complimentary starter doses of non-controlled substances.

Policy Year Recommendation Physician’s Relationship with Limited Practitioners Retain, policy is still relevant, but modify to read as follows: A physician should at all times practice a method of healing founded on a scientific basis. A physician may refer a patient for Physician’s Relationship with License Limited Practitioners diagnostic or therapeutic services to another physician, licensed A physician should at all times practice a method of healing founded on a limited practitioner, or any other provider of health care services scientific basis. A physician may refer a patient for diagnostic or therapeutic permitted by law to furnish such services whenever the physician services to another physician, licensed limited practitioner, or any other believes that this will benefit the patient. As in the case of provider of health care services permitted by law to furnish such services referrals to physician specialists, referrals to limited practitioners whenever the physician believes that this will benefit the patient. As in the should be based on their individual competence and ability to case of referrals to physician specialists, referrals to license limited perform services needed by the patient. practitioners should be based on their individual competence and ability to Testimonials should not be used in advertising as such claims Prior to 1990 perform services needed by the patient. tend to mislead the public. In addition, the Society supports Edited 1998 Testimonials should not be used in advertising as such claims tend to Section 16265 of the Michigan Public Health code which states: mislead the public. In addition, the Society supports Section 16265 of the “1) An individual licensed under this article to engage in the Michigan Public Health code which states: practice of chiropractic, dentistry, medicine, optometry, “1) An individual licensed under this article to engage in the practice of osteopathic medicine and surgery, podiatric medicine and chiropractic, dentistry, medicine, optometry, osteopathic medicine and surgery, psychology, or veterinary medicine shall not use the surgery, podiatric medicine and surgery, psychology, or veterinary medicine terms doctor or dr. in any written or printed matter or display shall not use the terms doctor or dr. in any written or printed matter or without adding thereto of chiropractic, of dentistry, of medicine, display without adding thereto of chiropractic, of dentistry, of medicine, of of optometry, or of osteopathic medicine and surgery, of optometry, or of osteopathic medicine and surgery, of psychology, of psychology, of veterinary medicine or a similar term, veterinary medicine or a similar term, respectively.” respectively.” Physical Therapy: Direct Reimbursement Board-July95 Retain, policy is still relevant. MSMS opposes direct reimbursement to physical therapists. Physical Therapy: Reimbursement MSMS opposes requiring commercial payers to directly Board-Nov93 Retain, policy is still relevant. reimburse physical therapists for their services. Psychology: Prescribing Medications Res87-95A Retain, policy is still relevant. MSMS opposes psychologists prescribing medications. Psychology: Hospital Staff Privileges MSMS opposes hospitals credentialing a psychologist to practice Board-July96 Retain, policy is still relevant. independently. Surgical Assistants: Role and Reimbursement Res115-90A MSMS supports the role and reimbursement of surgical assistants Retain, policy is still relevant. Edited 1998 in the delivery of health care. e-Visit Reimbursements MSMS supports and advocates reimbursement of e-visits that Board-April06 Retain, policy is still relevant. involve encounters relating to a patient’s care as a part of 14

Policy Year Recommendation ongoing management and maintains appropriate elements of quality, physician accountability, and confidentiality. Support Patient Empowerment Controlled Health Records MSMS supports the development of functional patient-centric information exchange systems to and from a patient-accessible health record that gives patient control to share with others, Res80-10A Retain, policy is still relevant. protects their individual rights to privacy, and supports continuity of care, provider work flow, and provider fulfillment of meaningful use. Regionalization The private physician and local medical societies should be Prior to 1990 Retain, policy is still relevant. involved in planning for regionalization of medical services. Amending Medical Staff Bylaws MSMS will assist medical staffs by providing legal help and support, if determined appropriate by the MSMS Board of Res27-94A Retain, policy is still relevant. Directors, when a hospital board of directors unilaterally changes the medical staff bylaws. Physician Representation on Hospital Boards of Trustees MSMS supports the principle that all physicians seated on Res51-06A Retain, policy is still relevant. hospital boards of trustees be elected to their position by the hospital medical staff members. Physician Representation on Hospital Governing Boards MSMS encourages all physicians to participate on their hospital Res22-93A governing boards and/or boards of trustees, and recommends in Retain, policy is still relevant. Edited 1998 addition that elected chiefs of staff be voting members of their hospital governing boards. Arbitrary Denial or Termination of Medical Staff Privileges MSMS recognizes hospital medical staff bylaws as a contract that Res14-95A Retain, policy is still relevant. affords due process to all members of the medical staff. Consolidation of Medical Staff and Departments MSMS supports the concept that consolidation of medical staff and departments and associated bylaws and departmental Res15-95A Retain, policy is still relevant. policies and procedures must require the approval of all medical staffs and/or departments so involved. Guidelines – Applications for Hospital Medical Staff Privileges MSMS endorses the Guidelines on Applications for Hospital Prior to 1990 Retain, policy is still relevant. Medical Staff Privileges. (See Addendum G in website version) Guidelines for Medical Staff Funds Prior to 1990 Retain, policy is still relevant.

Policy Year Recommendation 1. Participation in such funds shall be voluntary. 2. Control of the use of medical staff funds shall be limited to the physicians who have contributed to the fund. 3. The constitution, bylaws or other governing rules of the fund shall provide that all elections and votes on major decisions by the membership shall be by secret written ballot. Guidelines for Physician-Hospital Relations Retain, policy is still relevant, but modify to read as follows: 1. Hospital-employed physicians should be included as

members of the medical staff and should be subject to its Guidelines for Physician-Hospital Relations bylaws, rules, and regulations. The following provisions 1. Hospital-employed physicians should be included as members of the should be included in medical staff bylaws: organized medical staff and should be subject to its bylaws, rules, and “The credentials committee (or other appropriate committee) regulations. The following provisions should be included in organized shall cooperate with the governing board in reviewing the medical staff bylaws: credentials of all physician applicants for employment by the “The credentials committee (or other appropriate committee) shall hospital to assure that such employees qualify for regular cooperate with the governing board in reviewing the credentials of all membership on the medical staff. The procedures followed in physician applicants for employment by the hospital to assure that processing applications for regular medical staff appointment such employees qualify for regular membership on the medical staff. and for continued staff privileges shall be applicable to and The procedures followed in processing applications for regular have control over such employed physicians.” medical staff appointment and for continued staff privileges shall be 2. The medical staff should include proper safeguards in all applicable to and have control over such employed physicians.” appropriate sections of the medical staff bylaws, rules and 2. The organized medical staff should include proper safeguards in all regulations to make certain that they apply to all physicians Prior to 1990 appropriate sections of the medical staff bylaws, rules, and serving on the medical staff, including those employed by the regulations to make certain that they apply to all physicians serving hospital. on the organized medical staff, including those employed by the 3. While medical staff bylaws must be approved by the hospital. governing board and, for this reason, are considered to be 3. While organized medical staff bylaws must be approved by the binding on the governing board, it would appear desirable to governing board and, for this reason, are considered to be binding on include a provision in any contracts with physicians, as well as the governing board, it would appear desirable to include a provision in the medical staff bylaws, to assure the desired result. The in any contracts with physicians, as well as in the organized medical following is suggested: staff bylaws, to assure the desired result. The following is suggested: “In accordance with and subject to the procedures of the “In accordance with and subject to the procedures of the organized organized medical staff, Doctor ______is granted and accepts medical staff, Doctor ______is granted and accepts appointment as a appointment as a member of the medical staff. This member of the organized medical staff. This Agreement shall Agreement shall terminate automatically if the staff privileges terminate automatically if the staff privileges of Doctor ______are of Doctor ______are revoked upon recommendation of the revoked upon recommendation of the organized medical staff.” organized medical staff.” 4. If there is no organized democratic departmental structure which 4. If there is no organized democratic departmental structure allows for communication and input, the organized medical staff which allows for communication and input, the medical staff

Policy Year Recommendation should establish an advisory committee to counsel and assist should establish an advisory committee to counsel and assist the the administrator in carrying out his or her responsibilities. administrator in carrying out his or her responsibilities. 5. Where the employment of a full-time physician to carry out 5. Where the employment of a full-time physician to carry out departmental administrative and operational functions is departmental administrative and operational functions is being being considered, it is recommended that consideration be considered, it is recommended that consideration be given to given to employing this physician as an administrative employing this physician as an administrative assistant to the elected assistant to the elected chief with the delegated functions chief with the delegated functions appropriately spelled out in the appropriately spelled out in the medical staff or departmental organized medical staff or departmental bylaws. bylaws. 6. Organized medical staffs in all types of non-federal hospitals should 6. Medical staffs in all types of non-federal hospitals should be be alert to the potential dangers of governing board dominance over alert to the potential dangers of governing board dominance the executive committee and the need for careful bylaw structuring of over the executive committee and the need for careful bylaw the executive committee to prevent this. structuring of the executive committee to prevent this. 7. It is emphasized that organized medical staffs should take a firm 7. The American Medical Association should firmly oppose the stand against governing board control of organized medical staff specific proposals of the American College of Hospital activities related to patient care. Administrators and the Catholic Hospital Association 8. State and local medical societies are urged to supplement AMA’s concerning medical staff structure and medical staff- effort to assist and offer support to organized medical staffs involved administrator-board relationships. (Note: The Board has in negotiations with governing boards and administrations. concerned itself only with those specific sections of the documents.) 8. It is emphasized that medical staffs should take a firm stand against governing board control of medical staff activities related to patient care. 9. State and local medical societies are urged to supplement AMA’s effort to assist and offer support to hospital medical staffs involved in negotiations with governing boards and administrations. Hospital Admissions by Allied Health Professionals Only physicians and surgeons with staff privileges may admit patients. Allied health professional services may be available, Prior to 1990 within limits of skill and law, only under direction and supervision Retain, policy is still relevant. Edited 1998 of a member of the medical staff qualified in that field. Such services are to be under direction of the department or section responsible for that type of service. Hospital Medical Staff Credentialing of Physicians who Board Action Provide Electronic and Other Telemedicine Services for Report #3, 1997 Retain, policy is still relevant. Hospital Patients HOD, Res29-

Policy Year Recommendation MSMS supports the requirement of physicians who provide 96A, Res97-96A, diagnostic or therapeutic services on a regular, ongoing or & Res98-96A contractual basis via electronic or other communications to patients in a hospital setting within Michigan to be fully credentialed by that hospital’s medical staff in accordance with the medical staff bylaws. MSMS supports the requirement of physicians who provide diagnostic or therapeutic services on a regular ongoing or contractual basis to patients in a hospital setting within Michigan solely via electronic or other distant communications (and so would not otherwise ever have any direct personal interaction with the remainder of the medical staff) be credentialed as active members of that hospital’s medical staff and be held to the same standards of requisite responsibilities as other active members of the medical staff. Medical Doctors and Department Heads of Hospital Staffs It is inappropriate for hospital medical departments in acute care Prior to 1990 Retain, policy is still relevant. general hospitals to be chaired by persons other than licensed Edited 1998 physicians or, when appropriate, dentists. Medical Staff Reappointment Reappointment of doctors to the active medical staff should not be denied except for medical ineptitude, character deficiency or Prior to 1990 Retain, policy is still relevant. conviction of unethical conduct, revocation of license by the state, or violation of the hospital medical staff bylaws that have been approved by the medical staff. Oppose Mandatory “Hospitalist” Care MSMS opposes mandatory requirements that a patient’s Res15-99A Retain, policy is still relevant. physician turn over inpatient care to “hospitalists.” Qualifications for Chief of Medical Staff MSMS encourages medical staffs to include in their bylaws a provision that all physicians be eligible for election to chief of Res12-97A Retain, policy is still relevant. staff unless the physicians serve in a major medical administrative position at the hospital. Unfair Competition by Non-profit and Tax-exempt Organizations MSMS opposes the unfair privilege of non-profit and tax-exempt Prior to 1990 Retain, policy is still relevant. organizations providing medical care in competition with the private and taxed physicians providing the same services.

Policy Year Recommendation Administration of Immunizations The immunization of children and adults for prophylaxis against infectious diseases is best performed at the direction of physicians involved in continuing care of the individual, taking into account the risks and benefits accruing to the individual. A concerted effort should be made by physicians to ensure that patients begin pediatric immunizations at the earliest medically appropriate time and that patients finish their series. Guidelines and schedules produced by scientific groups and/or governmental agencies, while often helpful, should not be regarded as overriding the exercise of informed decision-making by the physician where the welfare of his or her patient is involved.

Recognizing that circumstances occur in which immunization Prior to 1990 Retain, policy is still relevant. should be given under other auspices, the common good should be served with due regard for the concerns of the individual. Immunization programs thus carried out under other auspices should be developed with appropriate input from physicians and in concert with the laws regulating medical practice. Mass programs should, to the greatest possible degree, defer to successful and affordable approaches to immunization, which do not remove individuals from regular sources of care and should not scatter the individual’s immunization record. A uniform statewide record should be utilized and the parent/guardian should be provided with a cumulative copy of the record. An entry should be made into this record at the time of each immunization. Res91-90A and Immunizations and Preventive Health Care for Children 54-92A MSMS supports coverage for preventative health care visits and Edited 1998 Retain, policy is still relevant. immunizations for all children. MSMS also supports immunization Reaffirmed records being kept by the child’s physician, parents and schools. w/Res56-01A Insurance Coverage for Immunizations MSMS urges employers to provide health coverage that includes Board Action coverage of all immunizations that are recommended by the Report #3, 2009 Retain, policy is still relevant. Centers for Disease Control and the Advisory Committee on HOD, Res27-08A Immunization Practices for persons living in the U.S.

Policy Year Recommendation Mandatory Immunizations: Physicians Held Harmless MSMS supports physicians being held harmless in the event of a Prior to 1990 maloccurrence not involving negligence encountered during the Retain, policy is still relevant. Edited 1998 administration of immunization to patients as required by federal or state governmental agencies. Priority Vaccine Distribution to Physician Offices MSMS supports physicians receiving their orders for seasonal Res65-10A Retain, policy is still relevant. vaccine before delivery to non-medical venues or retail/urgent care clinics. Universal Access to Child Immunizations MSMS supports a policy of universal access to immunizations for all Michigan children. It further supports a strategy whereby the Board-Nov93 Retain, policy is still relevant. immunizations are purchased by the state at the lowest possible price and made available to all health care providers administering immunizations. Res2-92A & Retain, policy is still relevant, but modify to read as follows: Elimination of Informed Consent for HIV Testing Res95-92A MSMS supports (1) elimination of the informed consent Reaffirmed Elimination of Mandatory Consent for HIV Testing requirements for HIV testing and (2) the ability of physicians to w/Res98-01A MSMS supports (1) elimination of mandatory informed consent perform HIV tests on patients as they feel it is appropriate for Reaffirmed requirements for HIV testing and (2) the ability of physicians to perform HIV proper medical management of the patient. w/Board- tests on patients, as indicated by their medical judgement, for proper Oct2009 medical management of the patient.

Policy Year Recommendation MSMS Position on Informed Consent MSMS strongly endorses the principle of informed consent for medical treatment. Patients have a right to participate in decisions regarding their health care to the extent that they wish; and they have a right to the information necessary for meaningful participation. However, a right to the information necessary to participate to the extent that the patient desires does not imply that patients should be forced to accept information deemed relevant by an outside party. Respect for patient’s rights entails respecting a patient’s desires to receive or not receive particular items of information. Board-Sept91 Retain, policy is still relevant. In order to respect patients’ rights in a compassionate manner, information disclosure should be tailored to the particular needs and desires of the particular patient. MSMS opposes regulatory interference in the physician-patient relationship, either to prohibit the physician from discussing certain information, or requiring that certain information be disclosed in all cases regardless of patient circumstances. MSMS also believes that current law requires informed consent for all medical treatment and offers adequate recourse if consent is not obtained. Therefore, the Society sees no need for specific legislation mandating informed consent for particular procedures or diseases. Educational Commission for Foreign Medical Graduates (ECFMG) Credentials Verification Educational Commission for Foreign Medical Graduates (ECFMG) Res63-94A Retain, policy is still relevant. verification should be the primary source for granting permanent state licensing and hospital privileges for international medical graduates. Equality of Graduates of Foreign Medical Schools MSMS is concerned and sensitive toward issues facing Res98-90A international medical graduates in Michigan. It will work with the Amended 1993 Retain, policy is still relevant. AMA to provide, profess and propagate its intention to work for Edited 1998 equality of IMGs with United States medical graduates in training and work places.

Policy Year Recommendation J1 Visa Waivers for Specialists MSMS supports the distribution of J1 Visa waivers between Res5-05A Retain, policy is still relevant. primary care and specialists depending on their own need. Selection of Residents Based on Skills and Qualifications MSMS opposes policies that discriminate against international Res58-96A Retain, policy is still relevant. medical graduates for postgraduate medical training programs. Visa Status Changes for International Medical Graduates MSMS supports the position that IMG resident physicians with H- Res22-95A Retain, policy is still relevant. 1B status be allowed to keep their H-1B visas for the duration of their current graduate medical education in the United States. Laboratory as a Medical Practice The operation of a medical laboratory represents the practice of Prior to 1990 Retain, policy is still relevant. medicine and should be actively supervised and directed by a licensed physician. Educational Loans-Physician Licensure MSMS opposes using non-payment of student loans to place Board-Nov97 Retain, policy is still relevant. physicians’ licensure at risk. Examination for State Re-licensure MSMS opposes mandatory examination for re-licensure by the Res41-96A Retain, policy is still relevant. state of Michigan except for re-licensure after forfeiture of the original license. Fees to be Returned All medical licensing fees should be returned to the Michigan Prior to 1990 Retain, policy is still relevant. Board of Medicine. Interstate Practice of Medicine MSMS supports requiring out-of-state physicians treating Board Action Michigan patients to be fully licensed by the state of Michigan; Report #3, 1997 however, MSMS does support occasional and irregular medical HOD, Res29- Retain, policy is still relevant. consultations that are requested by out-of-state physicians who 96A, Res97-96A, are not licensed in the state of Michigan. MSMS policy is that an & Res98-96A out-of-state physician treating a patient within Michigan be subject to jurisdiction at the patient’s location. Language Fluency as Requirement for Licensure Res57-92A MSMS opposes requiring individuals to pass a spoken English Retain, policy is still relevant. Edited 1998 proficiency test to receive a medical license in Michigan. Licensing Non-physicians Res30-90A MSMS opposes extending to non-physicians the right to practice Amended 1993 Retain, policy is still relevant. medicine or surgery without physician supervision. Edited 1998

Policy Year Recommendation Licensure for Health Plan Medical Directors MSMS supports licensure by the state of Michigan for health plan Board-Sept98 Retain, policy is still relevant. medical directors, even if they are located outside of the state of Michigan and are not engaged in active clinical practice. Licensure of Medical Technologists Board-July97 Retain, policy is still relevant. MSMS opposes licensure of medical technologists. Sunset policy. The need for this policy is moot as Michigan has required a separate license for dispensing prescribers for more than Pharmacy Licensing Fee Res59-90A 25 years. All licensed physicians, podiatrists, optometrists, dentists, MSMS opposes the physician pharmacy license fee in Michigan. Edited 1998 and physician's assistants who wish to dispense prescription drugs must obtain a drug control license for each location in which the storage and dispensing of prescription drugs occur. Suspension of a Physician’s License Following Conviction of a Misdemeanor Involving Possession or Use of Alcohol MSMS is opposed to the discriminatory summary suspension of Res5-95A Retain, policy is still relevant. health professionals’ licenses or registrations upon their conviction for a misdemeanor involving alcohol. Sunset policy. This policy is no longer relevant as the Michigan Public Health Code defines nursing homes in MCL 333.20109 (1) "Nursing home" means a nursing care facility, including a county medical care facility, that provides organized nursing care and medical treatment to 7 or more unrelated individuals suffering or recovering from illness, injury, or infirmity. As used in this Definition of Nursing Home subsection, "medical treatment" includes treatment by an employee MSMS believes a nursing home should be a facility providing in- Prior to 1990 or independent contractor of the nursing home who is an individual patient care for persons requiring nursing care and related Edited 1998 licensed or otherwise authorized to engage in a health profession services not available at home, but not requiring the services of under part 170 or 175. Nursing home does not include any of the acute general hospital care. following: (a) A unit in a state correctional facility. (b) A hospital. (c) A veterans facility created under 1885 PA 152, MCL 36.1 to 36.12. (d) A hospice residence that is licensed under this article. (e) A hospice that is certified under 42 CFR 418.100. No Cardiopulmonary Resuscitation (CPR) Orders in Adult Foster Care and Assisted Living Settings MSMS supports do-not-resuscitate orders, as well as other Res24-97A Retain, policy is still relevant. advanced directives, for residents of adult foster care facilities, nursing homes and other non-hospital settings.

Policy Year Recommendation Separation of Physician Services from Day Rates All fees for physicians’ services and medicines should be kept entirely separate from day rates for nursing home care, since the Prior to 1990 Retain, policy is still relevant. establishment of an all-inclusive rate might lead to poor and inadequate medical care and tend to separate the patient from his/her physician. Shortage of Nursing Home Beds Res89-90A MSMS supports attempts to resolve the shortage of basic and Retain, policy is still relevant. Edited 1998 skilled nursing home beds. Therapeutic Intervention MSMS supports regulations regarding therapeutic interventions Res92-96A Retain, policy is still relevant. for nursing home patients accommodating patient and family choice for treatment of an individual on a case by case basis.

MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES

RESOLUTIONS BY COMMITTEE

REFERENCE COMMITTEE D – PUBLIC HEALTH

RESOLUTION DESCRIPTION 46-20 Depression Screening in Adolescents after Sport-Related Concussion 61-20 9-1-1 Dispatcher Telephone CPR Training 11-21 Updates to Organ Donation and Transplant Policies 24-21 Improved Outreach to Minority Communities Regarding the COVID-19 Vaccine 25-21 Public Health Considerations to Reduce Harm in Encampment Removals 35-21 COVID-19 Vaccine Distribution Regarding People Experiencing Homelessness

1 RESOLUTION 46-20 2 3 Title: Depression Screening in Adolescents after Sport-Related Concussion 4 5 Introduced by: Mara Darian, for the Medical Student Section 6 7 Original Author: Grace Peterson 8 9 Referred To: Reference Committee D 10 11 House Action: 12 13 14 Whereas, the estimated lifetime prevalence of concussion in middle school and high school 15 students is 20 percent, and 16 17 Whereas, the most common psychological sequelae diagnosed after concussion are 18 depression and anxiety, and 19 20 Whereas, the lifetime prevalence of depression in adolescents is estimated to be 11 percent, 21 and 22 23 Whereas, multiple studies have demonstrated that approximately 40 percent of children 24 and adolescents with depressive disorders do not receive treatment, and 25 26 Whereas, the sequelae of depression during childhood and adolescence include academic 27 difficulties and school avoidance, social withdrawal, and dysfunction in interpersonal relationships, 28 and 29 30 Whereas, athletes who have had previous concussions are shown to have higher levels of 31 depression than athletes who have not been concussed, and 32 33 Whereas, there is evidence that former athletes have higher rates of depression and 34 cognitive deficits when they have had multiple prior concussions, or with younger age of first 35 participation in organized sports, and 36 37 Whereas, the Michigan High School Athletic Association protocol for return to activity after 38 concussion states that students may not return to activity the same day as the injury and must be 39 examined and cleared by a physician, physician assistant, or nurse practitioner before they can 40 return to activity, and 41 42 Whereas, while individual schools, districts, and leagues may have more stringent inactivity 43 and screening requirements before a student athlete can return to activity after a concussion, there 44 are no reported recommendations for depression screening in athletes following concussion, and 45 46 Whereas, the Patient Health Questionnaire Modified for Teens (PHQ-9) is a rating scale used 47 for depression screening in adolescents age 12-18 and its use is supported by the American 48 Academy of Child and Adolescent Psychiatry; therefore be it 49 50 RESOLVED: That MSMS supports the screening of student athletes participating in 51 Michigan High School Athletic Association sports for depression after concussion by physicians, 52 physician assistants, or nurse practitioners using a screening tool such as the Patient Health 53 Questionnaire Modified for Teens; and be it further 54 55 RESOLVED: That MSMS encourage the Michigan High School Athletic Association to 56 include depression screening after concussion in the return to activity protocol. 57 58 59 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 60 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy:

Reduction of Sports-Related Injury and Concussion H-470.954 1. Our AMA will: (a) work with appropriate agencies and organizations to promote awareness of programs to reduce concussion and other sports-related injuries across the lifespan; and (b) promote awareness that even mild cases of traumatic brain injury may have serious and prolonged consequences. 2. Our AMA supports the adoption of evidence-based, age-specific guidelines on the evaluation and management of concussion in all athletes for use by physicians, other health professionals, and athletic organizations. 3. Our AMA will work with appropriate state and specialty medical societies to enhance opportunities for continuing education regarding professional guidelines and other clinical resources to enhance the ability of physicians to prevent, diagnose, and manage concussions and other sports-related injuries. 4. Our AMA urges appropriate agencies and organizations to support research to: (a) assess the short- and long-term cognitive, emotional, behavioral, neurobiological, and neuropathological consequences of concussions and repetitive head impacts over the life span; (b) identify determinants of concussion and other sports-related injuries in pediatric and adult athletes, including how injury thresholds are modified by the number of and time interval between head impacts and concussions; (c) develop and evaluate effective risk reduction measures to prevent or reduce sports-related injuries and concussions and their sequelae across the lifespan; and (d) develop objective biomarkers to improve the identification, management, and prognosis of athletes suffering from concussion to reduce the dependence on self-reporting and inform evidence- based, age-specific guidelines for these patients. 5. Our AMA supports research into the detection, causes, and prevention of injuries along the continuum from subconcussive head impacts to conditions such as chronic traumatic encephalopathy (CTE).

Reducing the Risk of Concussion and Other Injuries in Youth Sports H-470.959 1. Our American Medical Association promotes the adoption of requirements that athletes participating in school or other organized youth sports and who are suspected by a coach, trainer, administrator, or other individual responsible for the health and well-being of athletes of having sustained a concussion be removed immediately from the activity in which they are engaged and not return to competitive play, practice, or other sports-related activity without the written approval of a physician (MD or DO) or a designated member of the physician-led care team who has been properly trained in the evaluation and management of concussion. When evaluating individuals for return-to-play, physicians (MD or DO) or the designated member of the physician-led care team should be mindful of the potential for other occult injuries. 2. Our AMA encourages physicians to: (a) assess the developmental readiness and medical suitability of children and adolescents to participate in organized sports and assist in matching a child's physical, social, and cognitive maturity with appropriate sports activities; (b) counsel young patients and their parents or caregivers about the risks and potential consequences of sports-related injuries, including concussion and recurrent concussions; (c) assist in state and local efforts to evaluate, implement, and promote measures to prevent or reduce the consequences of concussions, repetitive head impacts, and other injuries in youth sports; and (d) support preseason testing to collect baseline data for each individual. 3. Our AMA will work with interested agencies and organizations to: (a) identify harmful practices in the sports training of children and adolescents; (b) support the establishment of appropriate health standards for sports training of children and adolescents; (c) promote evidenced-based educational efforts to improve knowledge and understanding of concussion and other sport injuries among youth athletes, their parents, coaches, sports officials, school personnel, health professionals, and athletic trainers; and (d) encourage further research to determine the most effective educational tools for the prevention and management of pediatric/adolescent concussions. 4. Our AMA supports (a) requiring states to develop and revise as necessary, evidenced-based concussion information sheets that include the following information: (1) current best practices in the prevention of concussions, (2) the signs and symptoms of concussions, (3) the short-and long-term impact of mild, moderate, and severe head injuries, and (4) the procedures for allowing a student athlete to return to athletic activity; and (b) requiring parents/guardians and students to sign concussion information sheets on an annual basis as a condition of their participation in sports.

Sources: 1. Veliz P, McCabe SE, Eckner JT, Schulenberg JE. Prevalence of Concussion Among US Adolescents and Correlated Factors. JAMA. 2017;318(12):1180-1182. doi:10.1001/jama.2017.9087 2. Veliz P, Eckner JT, Zdroik J, Schulenberg JE. Lifetime Prevalence of Self-Reported Concussion Among Adolescents Involved in Competitive Sports: A National U.S. Study. J Adolesc Health. 2019;64(2):272- 275. doi:10.1016/j.jadohealth.2018.08.023 3. Singh R, Mason S, Lecky F, Dawson J. Prevalence of depression after TBI in a prospective cohort: The SHEFBIT study. Brain Inj. 2018;32(1):84-90. doi:10.1080/02699052.2017.1376756 4. Avenevoli S, Swendsen J, He JP, Burstein M, Merikangas KR. Major Depression in the National Comorbidity Survey Adolescent-Supplement: Prevalence, Correlates, and Treatment. J Am Acad Child Adolesc Psychiatry. 2015;54(1):37-44.e2. doi:10.1016/j.jaac.2014.10.010 5. Costello EJ, He JP, Sampson NA, Kessler RC, Merikangas KR. Services for adolescents with psychiatric disorders: 12-Month data from the National Comorbidity Survey-Adolescent. Psychiatr Serv. 2014;65(3):359-366. doi:10.1176/appi.ps.201100518 6. Mojtabai R, Olfson M, Han B. National Trends in the Prevalence and Treatment of Depression in Adolescents and Young Adults. Pediatrics. 2016;138(6). doi:10.1542/peds.2016-1878 7. Soria-Saucedo R, Walter HJ, Cabral H, England MJ, Kazis LE. Receipt of Evidence-Based Pharmacotherapy and Psychotherapy Among Children and Adolescents With New Diagnoses of Depression. Psychiatr Serv. 2016;67(3):316-323. doi:10.1176/appi.ps.201500090 8. O Connor BC, Lewandowski RE, Rodriguez S, et al. Usual care for adolescent depression from symptom identification through treatment initiation. JAMA Pediatr. 2016;170(4):373-380. doi:10.1001/jamapediatrics.2015.4158 9. Bonin L. Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis. UpToDate. https://www.uptodate.com/contents/pediatric-unipolar-depression-epidemiology-clinical- features-assessment-and-diagnosis?search=depression adolescent&source=search_result&selectedTitle=3~32&usage_type=default&display_rank=3. Published 2019. Accessed February 3, 2020. 10. Kontos AP, Deitrick JM, Reynolds E. Mental health implications and consequences following sport- related concussion. Br J Sports Med. 2015;50(3):139-140. doi:10.1136/bjsports-2015-095564 11. Rice SM, Parker AG, Rosenbaum S, Bailey A, Mawren D, Purcell R. Sport-Related Concussion and Mental Health Outcomes in Elite Athletes: A Systematic Review. Sport Med. 2018;48(2):447-465. doi:10.1007/s40279-017-0810-3 12. Bailes JE, Petraglia AL, Omalu BI, Nauman E, Talavage T. Role of subconcussion in repetitive mild traumatic brain injury. J Neurosurg. 2013;119(5):1235-1245. doi:10.3171/2013.7.JNS121822 13. Manley G, Gardner AJ, Schneider KJ, et al. A systematic review of potential long-term effects of sport- related concussion. Br J Sports Med. 2017;51(12):969-977. doi:10.1136/bjsports-2017-097791 14. Vargas G, Rabinowitz A, Meyer J, Arnett PA. Predictors and prevalence of postconcussion depression symptoms in collegiate athletes. J Athl Train. 2015;50(3):250-255. doi:10.4085/1062-6050-50.3.02 15. MHSAA PROTOCOL FOR IMPLEMENTATION OF NATIONAL FEDERATION SPORTS PLAYING RULES FOR CONCUSSIONS.; 2016. 16. American Academy of Child and Adolescent Psychiatry. Policy Statement on Depression Screening.; 2019. https://www.aacap.org/AACAP/Policy_Statements/2019/Policy_Statement_on_Depression_Screening.as px. Accessed February 3, 2020. 17. Psychiatry AA of C and A. Resources for Clinicians. https://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Depression_Resource_Center/Re sources_for_Clinicians_Depression.aspx. Published 2019. Accessed February 3, 2020.

1 RESOLUTION 61-20 2 3 Title: 9-1-1 Dispatcher Telephone CPR Training 4 5 Introduced by: Mara Darian, for the Medical Student Section 6 7 Original Author: Erin Lee Currey 8 9 Referred To: Reference Committee D 10 11 House Action: 12 13 14 Whereas, five-year survival is higher in patients who received bystander cardiopulmonary 15 resuscitation (CPR) during an out-of-hospital cardiac arrest (14.3 percent versus 8.7 percent, 16 p<0.001), and 17 18 Whereas, increased survival from receiving bystander CPR translates to an average increase 19 of quality-adjusted life-years, and 20 21 Whereas, the American Heart Association has determined that the standard of care for out- 22 of-hospital cardiac arrest is 9-1-1 dispatchers delivering telephone CPR (T-CPR), and 23 24 Whereas, Module II of the 9-1-1 dispatcher training currently consists of 40 total hours of 25 training, including eight hours of study on domestic violence, suicide intervention, 9-1-1 liability, 26 stress management, and homeland security elective, and 27 28 Whereas, rapid recognition of out-of-hospital cardiac arrest and delivery of T-CPR is not 29 currently listed as one of the essential job tasks of 9-1-1 dispatchers in the state of Michigan in the 30 Dispatcher Training Manual, and 31 32 Whereas, T-CPR is a set of skills that can be taught in three to four hours of additional 33 training, and 34 35 Whereas, Louisiana, Kentucky, Wisconsin, Indiana, West Virginia, and Maryland already 36 mandate T-CPR training for 9-1-1 dispatchers; therefore be it 37 38 RESOLVED: That MSMS advocate for mandatory training for 9-1-1 dispatchers to provide 39 telephone cardiopulmonary resuscitation for out-of-hospital cardiac arrests. 40 41 42 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 43 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy:

Cardiopulmonary Resuscitation (CPR) and Defibrillators H-130.938 Our AMA: (1) supports publicizing the importance of teaching CPR, including the use of automated external defibrillation; (2) strongly recommends the incorporation of CPR classes as a voluntary part of secondary school programs; (3) encourages the American public to become trained in CPR and the use of automated external defibrillators; (4) advocates the widespread placement of automated external defibrillators, including on all grade K-12 school campuses and locations at which school events are held; (5) encourages all grade K-12 schools to develop an emergency action plan for sudden cardiac events; (6) supports increasing government and industry funding for the purchase of automated external defibrillator devices; (7) endorses increased funding for cardiopulmonary resuscitation and defibrillation training of community organization and school personnel; (8) supports the development and use of universal connectivity for all defibrillators; (9) supports legislation that would encourage high school students be trained in cardiopulmonary resuscitation and automated external defibrillator use; (10) will update its policy on cardiopulmonary resuscitation and automated external defibrillators (AEDs) by endorsing efforts to promote the importance of AED use and public awareness of AED locations, by using solutions such as integrating AED sites into widely accessible mobile maps and applications; (11) urges AED vendors to remove labeling from AED stations that stipulate that only trained medical professionals can use the defibrillators; and (12) supports consistent and uniform legislation across states for the legal protection of those who use AEDs in the course of attempting to aid a sudden cardiac arrest victim.

Sources: 1. Geri, G., Fahrenbruch, C., Meischke, H., Painter, I., White, L., Rea, T. D., & Weaver, M. R. (2017). Effects of bystander CPR following out-of-hospital cardiac arrest on hospital costs and long-term survival. Resuscitation, 115, 129-134. https://doi.org/10.1016/j.resuscitation.2017.04.016 2. Telephone CPR Recommendations and Performance Measures. (n.d.). Cpr.Heart.Org. Retrieved February 22, 2020, from https://cpr.heart.org/en/resuscitation-science/telephone-cpr/t-cpr- recommendations-and-performance-measures 3. Dispatcher Training Subcommittee. (n.d.). Telecommunicator Training Program Manual. State 911 Committee. Retrieved February 22, 2020, from https://www.michigan.gov/documents/msp/Dispatcher_Training_Manual_2013_455386_7.pdf 4. Telephone CPR could save lives. States are starting to require 911 operators to be trained for it, CNN. (n.d.). Retrieved February 22, 2020, from https://www.cnn.com/2019/04/09/health/telephone-cpr- trnd/index.html 1 RESOLUTION 11-21 2 3 Title: Updates to Organ Donation and Transplant Policies 4 5 Introduced by: Richard Burney, MD, for the Washtenaw County Delegation 6 7 Original Author: Richard Burney, MD 8 9 Referred To: Reference Committee D 10 11 House Action: 12 13 14 Whereas, living donation provides expanded access to kidney and liver transplants to 15 appropriate candidates, preventing waitlist death and in turn increasing organ availability of other 16 candidates to deceased donor transplants, and 17 18 Whereas, living donors often face considerable financial hardships to facilitate donation, 19 including time off employment and travel expenses, which are not able to be directly reimbursed 20 by law, and 21 22 Whereas, the Gift of Life Michigan is the state's only federally designated organ and tissue 23 recovery program, and 24 25 Whereas, the Gift of Life Michigan recovers organs from HIV-positive donors, in accordance 26 with the federal HIV Organ Policy Equity Act, or HOPE Act, and 27 28 Whereas, in Michigan, policy that was created decades ago during the AIDS crisis prohibits 29 blood and other anatomical gifts from HIV-positive donors to be given to recipients, even those 30 who are HIV-positive, and 31 32 Whereas, proposed legislation in Michigan would remove this outdated restriction on 33 organs and as a result, those organs could go to HIV-positive patients, instead of being allocated 34 out-of-state, and 35 36 Whereas, transplant programs that do not have waiting recipients who are HIV-positive also 37 will benefit, because more available organs relieves pressure on the waiting list in-state and 38 nationwide; therefore be it 39 40 RESOLVED: That MSMS amend MSMS policy, “Payment for Organs,” by addition to read as 41 follows: 42 43 MSMS opposes payment in any form to the donor, the donor’s family members, or the 44 donor’s agents for organs used for transplant. Payment does not mean provisions for 45 donation-related expenses incurred by a living organ donor including, but not limited 46 to medical expenses related to the donation or expenses incurred after the donation 47 as a consequence of donation; and be it further 48 49 RESOLVED: That MSMS actively advocate for and endorse legislation in Michigan that 50 would enable organ transplants from HIV-positive donors to HIV-positive recipients. 51 52 53 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 54 $25,000+

STATEMENT OF URGENCY: There is current legislation (sponsor Rep. Felicia Brabec) pending in the Michigan legislature related to organ donation and transplant policies. This is a joint advocacy opportunity supported by the Gift of Life Michigan.

Relevant MSMS Policy:

Payment for Organs MSMS opposes payment in any form to the donor, the donor’s family members, or the donor’s agents for organs used for transplant. (Res5-93A)

Relieve Burden for Living Organ Donors MSMS supports efforts to remove financial barriers to living organ donation, such as the provision of paid leave for organ donation. (Res61-17)

Relevant AMA Policy:

6.1.1 Transplantation of Organs from Living Donors Donation of nonvital organs and tissue from living donors can increase the supply of organs available for transplantation, to the benefit of patients with end-stage organ failure. Enabling individuals to donate nonvital organs is in keeping with the goals of treating illness and relieving suffering so long as the benefits to both donor and recipient outweigh the risks to both. Living donors expose themselves to harm to benefit others; novel variants of living organ donation call for special safeguards for both donors and recipients. Physicians who participate in donation of nonvital organs and tissues by a living individual should: (a) Ensure that the prospective donor is assigned an advocacy team, including a physician, dedicated to protecting the donor’s well-being. (b) Avoid conflicts of interest by ensuring that the health care team treating the prospective donor is as independent as possible from the health care team treating the prospective transplant recipient. (c) Carefully evaluate prospective donors to identify serious risks to the individual’s life or health, including psychosocial factors that would disqualify the individual from donating; address the individual’s specific needs; and explore the individual’s motivations to donate. (d) Secure agreement from all parties to the prospective donation in advance so that, should the donor withdraw, his or her reasons for doing so will be kept confidential. (e) Determine that the prospective living donor has decision-making capacity and adequately understands the implications of donating a nonvital organ, and that the decision to donate is voluntary. (f) In general, decline proposed living organ donations from unemancipated minors or legally incompetent adults, who are not able to understand the implications of a living donation or give voluntary consent to donation. (g) In exceptional circumstances, enable donation of a nonvital organ or tissue from a minor who has substantial decision-making capacity when: (i) the minor agrees to the donation; (ii) the minor’s legal guardians consent to the donation; (iii) the intended recipient is someone to whom the minor has an emotional connection. (h) Seek advice from another adult trusted by the prospective minor donor when circumstances warrant, or from an independent body such as an ethics committee, pastoral service, or other institutional resource. (i) Inform the prospective donor: (i) about the donation procedure and possible risks and complications for the donor; (ii) about the possible risks and complications for the transplant recipient; (iii) about the nature of the commitment the donor is making and the implications for other parties; (iv) that the prospective donor may withdraw at any time before undergoing the intervention to remove the organ or collect tissue, whether the context is paired, domino, or chain donation; and (v) that if the donor withdraws, the health care team will report simply that the individual was not a suitable candidate for donation. (j) Obtain the prospective donor’s separate consent for donation and for the specific intervention(s) to remove the organ or collect tissue. (k) Ensure that living donors do not receive payment of any kind for any of their solid organs. Donors should be compensated fairly for the expenses of travel, lodging, meals, lost wages, and medical care associated with the donation only. (l) Permit living donors to designate a recipient, whether related to the donor or not. (m) Decline to facilitate a living donation to a known recipient if the transplantation cannot reasonably be expected to yield the intended clinical benefit or achieve agreed on goals for the intended recipient. (n) Permit living donors to designate a stranger as the intended recipient if doing so produces a net gain in the organ pool without unreasonably disadvantaging others on the waiting list. Variations on donation to a stranger include: (i) prospective donors who respond to public solicitations for organs or who wish to participate in a paired donation (“organ swap,” as when donor-recipient pairs Y and Z with incompatible blood types are recombined to make compatible pairs: donor-Y with recipient-Z and donor-Z with recipient-Y); (ii) domino paired donation; (iii) nonsimultaneous extended altruistic donation (“chain donation”). (o) When the living donor does not designate a recipient, allocate organs according to the algorithm that governs the distribution of deceased donor organs. (p) Protect the privacy and confidentiality of donors and recipients, which may be difficult in novel donation arrangements that involve many patients and in which donation-transplant cycles may be extended over time (as in domino or chain donation). (q) Monitor prospective donors and recipients in proposed nontraditional donation arrangements for signs of psychological distress during screening and after the transplant is complete. (r) Support the development and maintenance of a national database of living donor outcomes to support better understanding of associated harms and benefits and enhance the safety of living donation. AMA Principles of Medical Ethics: I,V,VII,VIII

6.2.2 Directed Donation of Organs for Transplantation Efforts to increase the supply of organs available for transplant can serve the interests of individual patients and the public and are in keeping with physicians’ obligations to promote the welfare of their patients and to support access to care. Although public solicitations for directed donation—that is, for donation to a specific patient—may benefit individual patients, such solicitations have the potential to adversely affect the equitable distribution of organs among patients in need, the efficacy of the transplant system, and trust in the overall system.

Donation of needed organs to specified recipients has long been permitted in organ transplantation. However, solicitation of organs from potential donors who have no pre-existing relationship with the intended recipient remains controversial. Directed donation policies that produce a net gain of organs for transplantation and do not unreasonably disadvantage other transplant candidates are ethically acceptable.

Physicians who participate in soliciting directed donation of organs for transplantation on behalf of their patients should:

(a) Support ongoing collection of empirical data to monitor the effects of solicitation of directed donations on the availability of organs for transplantation. (b) Support the development of evidence-based policies for solicitation of directed donation. (c) Ensure that solicitations do not include potentially coercive inducements. Donors should receive no payment beyond reimbursement for travel, lodging, lost wages, and the medical care associated with donation. (d) Ensure that prospective donors are fully evaluated for medical and psychosocial suitability by health care professionals who are not part of the transplant team, regardless of any relationship, or lack of relationship, between prospective donor and transplant candidate. (e) Refuse to participate in any transplant that he or she believes to be ethically improper and respect the decisions of other health care professionals should they choose not to participate on ethical or moral grounds. AMA Principles of Medical Ethics: VII,VIII,IX

Removing Financial Barriers to Living Organ Donation H-370.965 1. Our AMA supports federal and state laws that remove financial barriers to living organ donation, such as: (a) provisions for expenses involved in the donation incurred by the organ donor; (b) providing access to health care coverage of any medical expense related to the donation; (c) provisions for expenses incurred after the donation as a consequence of donation; (d) prohibiting employment discrimination on the basis of living donor status; (e) prohibiting the use of living donor status as the sole basis for denying or limiting health, life, and disability and long-term care insurance coverage; and (f) provisions to encourage paid leave for organ donation. 2. Our AMA supports legislation expanding paid leave for organ donation. 3. Our AMA advocates that live organ donation surgery be classified as a serious health condition under the Family and Medical Leave Act.

Sources: 1. https://www.kidneynews.org/kidney-news/cover-story/kidney-donation-costs-too-high-for-potential- donors-with-low- income#:~:text=For%20donors%2C%20however%2C%20the%20reported,month%27s%20salary%20for% 20most%20donors 2. https://www.giftoflifemichigan.org/about-us 3. https://optn.transplant.hrsa.gov/learn/professional-education/hope-act/

1 RESOLUTION 24-21 2 3 Title: Improved Outreach to Minority Communities Regarding the COVID-19 4 Vaccine 5 6 Introduced by: Alangoya Tezel, for the Medical Student Section 7 8 Original Author: Sarosh Irani, Hannah Kimmel, Kayla Meyer, and Eric Rosen 9 10 Referred To: Reference Committee D 11 12 House Action: 13 14 15 Whereas, numerous historic bioethical violations of trust have been enacted upon minority 16 communities by medical institutions in human subjects research, and 17 18 Whereas, such violations of trust include the U.S. Public Health Service Syphilis Study at 19 Tuskegee, gynecological experimentation without anesthesia by J. Marion Sims, MD, and the HeLa 20 cell line borne from cells unknowingly and non-consensually taken from Henrietta Lacks by 21 researchers at Johns Hopkins Hospital, which particularly harm the relationship between the 22 African-American/Black community and medical institutions, and 23 24 Whereas, these violations are the backdrop to present-day racial discrimination, false racial 25 beliefs, and inequitable medical care allocation, access, and quality of care received by minority 26 communities, furthering the need for medical and governmental institutions to earn the trust of 27 Black and Latinx patients, and 28 29 Whereas, data has shown that COVID-19 hospitalization rates have been at least 2.5 times 30 higher in minority populations, and 31 32 Whereas, minority population tend to be overrepresented in occupations that are 33 considered "frontline," and therefore at higher risk of contracting COVID-19, and 34 35 Whereas, this discrepancy is rooted in years of inequality in housing, transportation, and 36 health care, and 37 38 Whereas, a September 2020 study by the NAACP and the COVID Collaborative that two of 39 three in the Black community believe "the government can rarely/never be trusted to look after 40 their interests" and that knowledge of the Tuskegee Syphilis Study is a negative predictor of 41 vaccine uptake, and 42 43 Whereas, this same study found that only 14 percent of Black Americans and 34 percent of 44 Latinx Americans "mostly or completely trust that a vaccine will be safe," and 45 46 Whereas, a December 2020 survey found that while 58 percent of white Michigan voters 47 plan to get the vaccine, only 33 percent of Black respondents intend to get the vaccine, with 26.1 48 percent saying "it depends," and 49 50 Whereas, the Minnesota Immunization Networking Initiative (MINI) successfully reached 51 vulnerable communities to administer influenza vaccines through building relationships with 52 community leaders, especially in faith communities, and holding clinics in these community-based 53 settings, and 54 55 Whereas, similar strategies were implemented in the vaccine development stage to actively 56 recruit and involve populations most affected by COVID-19, specifically racial and ethnic minorities, 57 and 58 Whereas, the Michigan COVID-19 Vaccination Plan has already addressed key partners for 59 critical populations to engage, including school-based health centers, faith-based leaders, and 60 other services where minority populations in Michigan reside and gather; therefore be it 61 62 RESOLVED: That MSMS will encourage evidence-based, community-driven interventions to 63 build trust between minority populations and health care institutions with increased urgency, given 64 the COVID-19 pandemic underscoring the disproportionate impact of longstanding historical 65 violations of trust; and be it further 66 67 RESOLVED: That MSMS will support the implementation of proven community-centered 68 strategies, such as collaboration with faith and school-based leaders, for education and 69 dissemination of information, specifically as it pertains to promotion of COVID-19 vaccination 70 uptake and vaccine education to minority populations; and be it further 71 72 RESOLVED: That MSMS supports community-centered strategies for annual vaccination 73 efforts, including influenza and childhood vaccine outreach. 74 75 76 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 77 or AMA policy - $500

Relevant MSMS Policy:

MSMS Task Force on Implicit Bias and Health Disparities Problem Statement: As leaders of change, physicians must be introspective and examine their own unconscious biases, including how those biases may inadvertently influence care decisions, as well as the systemic barriers to health equity within their places of employment and the system as a whole. Collective action is necessary to address institutional factors and social determinants that are roadblocks to achieving true health equity. Goal: To eliminate health disparities by pursuing health equity throughout society by direct engagement with policymakers, medical schools, health care leaders, members, and other stakeholders to advance policies that lead to a more diverse physician workforce, greater cultural awareness, mitigation of social determinants of health, and transparent and equitable organizational structures.

Relevant AMA Policy: None

Sources: 1. Scharff, D. P., Mathews, K. J., Jackson, P., Hoffsuemmer, J., Martin, E., & Edwards, D. (2010). More than Tuskegee: understanding mistrust about research participation. Journal of health care for the poor and underserved, 21(3), 879-897. https://doi.org/10.1353/hpu.0.0323 2. Mokwunye, N. O. (2006). African Americans' Trust and the Medical Research Community. Online Journal of Health Ethics, 3(1). http://dx.doi.org/10.18785/ojhe.0301.03 3. Gamble V. N. (1997). Under the shadow of Tuskegee: African Americans and health care. American journal of public health, 87(11), 1773-1778. https://doi.org/10.2105/ajph.87.11.1773 4. Ojanuga D. (1993). The medical ethics of the 'father of gynaecology', Dr J Marion Sims. Journal of medical ethics, 19(1), 28-31. https://doi.org/10.1136/jme.19.1.28 5. Boulware, L. E., Cooper, L. A., Ratner, L. E., LaVeist, T. A., & Powe, N. R. (2003). Race and trust in the health care system. Public health reports (Washington, D.C. : 1974), 118(4), 358-365. https://doi.org/10.1093/phr/118.4.358 6. Henrietta Lacks: Science must right a historical wrong. (2020). Nature, 585(7). doi:https://doi.org/10.1038/d41586-020-02494-z 7. Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America, 113(16), 4296-4301. https://doi.org/10.1073/pnas.1516047113 8. Williams, D. R., & Rucker, T. D. (2000). Understanding and addressing racial disparities in health care. Health care financing review, 21(4), 75-90 9. Sabin, J. A., & Greenwald, A. G. (2012). The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. American journal of public health, 102(5), 988-995. https://doi.org/10.2105/AJPH.2011.300621 10. Armstrong, K., Ravenell, K. L., McMurphy, S., & Putt, M. (2007). Racial/ethnic differences in physician distrust in the United States. American journal of public health, 97(7), 1283-1289. https://doi.org/10.2105/AJPH.2005.080762 11. Khazanchi, R., Evans, C. T., & Marcelin, J. R. (2020). Racism, not race, drives inequity across the COVID-19 continuum. JAMA network open, 3(9), e2019933-e2019933 12. Devakumar, D., Shannon, G., Bhopal, S. S., & Abubakar, I. (2020). Racism and discrimination in COVID-19 responses. The Lancet, 395(10231), 1194 13. Chapman, A. (2020). Ameliorating COVID-19's Disproportionate Impact on Black and Hispanic Communities: Proposed Policy Initiatives for the United States. Health and Human Rights, 22(2), 329 14. Covid Collaborative; NAACP; Unidos US; Langer Research Associates. (2020, September). Coronavirus Vaccine Hesitancy in Black and Latinx Communities. covidcollaborative.us. https://www.covidcollaborative.us/content/vaccine-treatments/coronavirus-vaccine-hesitancy-in-black- and-latinx-communities. 15. Detroit Regional Chamber; Glengariff Group Inc. (2020, December 5). Michigan Statewide Covid-19 Pandemic Survey. DetroitChamber.com. https://www.detroitchamber.com/wp- content/uploads/2020/12/December-2020-Michigan-Pandemic-Survey-Report.pdf 16. Peterson, P., McNabb, P., Maddali, S. R., Heath, J., & Santibañez, S. (2019). Engaging Communities to Reach Immigrant and Minority Populations: The Minnesota Immunization Networking Initiative (MINI), 2006-2017. Public Health Reports, 134(3), 241-248. https://doi.org/10.1177/0033354919834579 17. United States Department of Health and Human Services. Food and Drug Administration. Center for Biologics Evaluation and Research. (2020). Development and Licensure of Vaccines to Prevent COVID-19: Guidance for Industry. (Docket No. FDA-2020-D-1137). Retrieved from https://www.fda.gov/regulatory- information/search-fda-guidance-documents/development-and-licensure-vaccines-prevent-covid-19 18. Jaklevic MC. (2020). Researchers Strive to Recruit Hard-Hit Minorities Into COVID-19 Vaccine Trials. JAMA, 324(9), 826-828. doi:10.1001/jama.2020.11244 19. Michigan Department of Health & Human Services. (2020). COVID-19 Vaccination Plan: Michigan. Retrieved from https://www.michigan.gov/documents/coronavirus/COVID- 19_Vaccination_Plan_for_Michigan_InterimDraft10162020_705598_7.pdf 1 2 RESOLUTION 25-21 3 4 Title: Public Health Considerations to Reduce Harm in Encampment Removals 5 6 Introduced by: Mara Darian, for the Medical Student Section 7 8 Original Authors: Jennifer Byk, Arjun Chadha, Zoey Chopra, Sanjay Das, Moustafa Hadi, Sarosh 9 Irani, Jessyca Judge, Man Yee Keung, Remonda Khalil, Darian Mills, Chan 10 Nguyen, Alangoya Tezel, and Melanie Valentin, Will Vander Pols, and Francis 11 Yang 12 13 Referred to: Reference Committee D 14 15 House Action: 16 17 18 Whereas, 61,832 Michiganders experienced homelessness in 2019, with numbers growing 19 especially in the past year secondary to the pandemic and its economic crisis, with an estimated 20 250,000 new people expected to join this year nation-wide, and 21 22 Whereas, more people are living in urban encampments with growing income inequality 23 and housing insecurity, with up to 26 percent of Michiganders experiencing homelessness in 2018 24 living in an unsheltered location such as the street or in a tent camp, and 25 26 Whereas, people experiencing homelessness already face significant health disparities and 27 are more than twice as likely to have a chronic physical or mental health condition compared to the 28 general U.S. population, and 29 30 Whereas, the majority of current encampment closures fail in offering humane options for 31 individuals experiencing homelessness due to a lack of holistic aftercare support that addresses 32 housing, substance use, family reunification, and autonomy and further separates individuals from 33 those resources, and 34 35 Whereas, individuals who have experienced abuse or trauma indoors may choose to live in 36 encampments and avoid shelters because they do not want to relive that trauma and that negative 37 experiences with shelters have not been appropriately addressed by current housing initiatives, and 38 39 Whereas, police and sanitation departments largely break up encampments primarily on the 40 grounds that they are visually unsightly and not due to public health concerns, and 41 42 Whereas, the threat of unannounced encampment sweeps can lead to individuals being 43 hesitant to access medical care, due to the possibility of their belongings and lifesaving 44 medications being confiscated while they are gone, and is “disruptive to people who are 45 attempting to stabilize their lives and find a pathway to housing, and they may have lasting 46 traumatic psychological and emotional impact,” and 47 48 Whereas, the U.S. Interagency Council on Homelessness (USICH) stated in 2015, “The forced 49 dispersal of people from encampment settings is not an appropriate solution or strategy ... and can 50 make it more difficult to provide such lasting solutions to people who have been sleeping and 51 living in the encampment” and that “government agencies, service providers, [and] law 52 enforcement ... should work together to understand the needs of those living in an encampment 53 while assessing the needs of the service providers themselves,” and 54 55 Whereas, clearance of encampments “with little or no support may actually reduce the 56 likelihood that people will seek shelter because it erodes trust and creates an adversarial 57 relationship between people experiencing homelessness and law enforcement or outreach 58 workers,” and 59 60 Whereas, rather than removing encampments, the focus should be on improving sanitation 61 of existing sites to mitigate the environmental health issues such as inadequate waste disposal and 62 unsafe water, and 63 64 Whereas, the Center for Disease Control (CDC) guidelines on Interim Guidance on 65 Unsheltered Homelessness Coronavirus Disease 2019 (COVID-19) for Homeless Service Providers 66 and Local Officials states that “if individual housing options are not available, allow people who are 67 living unsheltered or in encampments to remain where they are,” and that “clearing encampments 68 can cause people to disperse throughout the community” leading to the increase in “potential for 69 infectious disease to spread,” and 70 71 Whereas, a study conducted in Denver showed that the COVID-19 positivity rate was three 72 times lower for those living in encampments compared to those living in shelters, and the closure 73 of homeless encampments during the COVID-19 pandemic is straining the capacity of homeless 74 shelters, disrupting or altogether halting the continuity of necessary medical care by separating 75 residents from their health care providers and putting more people at risk for transmission and 76 infection, and 77 78 Whereas, other cities have seen success in preventing and managing the spread of 79 infectious diseases, such as COVID-19, within encampments following guidelines published by the 80 U.S. Department of Housing and Urban Development, and 81 82 Whereas, there have been numerous encampment removals in Detroit, Lansing, and Grand 83 Rapids since the pandemic began in defiance of CDC guidelines and the Michigan Department of 84 Health and Human Services’, which endorsed encampments as the “most immediate reasonable 85 alternative to congregate shelters” during COVID-19 and warned against clearing of encampments 86 without a clear plan for housing and transportation of those individuals, and 87 88 Whereas, on July 22, 2020, the city of Detroit adopted interim policy for encampment health 89 and safety concerns that dictates all relocations are done in collaboration with the Housing and 90 Revitalization Department, Detroit Health Department, and Detroit Police Department to ensure 91 CDC guidance is being followed and includes direct coordination with unsheltered individuals, 92 communication and notice for occupant relocation, and outreach staff to help occupants determine 93 next steps; therefore it be 94 95 RESOLVED: That MSMS oppose the removal and relocation of encampments in Michigan 96 without the involvement of public health departments to mitigate potential risks and harms to 97 those living in affected encampments, in following with CDC guidelines; and be it further

98 RESOLVED: That for any planned encampment sweeps, MSMS advocates for the 99 announcement of the planned removal to affected parties with at least 48-hour notice in order to 100 minimize the disruptive and harmful nature of encampment removal on people experiencing 101 homelessness; and be it further 102 103 RESOLVED: That MSMS encourage city governments in Michigan to adopt a similar policy 104 and algorithm as established by the city of Detroit to improve existing encampment sanitation and 105 safety and, in the event of public health recommendation of encampment clearance, establish 106 procedures to safely and humanely remove or relocate encampments. 107 108 109 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 110 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy:

Eradicating Homelessness H-160.903 Our AMA: (1) supports improving the health outcomes and decreasing the health care costs of treating the chronically homeless through clinically proven, high quality, and cost effective approaches which recognize the positive impact of stable and affordable housing coupled with social services; (2) recognizes that stable, affordable housing as a first priority, without mandated therapy or services compliance, is effective in improving housing stability and quality of life among individuals who are chronically-homeless; (3) recognizes adaptive strategies based on regional variations, community characteristics and state and local resources are necessary to address this societal problem on a long-term basis; (4) recognizes the need for an effective, evidence-based national plan to eradicate homelessness; (5) encourages the National Health Care for the Homeless Council to study the funding, implementation, and standardized evaluation of Medical Respite Care for homeless persons; (6) will partner with relevant stakeholders to educate physicians about the unique healthcare and social needs of homeless patients and the importance of holistic, cost-effective, evidence-based discharge planning, and physicians’ role therein, in addressing these needs; (7) encourages the development of holistic, cost-effective, evidence-based discharge plans for homeless patients who present to the emergency department but are not admitted to the hospital; (8) encourages the collaborative efforts of communities, physicians, hospitals, health systems, insurers, social service organizations, government, and other stakeholders to develop comprehensive homelessness policies and plans that address the healthcare and social needs of homeless patients; (9) (a) supports laws protecting the civil and human rights of individuals experiencing homelessness, and (b) opposes laws and policies that criminalize individuals experiencing homelessness for carrying out life- sustaining activities conducted in public spaces that would otherwise be considered non-criminal activity (i.e., eating, sitting, or sleeping) when there is no alternative private space available; and (10) recognizes that stable, affordable housing is essential to the health of individuals, families, and communities, and supports policies that preserve and expand affordable housing across all neighborhoods. Res. 401, A-15; Appended: Res. 416, A-18; Modified: BOT Rep. 11, A-18; Appended: BOT Rep. 16, A-19; Appended: BOT Rep. 28, A-19

Eradicating Homelessness: 440.048MSS AMA-MSS will ask the AMA to: (1) support improving the health outcomes and decreasing the health care costs of treating the chronically homeless through housing first approaches; and (2) support the appropriate organizations in developing an effective national plan to eradicate homelessness. MSS Res 33, A-14; Reaffirmed: MSS GC Rep A, I-19

Housing Provision and Social Support to Immediately Alleviate Chronic Homelessness in the United States: 440.060MSS AMA-MSS will ask that our AMA amend policy H-160.903 by addition and deletion to read as follows: Eradicating Homelessness H-160.903 Our American Medical Association: (1) supports improving the health outcomes and decreasing the health care costs of treating the chronically homeless through clinically proven, high quality, and cost effective approaches which recognize the positive impact of stable and affordable housing coupled with social services; (2) will work with state medical societies to advocate for legislation implementing stable, affordable housing and appropriate voluntary social services as a first priority in the treatment of chronically-homeless individuals, without mandated therapy or services compliance and (3) supports the appropriate organizations in developing an effective national plan to eradicate homelessness. MSS Res 38, I-16; AMA Res 208, A-17 Referred

Opposition to Measures That Criminalize Homelessness: 440.066MSS AMA-MSS will ask the AMA to 1) oppose measures that criminalize necessary means of living among homeless persons, including, but not limited to, sitting or sleeping in public spaces; and (2) advocate for legislation that require nondiscrimination against homeless persons, such as homeless bills of rights. MSS Res 410, A-18

Sources: 1. Michigan Campaign to End Homelessness; 2020. https://www.michigan.gov/documents/mcteh/2019_MCTEH_Annual_Report_713330_7.pdf Accessed February 11, 2021 2. COVID-19 and the State of Homelessness. National Alliance to End Homelessness. https://endhomelessness.org/covid-19-and-the-state-of-homelessness/ Published May 22, 2020. Accessed February 14, 2021. 3. N. State report: Michigan economy strong, but homelessness in families, seniors on the rise. WWMT. https://wwmt.com/news/local/state-report-michigan-economy-strong-but-homelessness-in-families- seniors-on-the-rise Published October 4, 2019. Accessed February 14, 2021 4. National Health Care for the Homeless Council; 2019. https://nhchc.org/wp- content/uploads/2019/08/homelessness-and-health.pdf Accessed February 11, 2021 5. Coffey S. Study confirms serious health problems, high trauma rates among unsheltered people in U.S. UCLA. https://newsroom.ucla.edu/releases/serious-health-conditions-trauma-unsheltered-homeless Published October 7, 2019. Accessed February 14, 2021 6. Hunter J, Linden-Retek P, Shebaya S, Halpert S. Welcome Home : the rise of tent cities in the United States. Community. https://community-wealth.org/content/welcome-home-rise-tent-cities-united-states. Published May 2, 2014. Accessed February 14, 2021 7. Speer J. “It's not like your home”: Homeless Encampments, Housing Projects, and the Struggle over Domestic Space. Antipode. 2016;49(2):517-535. doi:10.1111/anti.12275 8. Swept Away: Reporting on the Encampment Closure Crisis. National Coalition for the Homeless. https://nationalhomeless.org/swept-away/ Published August 1, 2016. Accessed February 14, 2021 9. Cusack M, Graham F, Metraux S, Metzger D, Culhane D. At the Intersection of Homeless Encampments and Heroin Addiction: Service Use Barriers, Facilitators, and Recommendations from the City of Philadelphia’s Encampment Resolution Pilot. Social Work in Public Health. Published online January 24, 2021:1-14. doi:10.1080/19371918.2021.1877591 10. Speer J. Urban makeovers, homeless encampments, and the aesthetics of displacement. Social & Cultural Geography. 2018;20(4):575-595. doi:10.1080/14649365.2018.1509115 11. Corrigan, Patrick, et al. "Community-based participatory research examining the health care needs of African Americans who are homeless with mental illness." Journal of health care for the poor and underserved 26.1 (2015): 119. 12. Bishari, Nuala Sawyer. “Drug Users Face Extra Health Challenges With Uptick in Homeless Sweeps.” SF Weekly, 26 July 2019, www.sfweekly.com/news/drug-users-face-extra-health-challenges-with-uptick-in- homeless-sweeps/ 13. Bishari, Nuala Sawyer. “Lost, Stolen, Sold: S.F. Violates Homeless Property Policy.” SF Weekly, 8 June 2019, www.sfweekly.com/news/lost-stolen-sold-s-f-violates-homeless-property-policy/ 14. Junejo, Samir and Skinner, Suzanne and Rankin, Sara, No Rest for the Weary: Why Cities Should Embrace Homeless Encampments (May 9, 2016). Seattle University School of Law, Homeless Rights Advocacy Project, 2016. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2776425 15. Jones, P., K. Parish, P. Radu, T. Smiley, and J. van der Heyde. Alternatives to Unsanctioned Homeless Encampments. Berkeley, CA: University of California, Berkeley, Goldman School of Public Policy. 2015 16. Siegel L, Singer J. Leave Baltimore's homeless encampments alone. The Baltimore Sun (Online). January 2018. 17. Against CDC Guidance, Some Cities Sweep Homeless Encampments. Against CDC Guidance Some Cities Sweep Homeless Encampments | The Pew Charitable Trusts. https://www.pewtrusts.org/en/research-and- analysis/blogs/stateline/2020/04/28/against-cdc-guidance-some-cities-sweep-homeless-encampments Published April 28, 2020. Accessed February 14, 2021 18. Tremoulet A. Addressing Homeless Encampments on Public Right-of-Way: A Knowledge Transfer Project. 2013. doi:10.15760/trec.137 19. "Tent City, USA: The Growth of America's Homeless Encampments and How Communities are Responding." Editorial. The National Law Center on Homelessness & Poverty, Oct. 2018, p. 50 20. Cohen, Rebecca and Yetvin, Will and Khadduri, Jill, Understanding Encampments of People Experiencing Homelessness and Community Responses: Emerging Evidence as of Late 2018. January 7, 2019. http://dx.doi.org/10.2139/ssrn.3615828 21. DiGuiseppi G, Corcoran C, Cunningham T, et al. Mobilizing a Community–Academic Partnership to Provide DIY Handwashing Stations to Skid Row Residents During COVID-19. Health Promotion Practice. 2020;22(1):9-12. doi:10.1177/1524839920953092 22. "Interim Guidance on People Experiencing Unsheltered Homelessness." Center for Disease Control, United States Center for Disease Control, 6 Aug. 2020, www.cdc.gov/coronavirus/2019- ncov/community/homeless-shelters/unsheltered-homelessness.html. 23. Homeless Camps Less Risky Than Shelters for COVID-19. Published October 27, 2020. Accessed February 13, 2021. https://www.medpagetoday.com/meetingcoverage/idweek/89353 24. Infectious Disease Toolkit for Continuums of Care. https://files.hudexchange.info/resources/documents/Infectious-Disease-Toolkit-for-CoCs-Preventing- and-Managing-the-Spread-of-Infectious-Disease-within-Encampments.pdf Published March 2020. Accessed February 15, 2021. 25. "Response to Address Encampment Health and Safety Concerns." City of Detroit Interim Policies & Procedures, 22 July 2020, p. 3. 26. Lehr S. Garbage trucks sent by city cart away some tents at Lansing homeless camp after death. Lansing State Journal. https://www.lansingstatejournal.com/story/news/2021/01/07/garbage-trucks-arrive-back- 40-homeless-camp-day-after- death/6582414002/?fbclid=IwAR0GO_AGecykDlRTqQHIuNUeUR0GUexl3MYTvO- mnPdyZnVo_Z_3dkSEdNU Published January 8, 2021. Accessed February 14, 2021 27. Kransz M. Emotions high as Grand Rapids cracks down on homeless encampments. mlive. https://www.mlive.com/news/grand-rapids/2020/12/emotions-high-as-grand-rapids-cracks-down-on- homeless-encampments.html Published December 22, 2020. Accessed February 14, 2021 28. https://nlchp.org/wp-content/uploads/2020/06/Encampment-Removal-Policy-Letter-Brenda-Jones-1.pdf 29. Barker K, Matthews D. U.S. Department of Housing and Urban Development; 2020. https://files.hudexchange.info/resources/documents/Infectious-Disease-Toolkit-for-CoCs-Preventing- and-Managing-the-Spread-of-Infectious-Disease-within-Encampments.pdf. Accessed February 11, 2021 1 RESOLUTION 35-21 2 3 Title: COVID-19 Vaccine Distribution Regarding People Experiencing 4 Homelessness 5 6 Introduced by: Laura Carravallah, MD 7 8 Original Authors: Elizabeth Anteau, Donita Barrameda, Tyler Gresham, Aleena Hajek, Rachel 9 Hollander, Laina Weinman, and Laura Carravallah, MD 10 11 Referred To: Reference Committee D 12 13 House Action: 14 15 16 Whereas, approximately 8,575 people in Michigan experience homelessness on a given day, 17 where homelessness is defined as “a person sleeping in a place not meant for human habitation 18 (e.g. living on the streets, for example) or living in a homeless emergency shelter,” and 19 20 Whereas, people experiencing homelessness have limited access to essential hygiene 21 supplies and lack of resources to safely social distance or self-quarantine without having their basic 22 needs threatened, and 23 24 Whereas, people experiencing homelessness are at increased risk to contract COVID-19 due 25 to close contact with varying people and are at increased risk for complications due to high rate of 26 underlying health conditions with an estimated peak infection rate of 40 percent and 4.3 percent 27 requiring hospitalization, compared to an estimated infection rate of less than ten percent in the 28 overall United States population, and 29 30 Whereas, people experiencing homelessness are more likely to have difficulty accessing 31 medical services/vaccinations traditionally, due to decreased internet, telephone, and/or 32 transportation access, and 33 34 Whereas, public health priorities are to prevent COVID-19 outbreaks in facilities and 35 vaccinate those who are not able to maintain social distance, people experiencing homelessness 36 are not included as a specific group in the phases although the workers of the shelter are, and 37 38 Whereas, some states such as North Carolina and Rhode Island have specifically listed 39 people who experience homelessness as part of their vaccine distribution strategy prior to 40 distribution to the general population; therefore be it 41 42 RESOLVED: That MSMS support the inclusion of people experiencing homelessness in an 43 earlier phase of COVID-19 vaccine distribution by advocating for them to be included as part of 44 phase 1B of the COVID-19 vaccine distribution plan or in an earlier distribution phase than the 45 general population; and be it further 46 47 RESOLVED: That MSMS support increased access to vaccines for people experiencing 48 homelessness by advocating for the provision of vaccines at sites easily accessible to people 49 experiencing homelessness such as shelters, food distribution centers, and community centers. 50 51 52 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 53 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy: None

Sources: 1. Michigan homelessness Statistics. (n.d.). Retrieved February 08, 2021, from https://www.usich.gov/homelessness-statistics/mi/ 2. Defining homelessness. (n.d.). Retrieved February 08, 2021, from http://www.housingaccess.net/defining- homelessness.html 3. Hadden, K., Partlow, D., Liverett, H., Payakachat, N., Jha, B., & Lipschitz, R. (2020, June 11). Addressing homelessness and covid-19 quarantine: A streamlined assessment and referral process. Retrieved February 08, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371311/ 4. Perri, M., Dosani, N., & Hwang, S. (2020, June 29). COVID-19 and people Experiencing Homelessness: Challenges and mitigation strategies. Retrieved February 08, 2021, from https://www.cmaj.ca/content/192/26/E716 5. Bajema KL, Wiegand RE, Cuffe K, et al. (2020, November 24). Estimated SARS-CoV-2 Seroprevalence in the US as of September 2020. JAMA Internal Medicine. Retrieved February 17, 2021, from https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2773576 6. National Health Care for the Homeless Council. (2020, December). COVID-19 & the HCH Community. Retrieved February 08, 2021, from https://nhchc.org/wp-content/uploads/2020/12/Issue-brief-10-COVID- 19-HCH-Community-Vaccines.pdf 7. Vaccine locations. (n.d.). Retrieved February 08, 2021, from https://www.michigan.gov/coronavirus/0,9753,7-406-98178_103214_104822---,00.html#comp_121341 MICHIGAN STATE MEDICAL SOCIETY 2021 HOUSE OF DELEGATES

RESOLUTIONS BY COMMITTEE

REFERENCE COMMITTEE E – SCIENTIFIC AND EDUCATIONAL AFFAIRS

RESOLUTION DESCRIPTION 44-20 Uniform Standards for Brain Death Determination 02-21 Vision Qualifications for Driver’s License 28-21 Access to Menstrual Products in Correctional Facilities 30-21 Over the Counter Hormonal Contraception 31-21 Availability of Medical Respite Centers

1 RESOLUTION 44-20 2 3 Title: Uniform Standards for Brain Death Determination 4 5 Introduced by: Mara Darian, for the Medical Student Section 6 7 Original Authors: Bhavna Guduguntla, Ahmad Hider, and Jiwon Park 8 9 Referred To: Reference Committee E 10 11 House Action: 12 13 14 Whereas, the American Academy of Neurology (AAN) has called for uniform brain death 15 laws, policies, and practices, and 16 17 Whereas, a specific, uniform standard for declaring brain death is critical for high quality 18 patient-centered neurologic and end-of-life care, as well as for patient and public trust, and 19 20 Whereas, the American Neurological Association and the Child Neurology Society have 21 declared their support for this AAN statement position, and 22 23 Whereas, brain death is defined as the death of the individual due to irreversible loss of 24 function of the entire brain and is the equivalent of circulatory death, which is due to irreversible 25 loss of function of the circulatory system, which includes the heart, and 26 27 Whereas, the 1981 Uniform Determination of Death Act (UDDA) deferred to the medical 28 profession to identify the “accepted medical standards” regarding death determination, the lack of 29 specificity in most states' laws and inconsistency among institutional brain death protocols has led 30 to differing interpretations by courts, and 31 32 Whereas, brain death policies vary considerably between institutions, states, and other 33 governing bodies, and 34 35 Whereas, AAN has published evidence-based guideline recommendations to assist 36 clinicians in determining brain death, and 37 38 Whereas, the AAN is unaware of a single case where these guidelines failed to accurately 39 declare brain death, and 40 41 Whereas, these guidelines function to clarify ambiguity in the UDDA while presenting a 42 uniform evidence-based protocol to declare brain death, and 43 44 Whereas, establishing such a uniform protocol will decrease the burden and reliance on 45 individual clinician judgement in determining brain death and will create consistency in practice; 46 therefore be it 47 48 RESOLVED: That MSMS support the American Academy of Neurology in their efforts to 49 establish universal brain death protocols; and be it further 50 RESOLVED: That MSMS support legislation that defers to current adult and pediatric brain 51 death guidelines and any future updates in the declaration of brain death; and be it further 52 53 RESOLVED: That MSMS support the adoption of uniform policies in medical facilities that 54 ensure compliance with uniform evidence-based guidelines for declaring brain death; and be it 55 further 56 57 RESOLVED: That MSMS support the development of programs that train physicians to 58 declare death by neurologic criteria and provide public and medical education regarding brain 59 death and its determination. 60 61 62 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 63 $25,000+

Relevant MSMS Policy:

Declaring a Patient Dead/End-of-Life Care Training MSMS supports implementation of curricula in end-of-life care, hospice, and declaration of patient death in residency training programs where appropriate and the development of continuing medical education programs in end-of-life care and sensitivity/communication training for physicians. (Res34-13)

Relevant AMA Policy: None

Sources: 1. James A. Russell, Leon G. Epstein, David M. Greer, Matthew Kirschen, Michael A. Rubin, Ariane Lewis. “Brain death, the determination of brain death, and member guidance for brain death accommodation requests.” Neurology (2019). DOI: https://doi.org/10.1212/WNL.0000000000006750 2. AAN CALLS FOR UNIFORMITY OF BRAIN DEATH DETERMINATION [press release]. American Academy of Neurology, American Academy of Neurology; 2 Jan. 2019. www.aan.com/PressRoom/Home/PressRelease/2687. 3. Wijdicks, E. F. M., Varelas, P. N., Gronseth, G. S., & Greer, D. M. (2010). Evidence-based guideline update: Determining brain death in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 74(23), 1911-1918. doi: 10.1212/wnl.0b013e3181e242a8 4. Bartscher , J. F., & Varelas, P. N. (2010). Determining Brain Death: No Room for Error. AMA Journal of Ethics, 12(11), 879-884. doi: 10.1001/virtualmentor.2010.12.11.pfor1-1011 1 RESOLUTION 02-21 2 3 Title: Vision Qualifications for Driver’s License 4 5 Introduced by: Patrick J. Droste, MD, for the Michigan Society of Eye Physicians & Surgeons 6 7 Original Author: Patrick J. Droste, MD 8 9 Referred To: Reference Committee E 10 11 House Action: 12 13 14 Whereas, current vision qualifications for operating motor vehicles were derived by various 15 states in the 1920s and 1930s, and 16 17 Whereas, the American Medical Association (2003) in its Physician's Guide to Assessing and 18 Counseling Older Drivers stated, "Although many states currently require far visual acuity of 20/40 19 for an unrestricted license, current research indicates that there is no scientific basis for this cut-off. 20 In fact, studies undertaken in some states have demonstrated that there is no increased crash risk 21 between 20/40 and 20/70 resulting in several new state requirements," and 22 23 Whereas, good data exists to recommend reconsideration of visual acuity standards in 24 many states, and 25 26 Whereas, it has been well known that some persons with reduced acuity continue to drive 27 safely, and 28 29 Whereas, persons with significant visual field defects that violate state licensure 30 requirements can be taught to drive safely, and 31 32 Whereas, tests for cognitive well-being are generally not used in motor vehicle licensure 33 testing protocols in most states, and 34 35 Whereas, denying drivers licensure without evidence to support that denial frequently 36 causes isolation, depression, and increased expenses for ill-advised and unnecessary medical visits, 37 and 38 39 Whereas, crash avoidance systems, unimagined one century ago, are routinely incorporated 40 in automotive and roadway systems, and 41 42 Whereas, autonomous vehicle technology is in advanced stages of development and has 43 been supported by MSMS, the AMA, and the National Highway Traffic and Safety Administration 44 (NHTSA), and 45 46 Whereas, it is well known that a large proportion of mortality involved auto crashes are 47 accompanied by "driver error,” and

48 Whereas, studies have been performed that show that drivers with the visual acuity less 49 than 20/50 can be safe and competent drivers, and 50 51 Whereas, the Michigan Society of Eye Physicians and Surgeons (MiSEPS) has submitted a 52 Council Advisory Recommendation (CAR: 21-03) to the American Academy of Ophthalmology 53 (AAO) urging state ophthalmologic societies to approach their legislators to consider reviewing, 54 perhaps relaxing, the visual acuity / visual field requirements for licensure while simultaneously 55 advocating for simple appropriate tests where cognitive decline is suspected; therefore be it 56 57 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) urge 58 our AMA to engage with stakeholders including, but not limited to, the American Academy of 59 Ophthalmology, National Highway Traffic Safety Commission, and interested state medical 60 societies, to make recommendations on standardized vision requirements and cognitive testing, 61 when applicable, for unrestricted and restricted driver’s licensing privileges; and be it further 62 63 RESOLVED: That MSMS work with the American Medical Association (AMA) in any efforts 64 by our AMA to seek stakeholder engagement to address standardized vision requirements and 65 cognitive testing, when applicable, for unrestricted and restricted driver’s licensing privileges. 66 MSMS shall communicate any resulting recommendations to the Michigan Secretary of State 67 legislative liaison, Michigan legislators serving on committees with oversight of transportation 68 issues, and other stakeholders as appropriate. 69 70 71 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 72 or AMA policy - $500 73 STATEMENT OF URGENCY: The Michigan Society of Eye Physicians and Surgeons (MiSEPS) has submitted a Council Advisory Recommendation (CAR: 21-03) to the American Academy of Ophthalmology (AAO) urging state ophthalmologic societies to approach their legislators to consider reviewing, perhaps relaxing, the visual acuity/visual field requirements for licensure while simultaneously advocating for simple appropriate tests where cognitive decline is suspected. Timing is everything. Waiting a year to introduce this resolution could be detrimental to harnessing the momentum that could put Michigan at the forefront of addressing this important national health and safety issue. Current vision qualifications for operating motor vehicles were derived with no firm scientific underpinnings by the various states in the 1920s and 1930s and are outdated. This CAR was cosponsored by 10 state and subspecialty societies showing national momentum and support for this effort. At the state level, legislation to update vision qualifications for operating motor vehicles serves the public good. It also offers a good opportunity for stronger relations, increased credibility and capacity building to be better prepared to stand up to potential threats to medically led vision care including the strong potential of a scope challenge by optometry.

Relevant MSMS Policy: None

Relevant AMA Policy:

8.2 Impaired Drivers & Their Physicians A variety of medical conditions can impair an individual’s ability to operate a motor vehicle safely, whether a personal car or boat or a commercial vehicle, such as a bus, train, plane, or commercial vessel. Those who operate a vehicle when impaired by a medical condition pose threats to both public safety and their own well-being. Physicians have unique opportunities to assess the impact of physical and mental conditions on patients’ ability to drive safely and have a responsibility to do so in light of their professional obligation to protect public health and safety. In deciding whether or how to intervene when a patient’s medical condition may impair driving, physicians must balance dual responsibilities to promote the welfare and confidentiality of the individual patient, and to protect public safety.

Not all physicians are in a position to evaluate the extent or effect of a medical condition on a patient’s ability to drive, particularly physicians who treat patients only on a short-term basis. Nor do all physicians necessarily have appropriate training to identify and evaluate physical or mental conditions in relation to the ability to drive. In such situations, it may be advisable to refer a potentially at-risk patient for assessment.

To serve the interests of their patients and the public, within their areas of expertise physicians should: (a) Assess at-risk patients individually for medical conditions that might adversely affect driving ability, using best professional judgment and keeping in mind that not all physical or mental impairments create an obligation to intervene. (b) Tactfully but candidly discuss driving risks with the patient and, when appropriate, the family when a medical condition may adversely affect the patient’s ability to drive safely. Help the patient (and family) formulate a plan to reduce risks, including options for treatment or therapy if available, changes in driving behavior, or other adjustments. (c) Recognize that safety standards for those who operate commercial transportation are subject to governmental medical standards and may differ from standards for private licenses. (d) Be aware of applicable state requirements for reporting to the licensing authority those patients whose impairments may compromise their ability to operate a motor vehicle safely. (e) Prior to reporting, explain to the patient (and family, as appropriate) that the physician may have an obligation to report a medically at-risk driver: (i) when the physician identifies a medical condition clearly related to the ability to drive; (ii) when continuing to drive poses a clear risk to public safety or the patient’s own well-being and the patient ignores the physician’s advice to discontinue driving; or (iii) when required by law.(f) Inform the patient that the determination of inability to drive safely will be made by other authorities, not the physician. (g) Disclose only the minimum necessary information when reporting a medically at-risk driver, in keeping with ethics guidance on respect for patient privacy and confidentiality.

Sources: 1. Keeney, A., (1976). The visually impaired driver and physician responsibilities. (American Journal of Ophthalmology) 83: 799-801. 2. American Medical Association, (2003) Physicians guide to assessing and counseling older drivers. pp. 1- 49. a. Essential Quote: "Although many states currently require far visual acuity for 20/40 for an unrestricted license, current research indicates that there is no scientific basis for this cut-off. In fact, studies undertaken in some states have demonstrated that there is no increased crash risk between 20/40 and 20/70 resulting in several new state requirements" page 45. 3. Rubin, G., Ng, E., et al., (2007) A prospective, population-based study of the role of visual impairment in motor vehicle crashes among older drivers: the SEE Study. (Investigative Ophthalmology & Visual Sciences) 48, (4) :1483-1491. a. Essential Quote: "Conclusions: Glare sensitivity, visual field loss and UFOV (useful field of vision) were significant predictors of crash involvement. Acuity, contrast sensitivity and stereo acuity were not associated with crashes. These results suggest that current vision screening for driver's licensure, based primarily on visual acuity, may miss important aspects of visual impairment." Owsley, C., Mc Gwin, G., (2010) Vision and driving. (Vision Research) 50:2348-2361. a. Essential Quote: "Based upon the research to date it is clear that if there is an association between visual acuity and driver safety, it is at best weak,...how does one rectify this conclusion in light of the significant findings from performance-based studies? One important consideration in this regard is that visual acuity related driving skill (e.g., sign recognition many not be crucial to the safe operation of a vehicle. Reading signage may be important for route planning or maintaining regulatory compliance with the "rule of the road" but it may not be critical for collision avoidance. " Owsley, C., Wood,. J., et al., (2015). A road map for interpreting the literature on vision and driving. (Survey of Ophthalmology) 60:250-262. Tervo, T., (2018) Driver's health and fitness as a cause of a fatal motor vehicle accident in Finland. (The Eye, The Brain, and The Auto) 2018 (Link and /or abstract available from CAR author PCH). Keeney, A., (1976) The visually impaired driver and physician responsibilities. (American Journal of Ophthalmology) 82 (5):799-801. Fonda, G., (1989) Legal blindness can be compatible with safe driving. (Ophthalmology) 96 (10):1457- 1459. Appel, S., Brilliant, R., et al., (1990) Driving with visual impairment: Facts and Issues. (Journal of Visual Rehabilitation) 4: 19-31. Peli, E., (2008) Driving with low vision: who, where, when and why. In Robert Massof, editor. (Albert and Jokobiec's Principles and Practice of Ophthalmology) 3rd Ed. Philadelphia, PA. Elsevier, 5369-5376. PLoS ONE 4. Johnson, C., Keltner, J., (1983) Incidence of visual field loss in 20,000 eyes and its relationship to driving performance. (Archive Ophthalmology) 10: 371-375. Wood, J., Troutbeck, R., (1992) Effect of restriction of the binocular visual field on driving performance. (Ophthal. Physiol. Opt.) 12: 291-298. Seculer, A., Bennett, P., et al., (2000) Effects of aging on the useful field of vision. (Experimental Aging research) 26: 103-120. Mc Gwin, G., Xie, A., et al., (2005) Visual field defects and the risk of motor vehicle collisions among patients with glaucoma. (Investigative Ophthalmology & Visual Science) 46 (12): 4437-4441. Wood, J., Mc Gwin, G., et al., (2009) On-road driving performance by persons with hemianopia and quadrantanopia. (Investigative Ophthalmology & Visual Science) 50(2):577-585. 5. Kasneci, E., Sipple, K., et al., (2014) Driving with binocular visual field loss? (Journal of Alzheimer's Disease and Head Tracking) PLoS ONE 9 (2):e8.7470) dol: 10.1371/journal.pone.0087470 Coyne, A., Feins, R., (1993) Driving patterns of dementia diagnostic clinic out patients. (New Jersey Medicine) 90: 615. Bedard, M., Molloy, D., (1998) Factors associated with motor vehicle crashes in cognitively impaired older adults. (Alzheimer Disease and Associated Disorders) 12: 135-139. Duchek, J., Hunt, L., et al., (1998) Alzheimer changes are common in aged drivers killed in single car crashes at intersections. (Forensic Science International) 96: 115-126. 6. Carr, D., (2000), The older adult driver. (American Family Physician) 7. Stutts, J., (2003). Driver Distraction and Traffic Crashes. (The Eye and The Auto) Link and/or abstract available from CAR author PCH. Coben, J., Zju, M., (2013). Keeping an eye on distracted driving. (Journal American Medical Association) 309:877-878. Lappin, J., (2020) Measuring the rate of human perception and the cost of spreading attention (The Eye, The Brain and The Auto) Lappin: https://vimeo.com/491423747. 8. MSMS Resolution #8-2019 AMA Resolution #427, June 2019 9. Stutts, J., (2003). Driver Distraction and Traffic Crashes. (The Eye and The Auto) Link and/or abstract available from CAR author PCH. Coben, J., Zju, M., (2013) Keeping an eye on distracted driving. (Journal American Medical Association) 309:877-878. Lappin, J., (2020) Measuring the rate of human perception and the cost of spreading attention (The Eye, The Brain and The Auto) Lappin: https://vimeo.com/491423747. 10. Keltner, J., Johnson, C., (1987) Visual function, driving safety and the elderly. (Ophthalmology) 1180-1188. Wood, J., Owens, D., (2005) Standard measures of visual acuity do not predict drivers' recognition or performance under day or night conditions (Optom Vis Sciences) 82: 698-705. Tervo, T., (2011) Observational failures and fatal traffic accidents (The Eye and The Auto) Link and/or abstract available from CAR author PCH. 11. Council Advisory Recommendation. CAR: 21-03. Shinar, D., (1977) Driver Visual Limitations, Diagnosis and Treatment. (NHTSA, US Department of Transportation, National Technical Information Service, Springfield, VA).

1 RESOLUTION 28-21 2 3 Title: Access to Menstrual Products in Correctional Facilities 4 5 Introduced by: Mara Darian, for the Medical Student Section 6 7 Original Authors: Yasmine Abushukur, Kaylie Bullock, Anne Grossbauer, Alice Hou, Yousef 8 Ibrahim, Tiffany Loh, Dana Rector, Leah Rotenbakh, and Manraj Sekhon 9 10 Referred To: Reference Committee E 11 12 House Action: 13 14 15 Whereas, nationwide approximately 200,000 women are in local jails or state prisons, while 16 16,000 women are in federal jails and prisons, and 17 18 Whereas, the length of stay for incarcerated women in Michigan prisons has increased 15.5 19 percent between the years of 2007 and 2017 and the number of women incarcerated in Michigan 20 prisons has increased more than 30 percent between the years of 1978 and 2015, and 21 22 Whereas, correctional facilities are severely lacking in providing menstrual products for 23 female-identifying inmates because they have not adapted to their changing population, as women 24 are the fastest growing population in the U.S. prison system, and 25 26 Whereas, the menstrual cycle affects all women of child-bearing age and inadequate access 27 to feminine hygiene products poses dire medical consequences such as toxic shock syndrome 28 (TSS), sepsis, and ovarian cancer, and 29 30 Whereas, many women have resorted to using makeshift tampons and pads, which can be 31 unsanitary and dangerous. In 2015, a woman in a Maryland prison developed toxic shock 32 syndrome as a result of makeshift products which resulted in an emergency hysterectomy, and 33 34 Whereas, basic menstrual products are not always available for women in Michigan prisons 35 and many women often purchase products with their own wages, and 36 37 Whereas, a box of eight tampons in Michigan correctional facilities ranges in price from 38 $4.97 to $7.10, and 39 40 Whereas, the average wage for an individual who is incarcerated in Michigan is between 14 41 to 56 cents per hour, making it nearly infeasible to purchase feminine hygiene products at their 42 current cost, and 43 44 Whereas, only 13 percent of an approximately $2 billion Michigan state corrections facilities 45 budget is allocated to health care services for inmates, and

46 Whereas, 73 percent of women in state prisons struggle with mental health disorders, 47 compared to 12 percent in the general population, and the symptoms of these disorders may be 48 perpetuated when access to menstrual health and hygiene products is limited, and

49 Whereas, the United Nations declares menstrual health and hygiene a basic human right 50 and is prioritized through its Sustainable Development Goals specifically in Goals 5.1, 5.6, and 6.2, 51 and 52 53 Whereas, the practice of restricting access to menstrual health products discriminates on 54 the basis of sex, therefore violating the Equal Protection Clause of the Fourteenth Amendment, and 55 56 Whereas, women in federal prisons already receive free hygiene products as mandated by 57 the 2018 First Step Act, and 58 59 Whereas, MSMS has previously considered reclassifying feminine products from paper 60 products to medical necessities but did not pass the resolution due to a request to make these 61 products purchasable via federally-funded Bridge cards, and 62 63 Whereas, the AMA has existing policy H-525.974 Considering Feminine Hygiene Products as 64 Medical Necessities that the AMA will work with federal, state, and specialty medical societies to 65 advocate for the removal of barriers to feminine hygiene products in state and local prisons and 66 correctional institutions to ensure incarcerated women be provided free of charge, the appropriate 67 type and quantity of feminine hygiene products including tampons for their needs; therefore be it 68 69 RESOLVED: That MSMS supports access to free menstrual products at all Michigan state 70 and local correctional facilities, regardless of an institution's private, state, or federal funding 71 source. 72 73 74 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 75 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy:

Considering Feminine Hygiene Products as Medical Necessities H-525.974 Our AMA will: (1) encourage the Internal Revenue Service to classify feminine hygiene products as medical necessities; and (2) work with federal, state, and specialty medical societies to advocate for the removal of barriers to feminine hygiene products in state and local prisons and correctional institutions to ensure incarcerated women be provided free of charge, the appropriate type and quantity of feminine hygiene products including tampons for their needs.

Sources: 1. Kajstura A. Women's Mass Incarceration: The Whole Pie 2019 | Prison Policy Initiative. Published October 29, 2019. Accessed February 15, 2021. https://www.prisonpolicy.org/reports/pie2019women.html 2. Women in Prison: Fewer but growing - Safe & Just Michigan. Published May 9, 2019. Accessed February 9, 2021. https://www.safeandjustmi.org/2019/05/09/women-in-prison-fewer-but-growing/ 3. Sawyer W. Women's incarceration rate in Michigan state prisons, 1978 to 2015 | Prison Policy Initiative. Published January 2018. Accessed February 9, 2021. https://www.prisonpolicy.org/graphs/MI_Women_Rates_1978_2015.html 4. Johnson, M. Progress on Providing Dignity to Menstruating Inmates. Human Rights at Home Blog (blog). https://lawprofessors.typepad.com/human_rights/2018/12/progress-on-providing-dignity-to- menstruating-inmates.html Published December 9, 2018. Accessed February 9, 2021 5. Crays, Allyson. Menstrual equity and justice in the United States. Sexuality, Gender & Policy. 2020;3.2: 134-147. Published October 19, 2020. Accessed February 9, 2021 6. Carney, MO. Cycles of Punishment: The Constitutionality of Restricting Access to Menstrual Health Products in Prisons . Boston College Law Review. 2020;61(7):1-55. Published October 2020. Accessed February 9, 2021 7. Billon A, Gustin MP, Tristan A, et al. Association of characteristics of tampon use with menstrual toxic shock syndrome in France. EClinicalMedicine. 2020;21:100308. Published 2020 Mar 10. doi:10.1016/j.eclinm.2020.100308 8. Laske, Bailey. "Tampons, pads cost money in Michigan's women's prison." Michigan State University of Journalism (2018) 9. Order Commissary. Tigg's Canteen Services. Accessed February 15, 2020. http://www.canteenservices.com/commissary-purchase-menus/ 10. Sawyer W. How Much Do Incarcerated People Earn in Each State |Prison Policy Initiative. Published April 2017. Accessed February 9, 2021 https://www.prisonpolicy.org/blog/2017/04/10/wages/ 11. Risko, Robin R. Budget Briefing : Corrections. House Fiscal Agency. https://www.house.mi.gov/hfa/PDF/Briefings/Corrections_BudgetBriefing_fy18-19.pdf Published January 2019. Accessed February 9, 2021 12. Covington, Stephanie S. Women and the Criminal Justice System. Women's Health Issues. 2007;7:180- 182. https://www.whijournal.com/article/S1049-3867(07)00079-5/fulltext Published May 7, 2007. Accessed February 9, 2021 13. UNICEF Guidance on Menstrual Health and Hygiene. unicef.org. https://www.unicef.org/wash/files/UNICEF-Guidance-menstrual-health-hygiene-2019.pdf Published March 2019. Accessed February 9, 2021 14. Grassley C. First Step Act. Washington D.C.: Senate; 2018. https://www.congress.gov/bill/115th- congress/senate-bill/3649 1 RESOLUTION 30-21 2 3 Title: Over the Counter Hormonal Contraception 4 5 Introduced by: Alangoya Tezel, for the Medical Student Section 6 7 Original Author: Erin Currey and Micaela Stevenson 8 9 Referred To: Reference Committee E 10 11 House Action: 12 13 14 Whereas, contraceptive vaginal rings and contraceptive patches have been available for 15 almost 20 years via prescription, and 16 17 Whereas, contraceptive rings and patches are documented to have relatively few side 18 effects, and 19 20 Whereas, these contraceptive methods have been linked to reduced rates of ovarian and 21 endometrial cancer, and 22 23 Whereas, these devices are effective forms of contraception with failure rates comparable to 24 those of combined oral contraceptive pills, and 25 26 Whereas, the United States continues to have the highest rates of unintended pregnancy in 27 the industrialized world, with 54.7 percent of all pregnancies unplanned in 2011, and 28 29 Whereas, unintended pregnancies are associated with delays in initiating prenatal care, 30 reduced likelihood of breastfeeding, increased risk of maternal depression, and increased risk of 31 physical violence during pregnancy, and 32 33 Whereas, reducing the unintended pregnancy rate is a national priority reflected in the 34 Healthy People 2020 goal, and 35 36 Whereas, unintended pregnancies disproportionately affect low-income women, Black 37 women, and women who have not completed high school, and 38 39 Whereas, cost of medical appointments and access to physicians is commonly cited as 40 barriers to receiving adequate contraceptive care, and 41 42 Whereas, the American College of Obstetricians and Gynecologists (ACOG) are in favor of 43 making all hormonal contraceptives available over the counter as stated in committee opinion 788, 44 and 45 46 Whereas, MSMS has already supported the ACOG Committee Opinion 544, to make oral 47 contraceptives available over the counter; therefore be it

48 RESOLVED: That MSMS supports the American College of Obstetricians and Gynecologists 49 Committee policy to allow contraceptive vaginal rings and contraceptive patches to be available 50 over the counter. 51 52 53 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 54 or AMA policy - $500

Relevant MSMS Policy:

Oral Contraceptives Available Over-the-Counter MSMS supports the American College of Obstetricians and Gynecologists’ committee opinion 544 which supports making oral contraceptives available as over the counter medication. (Res95-16)

Over the Counter Contraception (The Morning After Pill) MSMS supports the concept of making the “morning after” contraceptive pill an over the counter medication. (Res6--06A)

Relevant AMA Policy:

Over-the-Counter Access to Oral Contraceptives D-75.995 Our AMA: 1. Encourages manufacturers of oral contraceptives to submit the required application and supporting evidence to the US Food and Drug Administration for the Agency to consider approving a switch in status from prescription to over-the-counter for such products. 2. Encourages the continued study of issues relevant to over-the-counter access for oral contraceptives.

Sources: 1. Galzote RM, Rafie S, Teal R, Mody SK. Transdermal delivery of combined hormonal contraception: a review of the current literature. Int J Womens Health. 2017;9:315-321. Published 2017 May 15. doi:10.2147/IJWH.S102306 2. Trussell J, Aiken ARA, Micks E, Guthrie KA. Efficacy, safety, and personal considerations. In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc., 2018 3. Burkman, R. T. Contraception: Transdermal contraceptive patches 4. Access to contraception. Committee Opinion No. 615. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:250-5 5. American College of Obstetricians and Gynecologists. (2019). Over-the-Counter Access to Hormonal Contraception: ACOG Committee Opinion, Number 788. Obstet. Gynecol, 134, e96-e105 6. Hislop, David. Michigan State Medical Society. (2016) Resolution 95, Over the Counter Available Oral Contraceptives 7. Family Planning. Office of Disease Prevention and Health Promotion. Access February 22, 2021. https://www.healthypeople.gov/2020/topics-objectives/topic/family-planning 1 RESOLUTION 31-21 2 3 Title: Availability of Medical Respite Centers 4 5 Introduced by: Mara Darian, for the Medical Student Section 6 7 Original Author: Katanya C. Alaga 8 9 Referred To: Reference Committee E 10 11 House Action: 12 13 14 Whereas, the 2018 State of Homelessness Annual Report cited there were more than 10,700 15 people that experienced homelessness in the Detroit continuum in 2018 with 2,231 of them being 16 chronically homeless, and 17 18 Whereas, in a given year, homeless individuals are three times more likely to utilize 19 emergency room services than housed individuals and are more likely to be readmitted to inpatient 20 services, and 21 22 Whereas, when persons experiencing homelessness are hospitalized, they have longer 23 lengths of stay than housed patients and thus have increased medical costs, and 24 25 Whereas, homeless patients are often discharged into a setting, such as a homeless shelter 26 or back on the streets, where they cannot receive adequate care for their medical needs, and 27 28 Whereas, medical respite programs are centers staffed by health care providers and nurses 29 that provide medical care and housing to homeless patients who are too sick to be in a shelter or 30 on the streets, but not sick enough to require an inpatient stay, and 31 32 Whereas, there are a total of 65 medical respite programs in the United States and 3 respite 33 programs in Michigan located in Detroit, Pontiac, and Ann Arbor, with a total of only 45, 15, and 6 34 beds, respectively, and 35 36 Whereas, access to care in a medical respite center is restricted by limited beds and 37 resources, as well as specific program eligibility requirements, including that patients must be 38 independently mobile, patients have a condition that can be addressed within a relatively short 39 time, and patients must be able to perform their own activities of daily living, and 40 41 Whereas, the majority of medical respite programs receive funding from three or more 42 sources, the majority sourced from hospitals and private donations, and 18 percent of programs 43 receive public funding through Medicaid/Medicare, and 44 45 Whereas, medical respite care for homeless patients has been shown to reduce hospital 46 re-admittance rates and length of stay, increase outpatient provider visits, and decrease health care 47 charges, and

48 Whereas, a program in Boston demonstrated that patients discharged to a homeless respite 49 program experienced an approximate 50 percent reduction in readmission rates at 90 days post- 50 discharge, compared to those discharged to streets and shelters, and 51 52 Whereas, a two-year study in Durham, North Carolina assessing health care utilization 53 among homeless patients following a homeless medical respite pilot program determined that 54 hospital admissions decreased by 37 percent, inpatient days decreased by 70 percent, and medical 55 system charges for participants decreased by 48.6 percent, and 56 57 Whereas, an $800,000 investment in a medical respite program for homeless patients has 58 saved participating hospitals in Santa Rosa, California $17 million in the first three years, and 59 60 Whereas, emergency department residents have reported being more likely to admit a 61 homeless patient than a non-homeless patient experiencing the same illness, leading to resource- 62 intensive hospital stays that could be handled at the level of care provided in medical respite 63 centers, and 64 65 Whereas, our AMA supports “improving the health outcomes and decreasing the health 66 care costs of treating the chronically homeless through clinically proven, high quality, and cost 67 effective approaches” and “development of holistic, cost-effective, evidence-based discharge plans 68 for homeless patients who present to the emergency department but are not admitted to hospital,” 69 and 70 71 Whereas, the Board of Trustees recommends that “our AMA should encourage collaborative 72 efforts to address homelessness that do not leave hospitals and physicians alone to bear their 73 costs;” therefore be it 74 75 RESOLVED: That MSMS support increased availability of medical respite centers and 76 programs for use by the homeless population; and be it further 77 78 RESOLVED: That MSMS support local stakeholders to secure increased funding for medical 79 respite programs, including but not limited to expansion of current facilities in urban areas with 80 large populations of homeless individuals. 81 82 83 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 84 or AMA policy - $500

STATEMENT OF URGENCY: In light of the COVID19 pandemic, the effect of deficiencies in transitional care are even more detrimental to those experiencing homelessness. The WCMS has supported this resolution and we ask that the MSMS do the same.

Relevant MSMS Policy: None

Relevant AMA Policy:

Sources 1. 2018 State of Homelessness Annual Report for the Detroit Continuum of Care. Homeless Action Network of Detroit; 2018. https://static1.squarespace.com/static/5344557fe4b0323896c3c519/t/5d8106a6b87890058943840c/1568 736936423/2018+State+of+Homlessness+Annual+Report+for+the+Detroit+CoC.pdf 2. Sun R, Karaca Z, Wong HS. Characteristics of Homeless Individuals Using Emergency Department Services in 2014: Statistical Brief #229. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. http://www.ncbi.nlm.nih.gov/books/NBK481367/ 3. Lin W-C, Bharel M, Zhang J, O’Connell E, Clark RE. Frequent Emergency Department Visits and Hospitalizations Among Homeless People With Medicaid: Implications for Medicaid Expansion. Am J Public Health. 2015;105 Suppl 5:S716-722. doi:10.2105/AJPH.2015.302693 4. Hwang SW, Weaver J, Aubry T, Hoch JS. Hospital costs and length of stay among homeless patients admitted to medical, surgical, and psychiatric services. Med Care. 2011;49(4):350-354. doi:10.1097/MLR.0b013e318206c50d 5. Doran KM, Ragins KT, Gross CP, Zerger S. Medical Respite Programs for Homeless Patients: A Systematic Review. Journal of Health Care for the Poor and Underserved. 2013;24(2):499-524. doi:10.1353/hpu.2013.0053 6. Medical Respite Care: Financing Approaches. National Health Care for the Homeless Council; 2017. https://nhchc.org/wp-content/uploads/2019/08/policy-brief-respite-financing.pdf 7. Medical Respite Directory | National Health Care for the Homeless Council. https://nhchc.org/clinical- practice/medical-respite-care/medical-respite-directory/ 8. Buchanan D, Doblin B, Sai T, Garcia P. The Effects of Respite Care for Homeless Patients: A Cohort Study. Am J Public Health. 2006;96(7):1278-1281. doi:10.2105/AJPH.2005.067850 9. Kertesz SG, Posner MA, O’Connell JJ, et al. Post-Hospital Medical Respite Care and Hospital Readmission of Homeless Persons. J Prev Interv Community. 2009;37(2):129-142. doi:10.1080/10852350902735734 10. Biederman DJ, Gamble J, Wilson S, Douglas C, Feigal J. Health care utilization following a homeless medical respite pilot program. Public Health Nursing. 2019;36(3):296-302. doi:10.1111/phn.12589 11. Shetler D, Shepard DS. Medical Respite for People Experiencing Homelessness: Financial Impacts with Alternative Levels of Medicaid Coverage. Journal of Health Care for the Poor and Underserved. 2018;29(2):801-813. doi:10.1353/hpu.2018.0059 12. Doran KM, Vashi AA, Platis S, et al. Navigating the Boundaries of Emergency Department Care: Addressing the Medical and Social Needs of Patients Who Are Homeless. Am J Public Health. 2013;103(Suppl 2):S355-S360. doi:10.2105/AJPH.2013.301540 13. Respite Care for Homeless After Discharge Cuts Avoidable Days, Readmissions. Hosp Case Manag. 2016;24(11):157-158 14. H-160.903 Eradicating Homelessness | AMA. 2019. https://policysearch.ama- assn.org/policyfinder/detail/eradicating%20homelessness?uri=%2FAMADoc%2FHOD.xml-0-718.xml 15. Res 826-1-18. Developing Sustainable Solutions to Discharge Chronically-Homeless Patients. B of T Report 16-A-19. https://www.ama-assn.org/system/files/2019-04/a19-bot16.pdf REPORT OF RESOLUTION REVIEW COMMITTEE Theodore B. Jones, MD, Chair

09-20 Medication-Assisted Treatment in Physician Health Programs - APPROVE 11-20 Fentanyl Patch for Patch Exchange Program - DISAPPROVE 12-20 Non-Stigmatizing Verbiage - DISAPPROVE 19-20 Medicare-For-All - DISAPPROVE 20-20 Michigan State Medical Society Judicial Commission - DISAPPROVE 23-20 Signage Balancing Patient Safety, Quality of Care, and Patient Dignity - DISAPPROVE 24-20 Prescription Medication Pill Size - DISAPPROVE 25-20 Limit Copay on Emergency Department Visits - DISAPPROVE 26-20 Joint Task Force to Improve Prior Authorization Processes - DISAPPROVE 28-20 ICD-10-CM Code for 'Statin Refusal' - DISAPPROVE 29-20 Enforce AMA Principles on Continuing Board Certification - DISAPPROVE 31-20 Bring Insurance Credentialing into Legal Compliance on Maintenance of Certification - APPROVE 33-20 Access to Direct Primary Care Physicians - DISAPPROVE 40-20 Tuition Cost Transparency - DISAPPROVE 44-20 Uniform Standards for Brain Death Determination - APPROVE 46-20 Depression Screening in Adolescents after Sport-Related Concussion - APPROVE 54-20 Resentencing for Individuals Convicted of Marijuana-Based Offenses - APPROVE 58-20 Use Term “Intellectual Disability” in Lieu of “Mental Retardation” in Academic Texts, Published Literature, and Medical Education - DISAPPROVE 61-20 9-1-1 Dispatcher Telephone CPR Training – APPROVE

02-21 Vision Qualifications for Driver’s License - APPROVE 03-21 Oppose Routine Use of Gonad Shields - APPROVE 04-21 Dissemination of Information to County Medical Societies - APPROVE 05-21 Health Information Card - DISAPPROVE 07-21 COVID-19 Vaccine Entry Into MCIR - DISAPPROVE 09-21 Repeal Safe Harbor Provisions - DISAPPROVE 10-21 Financial Impact and Fiscal Transparency of the American Medical Association Current Procedural Terminology Program - APPROVE 11-21 Updates to Organ Donation and Transplant Policies - APPROVE 12-21 Standard Practice for Members Joining or Transferring Membership - DISAPPROVE 13-21 Upholding the Integrity and Vitality of the State and County Medical Societies - APPROVE 14-21 Disposition of Complaints - DISAPPROVE 15-21 Electronic Prescribing Waiver for Michigan’s Free Clinics - APPROVE Resolution Review Committee - 04/01/21 - 2

16-21 Medicaid Dialysis Policy for Undocumented Patients - APPROVE 17-21 Surrogacy Options for Michigan Parents - DISAPPROVE 18-21 Medical and Dental Care for Prisoners - APPROVE 19-21 De-professionalization of the Medical Profession - DISAPPROVE 20-21 Designated Directors Serving as Chair of the MSMS Board of Directors - APPROVE 21-21 Address Adolescent Telehealth Confidentiality Concerns - APPROVE 22-21 Expanding Access to Medication for the Treatment of Opioid Use Disorder - APPROVE 23-21 Licensure of Nutritionists and Dietitians - DISAPPROVE 24-21 Improved Outreach to Minority Communities Regarding the COVID-19 Vaccine - APPROVE 25-21 Public Health Considerations to Reduce Harm in Encampment Removals - APPROVE 26-21 Decarceration During an Infectious Disease Pandemic - APPROVE 27-21 Pictorial Health Warnings on Alcoholic Beverages - DISAPPROVE 28-21 Access to Menstrual Products in Correctional Facilities - APPROVE 29-21 Fertility Treatment Coverage - DISAPPROVE 30-21 Over the Counter Hormonal Contraception - APPROVE 31-21 Availability of Medical Respite Centers - APPROVE 32-21 Access to Affordable Housing - DISAPPROVE 33-21 Participation in Alliance for Innovation on Maternal Health Safety Bundles - DISAPPROVE 34-21 Use Term “Deaf and Hard of Hearing” in lieu of “Hearing Impaired” - DISAPPROVE 35-21 COVID-19 Vaccine Distribution Regarding People Experiencing Homelessness - APPROVE

REPORT OF RESOLUTION REVIEW COMMITTEE Theodore B. Jones, MD, Chair

April 1, 2021

The Resolution Review Committee (RRC) was instructed by the House to identify resolutions that are time sensitive and must be acted on yet this year, and those that can be postponed until 2022. The intent of narrowing the number of resolutions is solely due to time constraints and the online format, and not intended to be an assessment of the resolution’s merit. The criteria for determining if a resolution will be reviewed this year will include: • Is the resolution time sensitive? Is this policy or ask needed before April 2022? • Is there existing policy that covers all or some of the same intent? • Is the resolution already being addressed by MSMS or regular staff work? • Can the resolution be addressed within MSMS in another venue like an MSMS Committee or regular staff work?

Authors do have the opportunity for a second assessment. They will need to submit an appeal by emailing Rebecca Blake at [email protected] by April 8, 2021. New information will be required that is different than what the Committee already reviewed. The Speaker and Vice-Speaker will provide the second evaluation.

* * * * * * *

09-20 – Medication-Assisted Treatment in Physician Health Programs - APPROVE

* * * * * * *

11-20 - Fentanyl Patch for Patch Exchange Program - DISAPPROVE

The Committee understands this is an important issue but did not believe the state would be in a position to implement a patch exchange program during the public health emergency. Therefore, the Committee determined this resolution does not been to be addressed before April 2022. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

12-20 - Non-Stigmatizing Verbiage - DISAPPROVE

After thorough review, the Committee thought this resolution did not meet the criteria for urgency but could be addressed within the MSMS Opioid Stewardship Task Force at a Resolution Review Committee - 04/01/21 - 2 future, regular scheduled meeting. This resolution will be forwarded to the 2022 House of Delegates unless otherwise completed by the Task Force before then.

* * * * * * *

19-20 - Medicare-For-All - DISAPPROVE The Committee acknowledged resolutions similar to 19-20 are introduced almost annually. This is a resolution that engages a broad dialogue with many strongly held beliefs and opinions. The Committee believes this resolution would benefit best with in an in-person setting to allow for lengthy, open discussion, and debate. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

20-20 - Michigan State Medical Society Judicial Commission - DISAPPROVE

The Committee agrees that the bylaws regarding the Judicial Commission should be reviewed but because of the low number of reports every year, it did not meet the criteria to be completed before April 2022. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

23-20 - Signage Balancing Patient Safety, Quality of Care, and Patient Dignity - DISAPPROVE

The Committee understands this is an important issue but determined this resolution does not have the urgency to be addressed this year. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

24-20 - Prescription Medication Pill Size - DISAPPROVE

* * * * * * *

Resolution Review Committee - 04/01/21 - 3

25-20 - Limit Copay on Emergency Department Visits - DISAPPROVE

* * * * * * *

26-20 - Joint Task Force to Improve Prior Authorization Processes - DISAPPROVE

The Committee reviewed MSMS’ work on prior authorization and determined the intent of this resolution is being addressed by MSMS through regular staff work on prior authorization. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

28-20 - ICD-10-CM Code for 'Statin Refusal' - DISAPPROVE

The Committee learned there is a generic ICD-10 code that can be used for statin refusal; therefore, the resolution did not meet the urgency requirement to be addressed this year. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

29-20 - Enforce AMA Principles on Continuing Board Certification - DISAPPROVE

The Committee supported the resolution but found existing MSMS and AMA policy adequate for this year. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

31-20 - Bring Insurance Credentialing into Legal Compliance on Maintenance of Certification - APPROVE

* * * * * * *

33-20 - Access to Direct Primary Care Physicians - DISAPPROVE

The Committee understands this is an important issue, but determined this resolution does not have the urgency to be addressed this year. This resolution will be forwarded to the 2022 House of Delegates.

Resolution Review Committee - 04/01/21 - 4

40-20 - Tuition Cost Transparency - DISAPPROVE

The Committee strongly supported the resolution, but found existing MSMS and AMA policy sufficient for this year. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

44-20 - Uniform Standards for Brain Death Determination - APPROVE

* * * * * * *

46-20 - Depression Screening in Adolescents after Sport-Related Concussion - APPROVE

* * * * * * *

54-20 - Resentencing for Individuals Convicted of Marijuana-Based Offenses - APPROVE

* * * * * * *

58-20 - Use Term “Intellectual Disability” in Lieu of “Mental Retardation” in Academic Texts, Published Literature, and Medical Education - DISAPPROVE

* * * * * * *

61-20 - 9-1-1 Dispatcher Telephone CPR Training - APPROVE

* * * * * * *

02-21 - Vision Qualifications for Driver’s License - APPROVE

* * * * * * *

03-21 - Oppose Routine Use of Gonad Shields – APPROVE

* * * * * * * Resolution Review Committee - 04/01/21 - 5

04-21 - Dissemination of Information to County Medical Societies - APPROVE

* * * * * * *

05-21 - Health Information Card – DISAPPROVE

* * * * * * *

07-21 - COVID-19 Vaccine Entry Into MCIR - DISAPPROVE

The Committee was pleased to learn that recent Michigan regulations require COVID -19 vaccines be entered into MCIR within 72 hours, and 24 hours is strongly encouraged. Since the resolution has been completed or accomplished, the Committee recommends that it not be reviewed at this year’s House of Delegates.

* * * * * * *

09-21 - Repeal Safe Harbor Provisions – DISAPPROVE

The Committee supported the resolution, but found existing policy to be adequate for this year. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

10-21 - Financial Impact and Fiscal Transparency of the American Medical Association Current Procedural Terminology Program - APPROVE

* * * * * * *

11-21 - Updates to Organ Donation and Transplant Policies - APPROVE

* * * * * * *

Resolution Review Committee - 04/01/21 - 6

12-21 - Standard Practice for Members Joining or Transferring Membership - DISAPPROVE

The Committee was sensitive to the nature of this resolution. This is a resolution that will require an extensive dialogue with ample opportunity for questions and input, similar to the most recent remodeling process. Therefore, the Committee believes this resolution would benefit best with in an in-person setting to allow for open discussion and debate. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

13-21 - Upholding the Integrity and Vitality of the State and County Medical Societies - APPROVE

* * * * * * *

14-21 - Disposition of Complaints - DISAPPROVE

The Committee agrees that the bylaws regarding the Judicial Commission should be reviewed, but because of the low number of reports every year, it did not meet the criteria to be completed before April 2022. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

15-21 - Electronic Prescribing Waiver for Michigan’s Free Clinics - APPROVE

* * * * * * *

16-21 - Medicaid Dialysis Policy for Undocumented Patients - APPROVE

* * * * * * * 17-21 - Surrogacy Options for Michigan Parents - DISAPPROVE

* * * * * * *

Resolution Review Committee - 04/01/21 - 7

18-21 - Medical and Dental Care for Prisoners - APPROVE

* * * * * * *

19-21 - De-professionalization of the Medical Profession - DISAPPROVE

The Committee supported the resolution, but found existing AMA and MSMS policy to be sufficient for this year. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

20-21 - Designated Directors Serving as Chair of the MSMS Board of Directors - APPROVE

* * * * * * *

21-21 - Address Adolescent Telehealth Confidentiality Concerns - APPROVE

* * * * * * *

22-21 - Expanding Access to Medication for the Treatment of Opioid Use Disorder – APPROVE

* * * * * * *

23-21 - Licensure of Nutritionists and Dietitians - DISAPPROVE

The Committee determined this resolution is not pressing at this time and can be addressed next year. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

24-21 - Improved Outreach to Minority Communities Regarding the COVID-19 Vaccine – APPROVE

* * * * * * *

25-21 - Public Health Considerations to Reduce Harm in Encampment Removals - APPROVE

Resolution Review Committee - 04/01/21 - 8

26-21 - Decarceration During an Infectious Disease Pandemic - APPROVE

* * * * * * *

27-21 - Pictorial Health Warnings on Alcoholic Beverages – DISAPPROVE

* * * * * * *

28-21 - Access to Menstrual Products in Correctional Facilities – APPROVE

* * * * * * *

29-21 - Fertility Treatment Coverage - DISAPPROVE

The Committee determined this resolution did not meet the criteria as time sensitive and can be addressed next year. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

30-21 - Over the Counter Hormonal Contraception - APPROVE

* * * * * * *

31-21 - Availability of Medical Respite Centers - APPROVE

* * * * * * *

32-21 - Access to Affordable Housing - DISAPPROVE

The Committee determined this resolution did not meet the criteria as time sensitive and can be addressed next year. This resolution will be forwarded to the 2022 House of Delegates.

* * * * * * *

Resolution Review Committee - 04/01/21 - 9

33-21 - Participation in Alliance for Innovation on Maternal Health Safety Bundles – DISAPPROVE

The Committee agreed this is an important issue but determined this resolution did not meet the criteria as time sensitive. This resolution will be forwarded to the 2022 House of Delegates. * * * * * * *

34-21 - Use Term “Deaf and Hard of Hearing” in lieu of “Hearing Impaired” – DISAPPROVE

* * * * * * *

35-21 - COVID-19 Vaccine Distribution Regarding People Experiencing Homelessness - APPROVE

* * * * * * *

Members of the Committee include: *Theodore B. Jones, MD, Chair; Phillip G. Wise, MD; *Barry I. Auster, MD; *Laura A. Carravallah, MD; *Sanjay Das; *Kaitlyn D. Dobesh, MD, JD; *Martha L. Gray, MD; *Bryan W. Huffman, MD; *Charles F. Koopmann, Jr., MD, FACS; *Rose M. Ramirez, MD; *Caroline G. M. Scott, MD; and *David T. Walsworth, MD.

The Committee was staffed by: Rebecca J. Blake and Carrie J. Wheeler.

* Denotes members in attendance 1 RESOLUTION 11-20 2 3 Title: Fentanyl Patch for Patch Exchange Program 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Authors: Sandy Dettmann, MD, and Gerald Lee, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, fentanyl is a powerful synthetic opioid analgesic and 50-100 times more potent 15 than morphine, and 16 17 Whereas, fentanyl is a Schedule II prescription drug, and it is typically used to treat patients 18 with severe pain or to manage pain after surgery, and 19 20 Whereas, roughly 28,400 people died from overdose of synthetic opiates, other than 21 methadone, in 2017 alone, and 22 23 Whereas, Michigan's overdose rate of 21.2 per 100,000 is above the national average of 14.6 24 per 100,000, and 25 26 Whereas, synthetic opioids, mainly fentanyl, overdose deaths have increased in Michigan 27 from 72 in 2012 to 1,368 in 2017, and 28 29 Whereas, Ontario, Canada, has instituted a successful patch for patch (P4P) exchange 30 program, and 31 32 Whereas, a key component of the Ontario P4P program includes the labeling of a new 33 fentanyl prescription as a first prescription, and 34 35 Whereas, this action will result in a onetime return of 9 out of 10 patches, and 36 37 Whereas, the returned patches should be stuck to a sheet of paper and turned into the 38 pharmacist when getting a new prescription, and 39 40 Whereas, if a pharmacy receives a prescription for fentanyl patches but does not collect all 41 used patches or collects fewer than the quantity to be dispensed, the pharmacy must contact the 42 prescriber, and 43 44 Whereas, this enables the pharmacist, together with the prescriber, to make an assessment, 45 consider the circumstances, and determine the best course of action and the quantity to be 46 dispensed, and 47 48 Whereas, it is the responsibility of the pharmacist to properly store and dispose of used 49 patches, as well as contacting appropriate law enforcement if there is suspected counterfeiting, 50 misuse, and/or tampering; therefore be it 51 52 RESOLVED: That MSMS supports and shall propose a fentanyl “patch for patch” (P4P) 53 exchange program in the state of Michigan modeled after the successful P4P program 54 implemented in Ontario, Canada; and be it further 55 56 RESOLVED: That MSMS advocate the Michigan Legislature adopt a fentanyl “patch for 57 patch” exchange program in Michigan modeled after the successful P4P program implemented in 58 Ontario, Canada. 59 60 61 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 62 $25,000+ 63 Relevant MSMS Policy:

Prescription Drug Abuse MSMS supports the following AMA position on “Curtailing Prescription Drug Abuse While Preserving Therapeutic Use – Recommendations for Drug Control Policy:”

“Our AMA (1) opposes expansion of multiple-copy prescription programs to additional states or classes of drugs because of their documented ineffectiveness in reducing prescription drug abuse, and their adverse effect on the availability of prescription medications for therapeutic use; (2) supports continued efforts to address the problems of prescription drug diversion and abuse through physician education, research activities, and efforts to assist state medical societies in developing proactive programs; and (3) encourages further research into development of reliable outcome indicators for assessing the effectiveness of measures proposed to reduce prescription drug abuse.

Relevant AMA Policy:

Curtailing Prescription Drug Abuse While Preserving Therapeutic Use - Recommendations for Drug Control Policy H-95.979 (see language above) 1 RESOLUTION 12-20 2 3 Title: Non-Stigmatizing Verbiage 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Author: Sandy Dettmann, MD, DABAM, FASAM 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, we are in the midst of the largest manmade epidemic in the history of the United 15 States, and 16 17 Whereas, drug overdose is the most common cause of death in Americans under the age of 18 50, and 19 20 Whereas, addiction is a medical disease with effective, evidence-based medical treatment 21 available, and 22 23 Whereas, persons who suffer from the disease of addiction are frequently referred to as 24 "drug addicts," and 25 26 Whereas, the verbiage "drug addict" conjures up a somewhat negative image in the minds 27 of most people, and 28 29 Whereas, in reality, addiction is an "equal opportunity destroyer;" therefore be it 30 31 RESOLVED: That MSMS encourages the use of clinically accurate, non-stigmatizing, person 32 first terminology when referring to persons with the disease of addition and shall incorporate such 33 terminology in future communications and publications, as well as update existing policies during 34 the normal process of updating the MSMS Policy Manual; and be it further 35 36 RESOLVED: That MSMS believes an individual with the disease of addiction should be 37 accurately referred to as a "person with the disease of addiction" instead of “drug addict” or other 38 stigmatizing verbiage. 39 40 41 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 42 or AMA policy - $500

Relevant MSMS Policy:

Communication, Documentation, and Professionalism MSMS endeavors to educate physicians and other health care providers about the importance of careful and accurate verbal discussions and written documentation of care provided.

MSMS encourages physicians to demonstrate and maintain high ethical standards to avoid inadvertently discrediting other physicians or other health care providers; thereby, leading by example so that resident physicians and medical students can learn in a supportive environment while providing excellent care for our mutual patients.

Relevant AMA Policy:

Destigmatizing the Language of Addiction H-95.917 Our AMA will use clinically accurate, non-stigmatizing terminology (substance use disorder, substance misuse, recovery, negative/positive urine screen) in all future resolutions, reports, and educational materials regarding substance use and addiction and discourage the use of stigmatizing terms including substance abuse, alcoholism, clean and dirty.

Destigmatizing the Language of Addiction D-95.966 Our AMA and relevant stakeholders will create educational materials on the importance of appropriate use of clinically accurate, non-stigmatizing terminology and encourage use among all physicians and U.S. healthcare facilities. 1 RESOLUTION 19-20 2 3 Title: Medicare-For-All 4 5 Introduced by: James Mitchiner, MD, MPH, for the Washtenaw County Delegation 6 7 Original Author: James Mitchiner, MD, MPH 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, approximately 29 million people remain uninsured despite the Affordable Care 15 Act, with an additional 44 million under-insured, and 16 17 Whereas, lack of health insurance causes citizens to forego care, to receive care in expensive 18 and inappropriate settings, or to receive care only at an advanced stage of disease, and 19 20 Whereas, Medicare-for-All is an alternative financing mechanism for national health 21 insurance that does not supplant the private practice of medicine, and preserves existing doctor- 22 patient relationships, and 23 24 Whereas, Medicare-for-All is subject to myths and misconceptions, including the false belief 25 that Medicare-for-All is “socialized medicine” and that physicians will be paid at the current 26 Medicare fee schedule rate, and 27 28 Whereas, Medicare is a single-payer model that receives high patient satisfaction ratings, 29 yet has much lower administrative costs, and 30 31 Whereas, Medicare-for-All has advantages to medical practices including simplicity in billing 32 and administration, and 33 34 Whereas, Medicare-for-All can make American businesses more competitive by eliminating 35 corporate responsibility for financing employee health care, and 36 37 Whereas, Medicare-for-All provides the opportunity to improve medical care according to 38 themes of the 2006 MSMS Future of Medicine report, including "Universal Coverage," "Prevention 39 and Wellness," and "Partnering with Patients;" therefore be it 40 41 RESOLVED: That MSMS create a Health Care Reform Task Force charged with thoughtful 42 and evidence-based deliberations on Medicare-for-All, with at least four periodic meetings 43 throughout the year, leading to recommendations on MSMS taking a definitive “pro or con” 44 position on Medicare-for-All. The Task Force shall report its recommendations to the 2022 MSMS 45 House of Delegates. 46 47 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions to form or join task forces (internal or external) - $5,000+

Relevant MSMS Policy:

National Health Care MSMS supports voluntary, free-choice methods of medical and health care rather than a system dominated and controlled by the federal government.

Physician Input for National Health Care Programs MSMS supports physician input at all levels in the development of any national health care programs.

Universal Coverage MSMS supports comprehensive health system reform described in the MSMS Future of Medicine Report. (See Addendum P “Guiding Principles for the Future of Medicine and Health Care” in website version)

Relevant AMA Policy:

Educating the American People About Health System Reform H-165.844 Our AMA reaffirms support of pluralism, freedom of enterprise and strong opposition to a single payer system.

Health System Reform Legislation H-165.838 1. Our American Medical Association is committed to working with Congress, the Administration, and other stakeholders to achieve enactment of health system reforms that include the following seven critical components of AMA policy: a. Health insurance coverage for all Americans b. Insurance market reforms that expand choice of affordable coverage and eliminate denials for pre-existing conditions or due to arbitrary caps c. Assurance that health care decisions will remain in the hands of patients and their physicians, not insurance companies or government officials d. Investments and incentives for quality improvement and prevention and wellness initiatives e. Repeal of the Medicare physician payment formula that triggers steep cuts and threaten seniors' access to care f. Implementation of medical liability reforms to reduce the cost of defensive medicine g. Streamline and standardize insurance claims processing requirements to eliminate unnecessary costs and administrative burdens

2. Our American Medical Association advocates that elimination of denials due to pre-existing conditions is understood to include rescission of insurance coverage for reasons not related to fraudulent representation.

3. Our American Medical Association House of Delegates supports AMA leadership in their unwavering and bold efforts to promote AMA policies for health system reform in the United States.

4. Our American Medical Association supports health system reform alternatives that are consistent with AMA policies concerning pluralism, freedom of choice, freedom of practice, and universal access for patients.

5. AMA policy is that insurance coverage options offered in a health insurance exchange be self-supporting, have uniform solvency requirements; not receive special advantages from government subsidies; include payment rates established through meaningful negotiations and contracts; not require provider participation; and not restrict enrollees' access to out-of-network physicians.

6. Our AMA will actively and publicly support the inclusion in health system reform legislation the right of patients and physicians to privately contract, without penalty to patient or physician.

7. Our AMA will actively and publicly oppose the Independent Medicare Commission (or other similar construct), which would take Medicare payment policy out of the hands of Congress and place it under the control of a group of unelected individuals.

8. Our AMA will actively and publicly oppose, in accordance with AMA policy, inclusion of the following provisions in health system reform legislation: a. Reduced payments to physicians for failing to report quality data when there is evidence that widespread operational problems still have not been corrected by the Centers for Medicare and Medicaid Services b. Medicare payment rate cuts mandated by a commission that would create a double-jeopardy situation for physicians who are already subject to an expenditure target and potential payment reductions under the Medicare physician payment system c. Medicare payments cuts for higher utilization with no operational mechanism to assure that the Centers for Medicare and Medicaid Services can report accurate information that is properly attributed and risk-adjusted d. Redistributed Medicare payments among providers based on outcomes, quality, and risk-adjustment measurements that are not scientifically valid, verifiable and accurate e. Medicare payment cuts for all physician services to partially offset bonuses from one specialty to another f. Arbitrary restrictions on physicians who refer Medicare patients to high quality facilities in which they have an ownership interest

9. Our AMA will continue to actively engage grassroots physicians and physicians in training in collaboration with the state medical and national specialty societies to contact their Members of Congress, and that the grassroots message communicate our AMA's position based on AMA policy.

10. Our AMA will use the most effective media event or campaign to outline what physicians and patients need from health system reform.

11. AMA policy is that national health system reform must include replacing the sustainable growth rate (SGR) with a Medicare physician payment system that automatically keeps pace with the cost of running a practice and is backed by a fair, stable funding formula, and that the AMA initiate a "call to action" with the Federation to advance this goal.

12. AMA policy is that creation of a new single payer, government-run health care system is not in the best interest of the country and must not be part of national health system reform.

13. AMA policy is that effective medical liability reform that will significantly lower health care costs by reducing defensive medicine and eliminating unnecessary litigation from the system should be part of any national health system reform.

Evaluating Health System Reform Proposals H-165.888 1. Our AMA will continue its efforts to ensure that health system reform proposals adhere to the following principles: A. Physicians maintain primary ethical responsibility to advocate for their patients' interests and needs. B. Unfair concentration of market power of payers is detrimental to patients and physicians, if patient freedom of choice or physician ability to select mode of practice is limited or denied. Single-payer systems clearly fall within such a definition and, consequently, should continue to be opposed by the AMA. Reform proposals should balance fairly the market power between payers and physicians or be opposed. C. All health system reform proposals should include a valid estimate of implementation cost, based on all health care expenditures to be included in the reform; and supports the concept that all health system reform proposals should identify specifically what means of funding (including employer-mandated funding, general taxation, payroll or value-added taxation) will be used to pay for the reform proposal and what the impact will be. D. All physicians participating in managed care plans and medical delivery systems must be able without threat of punitive action to comment on and present their positions on the plan's policies and procedures for medical review, quality assurance, grievance procedures, credentialing criteria, and other financial and administrative matters, including physician representation on the governing board and key committees of the plan. E. Any national legislation for health system reform should include sufficient and continuing financial support for inner-city and rural hospitals, community health centers, clinics, special programs for special populations and other essential public health facilities that serve underserved populations that otherwise lack the financial means to pay for their health care. F. Health system reform proposals and ultimate legislation should result in adequate resources to enable medical schools and residency programs to produce an adequate supply and appropriate generalist/specialist mix of physicians to deliver patient care in a reformed health care system. G. All civilian federal government employees, including Congress and the Administration, should be covered by any health care delivery system passed by Congress and signed by the President. H. True health reform is impossible without true tort reform.

2. Our AMA supports health care reform that meets the needs of all Americans including people with injuries, congenital or acquired disabilities, and chronic conditions, and as such values function and its improvement as key outcomes to be specifically included in national health care reform legislation.

3. Our AMA supports health care reform that meets the needs of all Americans including people with mental illness and substance use / addiction disorders and will advocate for the inclusion of full parity for the treatment of mental illness and substance use / addiction disorders in all national health care reform legislation.

4. Our AMA supports health system reform alternatives that are consistent with AMA principles of pluralism, freedom of choice, freedom of practice, and universal access for patients.

Sources: 1. Tolbert J, Orgera K. Key facts about the uninsured population. Kaiser Family Foundation, Nov. 6, 2020. https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/ 2. Collins SR, Bhupal HK, Doty MM. Health insurance coverage eight years after the ACA: fewer uninsured Americans and shorter coverage gaps, but more underinsured (Commonwealth Fund, Feb. 2019), at: https://www.commonwealthfund.org/publications/issue-briefs/2019/feb/health-insurance-coverage- eight-years-after-aca 3. eHealth Insurance. Medicare Consumer Survey, February 2019. https://news.ehealthinsurance.com/_ir/68/20191/eHealth%20Medicare%20Consumer%20Survey%20Febr uary%202019.pdf 1 RESOLUTION 20-20 2 3 Title: Michigan State Medical Society Judicial Commission 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Author: Jayne E. Courts, MD, FACP 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, the Judicial Commission serves to review any concern about the conduct of a 15 physician member that is potentially in violation of the American Medical Association (AMA) Code 16 of Ethics, and 17 18 Whereas, concerns may originate from patients or other people and may include, but are 19 not limited to, inappropriate behavior, sexual harassment, or issues of gender identity, and 20 21 Whereas, the MSMS Judicial Commission serves as the disciplinary body within MSMS, and 22 23 Whereas, the Judicial Commission works through the component county medical societies, 24 often in a slow and potentially inequitable process, and 25 26 Whereas, the Official Procedures of the Judicial Commission allow determination of 27 appropriate disciplinary action of a physician member, including possible censure, suspension, or 28 expulsion from MSMS membership, and 29 30 Whereas, clear and concise approaches to the judicial and disciplinary process would 31 improve timeliness, consistency, equity, and protection due to standardized processes and 32 expedited decisions; therefore be it 33 34 RESOLVED: That the MSMS Board of Directors consider making the Judicial Commission a 35 Committee of the Board so the Committee may perform its function in a more efficient and 36 equitable manner; and be it further 37 38 RESOLVED: That the MSMS Board of Directors study the structure and function of the 39 Judicial Commission and recommend Constitution and Bylaws changes that will be brought to the 40 2022 MSMS House of Delegates for first reading. 41 42 43 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions to form or join task forces (internal or 44 external) - $5,000+

Relevant MSMS Policy:

Judicial Commission Complaint Process

1. MSMS staff receive inquires from patients or physicians about filing a complaint for a physician, nurse, hospital, or any other healthcare facility. 2. If the complaint is about a physician, the staff member verifies that the physician is a MSMS member. If the physician is a member, the staff member explains that the Judicial Commission process is a peer review process which starts with the county society peer review committee. We encourage the complainant to personally discuss the issue with the physician. Finally, the staff member explains that the MSMS Judicial Commission does not have jurisdiction to award money damages, revoke, restrict or limit a physician’s license. 3. Many times, when the complainant realizes it is a peer review process only, they decide not to proceed. If they decide to proceed, the staff member sends a complaint form to gather further information. The complainant has 30 days to submit the form with the detailed information. 4. Once the form is received by MSMS, the MSMS staff member determines the appropriate county medical society (CMS) who should review the complaint and forwards the information to that CMS. If there is not an active county medical society, the MSMS Judicial Commission reviews the complaint. 5. Each CMS has their own process for reviewing a complaint. The MSMS staff member stays in touch with the CMS staff member asking for updates. 6. Once the CMS peer review process makes their determination, they send information about the final decision to the MSMS staff member. 7. The MSMS staff member notifies the Judicial Commission chair about the decision. The Chair decides how the full Commission will be notified of the complaint.

Statistics on Complaints

Year Forms Mailed Forms Received Full Complaint Process 2016 2 0 0 2017 1 1 1 2018 3 0 0 2019 1 0 0 2020 3 2 2

Relevant AMA Policy:

Conflicts of Interest H-140.967 Our AMA calls on state and county medical societies to seek out and to respond to complaints of significant violations of the Council on Ethical and Judicial Affairs' guidelines, and it reminds those societies of the AMA's pledge to stand behind and to provide financial support for any society enforcing in good faith and under approved disciplinary procedures AMA's code of ethics.

Source: 1. Michigan State Medical Society. Constitution and Bylaws, Supplement: Official Procedures for the MSMS Judicial Commission, 2015 edition. 1 RESOLUTION 23-20 2 3 Title: Signage Balancing Patient Safety, Quality of Care, and Patient Dignity 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Author: Jayne E. Courts, MD, FACP 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, patients who reside in a skilled nursing facility (SNF), either for sub-acute 15 rehabilitation (SAR) or long-term care (LTC), often have safety or care needs that need to be 16 addressed by the health care team at the SNF, and 17 18 Whereas, included in these patient care needs are often simple, but important, care plan 19 concerns such as the number needed for assist due to the fall risk, the need to follow a dysphagia 20 diet (with thickened liquids), or the need to follow a fluid restriction, and 21 22 Whereas, SNF staff are trained to respond to call lights as quickly as possible, including 23 responding to call lights of any residents who require assistance, even if the patient has not been 24 assigned to that staff member, and 25 26 Whereas, a staff member may provide assistance to a patient with whom he/she is not 27 familiar, including lack of familiarity with the care plan, and 28 29 Whereas, in the inpatient setting or in the acute rehabilitation setting, patients at risk for 30 falls often wear wristbands clearly indicating this potential risk in an effort to reduce falls and the 31 possible adverse consequences for the patient, and 32 33 Whereas, this readily visible reminder is seen as a patient safety and quality of care measure 34 that benefits the patient and helps to reduce the number of fall "never events," and 35 36 Whereas, the regulatory environment in the SNF setting is determined by the Centers for 37 Medicare and Medicaid Services (CMS), and 38 39 Whereas, CMS’s interpretive guidelines require that an environment must be maintained in 40 which there are no signs posted in residents’ rooms or in staff work areas able to be seen by other 41 residents and/or visitors that include confidential clinical or personal information (though signage 42 in non-visible, non-readily seen locations such as the inside of a cupboard door in the resident's 43 room is permissible), and 44 45 Whereas, any publicly visible identification of residents with a fall risk such as a wristband is 46 deemed to be a violation of patient dignity requirements, rather than as a potential method of 47 ensuring the patient's safety and provision of quality of care, and 48 49 Whereas, this requirement to ensure information is not viewable by the public doesn’t even 50 allow a colored dot on the room number by the door to alert SNF staff members to patient care 51 needs such as a dysphagia diet, fluid restrictions, or other patient safety and quality concerns, and 52 53 Whereas, non-adherence to this regulatory approach, believed to preserve the dignity of 54 the patient, will result in a citation which may include plan of correction requirements, education of 55 the staff, and monetary infractions, including but not limited to denial of payment until the CMS 7 56 surveyors have resurveyed the SNF and have determined that the regulatory guidelines have been 57 met through the plan of correction, and 58 59 Whereas, CMS citations may result in a reduction in the SNF's five-star rating which may 60 affect reimbursement rates and the SNF's reputation and possible referral rates until the five-star 61 rating has improved, and 62 63 Whereas, identification of patients at risk for falls in the inpatient setting or the acute 64 rehabilitation setting is not considered to be an infringement on the patient's dignity, but is viewed 65 instead as a safety concern for the protection of the patient; therefore be it 66 67 RESOLVED: That MSMS work with appropriate stakeholders to review the rationale for the 68 Centers for Medicare and Medicaid Services’ patient dignity regulations applicable to long-term 69 care facilities and determine acceptable indicators or markers with better visibility to indicate 70 patients with an increased fall risk or other health care risk concerns; and be it further 71 72 RESOLVED: That MSMS work with the appropriate stakeholders to develop and advocate 73 for recommended changes to the Centers for Medicare and Medicaid Services’ patient dignity 74 regulations applicable to long-term care facilities so that discrete, but readily visible, indicators or 75 markers of a patient’s health care risk concerns may be used for the benefit and safety of patients 76 without triggering a citation; and be it further 77 78 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 79 our AMA to work with the Centers for Medicare and Medicaid Services (CMS) to review the 80 rationale for CMS’s patient dignity regulations applicable to long-term care facilities and determine 81 acceptable indicators or markers with better visibility to indicate patients with an increased fall risk 82 or other health care risk concerns; and be it further 83 84 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 85 our AMA to work with the Centers for Medicare and Medicaid Services (CMS) to change the patient 86 dignity regulations applicable to long-term care facilities so that discrete, but readily visible, 87 indicators or markers of a patient’s health care risk concerns may be used for the benefit and safety 88 of patients without triggering a citation. 89 90 91 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 92 $25,000+

Relevant MSMS Policy: None

Relevant AMA Policy:

Residential Facility Regulations H-280.984 Our AMA advocates for patients in long-term care, group home and other residential settings and will: (1) strive to see that enhanced quality of care results from any new proposed state or federal regulations; (2) attempt to ensure that appropriate and necessary physician involvement be maintained for patients; (3) urge state regulatory bodies and HHS to seek consultation and advice from the AMA and other professional medical societies when developing rules and regulations that affect medical care; (4) support cooperative efforts with appropriate groups for the purpose of developing mutually supported positions regarding medical care regulations; (5) support efforts to monitor federal and state legislation and regulations which affect physicians involved in long-term, group home or other residential setting care, and provide testimony and information about appropriate medical management of patients to regulatory and/or licensing bodies; and (6) support actions to establish better understanding and cooperation among federal and state health agencies as they formulate health and safety standards. 1 RESOLUTION 24-20 2 3 Title: Prescription Medication Pill Size 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Authors: Michelle M. Condon, MD and David Whalen, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, dosing of medication frequently requires a patient to cut pills in half to achieve 15 the proper dose recommended by their physician, and 16 17 Whereas, these medication types requiring alteration in pill tab size may be to limit the 18 dose of controlled substances which is an advantage to many patients, and 19 20 Whereas, these dosage adjustments may be difficult for patients with limited dexterity to 21 cut on their own; therefore be it 22 23 RESOLVED: That MSMS ask the Michigan Board of Pharmacy to pursue pill medication size 24 to be no smaller than six mm in diameter or other size found by research to be best suited for pill 25 cutting by elderly or disabled patients; and be it further 26 27 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 28 our AMA to request pharmaceutical companies to manufacture pills larger than five mm in 29 diameter for medications most likely to be prescribed to elderly and disabled persons, especially 30 those consisting of controlled substances, to better allow pill cutting to help control dosages, 31 unless research shows this to be unnecessary in this group of patients. 32 33 34 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 35 $25,000+

Relevant MSMS Policy: None

Relevant AMA Policy: None 1 RESOLUTION 25-20 2 3 Title: Limit Copay on Emergency Department Visits 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Author: Michelle M. Condon, MD, FACP 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, some insurance products require a patient to pay an extra or larger co-pay or 15 deductible if an emergency department evaluation does not lead to a hospital admission, and 16 17 Whereas, these patients may have waited to confer with their private physician until office 18 hours are open, but are instructed by that physician to go to the emergency department for 19 evaluation; therefore be it 20 21 RESOLVED: That MSMS advocate that insurance companies waive the imposition of higher 22 co-pays or deductibles when a patient is directed by their primary care physician to seek treatment 23 for an acute problem in the emergency department, even if the patient is not admitted to the 24 hospital. 25 26 27 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 28 $25,000+

Relevant MSMS Policy: None

Relevant AMA Policy: None 1 RESOLUTION 26-20 2 3 Title: Joint Task Force to Improve Prior Authorization Processes 4 5 Introduced by: Richard Burney, MD, for the Washtenaw County Delegation 6 7 Original Author: Richard Burney, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, prior authorization of physician orders for selected medications, tests, and 15 procedures has long been a contentious issue associated with feelings of intense frustration by 16 health care providers, and 17 18 Whereas, the prior authorization process is perceived by physicians as excessively 19 bureaucratic, inefficient, and counterproductive, and 20 21 Whereas, the physicians believe that the majority of prior authorization requests are 22 approved, rendering the process a waste of time and money, and 23 24 Whereas, physicians believe patients are suffering from delays due to required 25 authorizations, and 26 27 Whereas, as with many policy issues, there is more than one side to this issue, and 28 29 Whereas, insurers may have legitimate reasons for instituting prior authorization programs, 30 and 31 32 Whereas, physicians acting in good faith on behalf of insurers to carry out prior 33 authorization programs may feel equally frustrated, and 34 35 Whereas, impediments in the current system, which is complex and misunderstood, are 36 unlikely to go away, and 37 38 Whereas, the American Medical Association has endorsed collaborative efforts to improve 39 the prior authorization process, and 40 41 Whereas, regardless of the outcome of any legislation regarding prior authorization, the 42 need will still exist to collaborate with insurers, therefore be it 43 44 RESOLVED: That in addition to legislative pursuits, MSMS advocate for a joint task force 45 process facilitated by a neutral, expert party, bringing together health care providers and insurers, 46 to examine ways in which a better mutual understanding of prior authorization processes can be 47 achieved, which can lead to mutually beneficial improvements in prior authorization processes. 48 49 50 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requiring external consultants - 51 $50,000+

Relevant MSMS Policy:

Compensation for Prior Authorization Efforts MSMS supports working with Michigan insurance companies to study the effectiveness, efficiency, and outcomes of prior authorization processes with the goal of minimizing the burden of prior authorization activities and eliminating non-value added processes including, but not limited to, such issues as value, efficiency, and compensation.

Prior Authorization for Delivery MSMS opposes the current practice/rule requiring prior authorization for elective delivery of any patient.

Prior Authorization for Surgical Procedures MSMS supports requiring Michigan health plans to finalize their decisions on “prior authorization” at least one calendar week before the scheduled procedure.

Prior Authorization Reform MSMS supports the American Medical Association’s 21 guiding principles to reform prior authorization requirements and will utilize the principles as a guide for prior authorization reform.

Coverage of Approved Medications MSMS supports that Medicaid Health Plans in Michigan cover all medications on the Michigan Medicaid’s Preferred Drug List, without having to repeat prior authorization or step-therapy that has already been documented on the patient.

Prior Authorization Compensation MSMS supports appropriate and adequate reimbursement for physicians who are required to spend time and resources defending orders for diagnostic tests due to the utilization of prior authorization policies by third- party payers.

Relevant AMA Policy

Prior Authorization and Utilization Management Reform H-320.939 1. Our AMA will continue its widespread prior authorization (PA) advocacy and outreach, including promotion and/or adoption of the Prior Authorization and Utilization Management Reform Principles, AMA model legislation, Prior Authorization Physician Survey and other PA research, and the AMA Prior Authorization Toolkit, which is aimed at reducing PA administrative burdens and improving patient access to care. 2. Our AMA will oppose health plan determinations on physician appeals based solely on medical coding and advocate for such decisions to be based on the direct review of a physician of the same medical specialty/subspecialty as the prescribing/ordering physician. 3. Our AMA supports efforts to track and quantify the impact of health plans’ prior authorization and utilization management processes on patient access to necessary care and patient clinical outcomes, including the extent to which these processes contribute to patient harm.

Prior Authorization Reform D-320.982 Our AMA will explore emerging technologies to automate the prior authorization process for medical services and evaluate their efficiency and scalability, while advocating for reduction in the overall volume of prior authorization requirements to ensure timely access to medically necessary care for patients and reduce practice administrative burdens.

Remuneration for Physician Services H-385.951 1. Our AMA actively supports payment to physicians by contractors and third party payers for physician time and efforts in providing case management and supervisory services, including but not limited to coordination of care and office staff time spent to comply with third party payer protocols. 2. It is AMA policy that insurers pay physicians fair compensation for work associated with prior authorizations, including pre-certifications and prior notifications, that reflects the actual time expended by physicians to comply with insurer requirements and that compensates physicians fully for the legal risks inherent in such work. 3. Our AMA urges insurers to adhere to the AMA's Health Insurer Code of Conduct Principles including specifically that requirements imposed on physicians to obtain prior authorizations, including pre- certifications and prior notifications, must be minimized and streamlined and health insurers must maintain sufficient staff to respond promptly.

Preauthorization for Payment of Services H-320.961 Our AMA supports legislation and/or regulations that would prevent the retrospective denial of payment for any claim for services for which a physician had previously obtained authorization, unless fraud was committed or incorrect information provided at the time such prior approval was obtained.

Payer Accountability H-320.982 Our AMA: (1) Urges that state medical associations and national medical specialty societies to utilize the joint Guidelines for Conduct of Prior Authorization Programs and Guidelines for Claims Submission, Review and Appeals Procedures in their discussions with payers at both the national and local levels to resolve physician/payer problems on a voluntary basis. (2) Reaffirms the following principles for evaluation of preadmission review programs, as adopted by the House of Delegates at the 1986 Annual Meeting: (a) Blanket preadmission review of all or the majority of hospital admissions does not improve the quality of care and should not be mandated by government, other payers, or hospitals. (b) Policies for review should be established by state or local physician review committees, and the actual review should be performed by physicians or under the close supervision of physicians. (c) Adverse decisions concerning hospital admissions should be finalized only by physician reviewers and only after the reviewing physician has discussed the case with the attending physician. (d) All preadmission review programs should provide for immediate hospitalization, without prior authorization, of any patient whose treating physician determines the admission to be of an emergency nature. (e) No preadmission review program should make a payment denial based solely on the failure to obtain preadmission review or solely on the fact that hospitalization occurred in the face of a denial for such admission. (3) Affirms as policy and advocates to all public and private payers the right of claimants to review by a physician of the same general specialty as the attending physician of any claim or request for prior authorization denied on the basis of medical necessity.

Sources: 1. Rosneck JS. Refocusing Medication Prior Authorization on Its Intended Purpose. JAMA 2020; 323:703-704 2. American Medical Association. Consensus statement on improving the prior authorization process. https//:www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/prior- authorization-consensus-statement.pdf. Accessed March 5, 2020

1 RESOLUTION 28-20 2 3 Title: ICD-10-CM Code for 'Statin Refusal' 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Author: Rose Ramirez, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, we are moving from a fee-for-service payment model to a value-based payment 15 model, and 16 17 Whereas, measuring and reporting quality metrics by providers has continued to increase, 18 and 19 20 Whereas, the Centers for Medicare and Medicaid Services (CMS) Medicare Stars program 21 requires insurers to also meet and report on quality metrics, and 22 23 Whereas, because of HEDIS measures and the CMS Medicare Stars program, there is a very 24 strong push by insurers to get all patients that might benefit from a statin onto one, and even 25 measuring the number of refills per unit of time to show patient compliance, and 26 27 Whereas, the number of allowed exclusions to the statin measure in specific have 28 decreased, which can reduce a provider’s ability to hit quality targets and impact the providers 29 quality payments, and 30 31 Whereas, despite our recommendations and education about the benefits of statins, some 32 patients still refuse to accept a statin, and 33 34 Whereas, patient choice in the partnership between physician and patient should be 35 honored whenever possible, and 36 37 Whereas, physicians simply cannot force patients to take a medication they do not want to 38 take, and 39 40 Whereas, there is an ICD-10-CM code for coumadin refusal and one for medication refusal, 41 but not a code for statin refusal, and 42 43 Whereas, a specific code for statin refusal could be useful for those patients who do not 44 have other exclusion criteria for a statin; therefore be it 45 46 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 47 our AMA for the creation of a new specific 'statin refusal' code and advocate it be a valid exclusion 48 criterion for patients. 49 50 51 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 52 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy: None 1 RESOLUTION 29-20 2 3 Title: Enforce AMA Principles on Continuing Board Certification 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Authors: Megan Edison, MD, and David Whalen, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, the American Medical Association (AMA) Principles on Continuing Board 15 Certification have been developed through the democratic process of various states’ Houses of 16 Delegates and the AMA House of Delegates, reflecting the collective will of state and national 17 medical societies and their physician members, and 18 19 Whereas, these longstanding principles clearly demand a continuing board certification 20 process that is low cost, evidence-based, untied to insurance and hospital credentialing, and free of 21 harm to the physician workforce, and 22 23 Whereas, the proprietary American Board of Medical Specialties (ABMS) and American 24 Osteopathic Association (AOA) continuing board certification product continues to be high cost, 25 high stress, without evidence over other forms of continuing medical education, required for 26 insurance and hospital credentialing, and harmful to the physician workforce, and 27 28 Whereas, ABMS and AOA boards continue to ignore the AMA on nearly every aspect of the 29 AMA policy handbook on continuing board certification, and 30 31 Whereas, this failure to protect physicians from recertification harm is having significant 32 effects upon cost of care, physician burnout, and access to qualified physicians, and 33 34 Whereas, this failure to advocate successfully for these principles reflects poorly upon the 35 ability of organized medicine to defend physicians and our right to care for patients; therefore be it 36 37 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 38 our AMA to continue to actively work to enforce current AMA Principles on Continuing Board 39 Certification; and be it further 40 41 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 42 our AMA to publicly report their work on enforcing AMA Principles on Continuing Board 43 Certification at the Annual and Interim meetings of the AMA House of Delegates. 44 45 46 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 47 or AMA policy - $500

Relevant MSMS Policy:

Review Board Recertification and Maintenance of Certification Process MSMS supports Maintenance of Certification (MOC) only under all of the following circumstances: 1. MOC must be voluntary. 2. MOC must not be a condition of licensure, hospital privileges, health plan participation, or any other function unrelated to the specialty board requiring MOC. 3. MOC should not be the monopoly of any single entity. Physicians should be able to access a range of alternatives from different entities. 4. The status of MOC should be revisited by MSMS if it is identified that the continuous review of physician competency is objectively determined to be a benefit for patients. If that benefit is determined to be present by objective data regarding value and efficacy, then MSMS should support the adoption of an evidence based process that serves only to improve patient care.

Relevant AMA Policy:

Continuing Board Certification H-275.924 Continuing Board Certification AMA Principles on Continuing Board Certification 1. Changes in specialty-board certification requirements for CBC programs should be longitudinally stable in structure, although flexible in content. 2. Implementation of changes in CBC must be reasonable and take into consideration the time needed to develop the proper CBC structures as well as to educate physician diplomates about the requirements for participation. 3. Any changes to the CBC process for a given medical specialty board should occur no more frequently than the intervals used by that specialty board for CBC. 4. Any changes in the CBC process should not result in significantly increased cost or burden to physician participants (such as systems that mandate continuous documentation or require annual milestones). 5. CBC requirements should not reduce the capacity of the overall physician workforce. It is important to retain a structure of CBC programs that permits physicians to complete modules with temporal flexibility, compatible with their practice responsibilities. 6. Patient satisfaction programs such as The Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient survey are neither appropriate nor effective survey tools to assess physician competence in many specialties. 7. Careful consideration should be given to the importance of retaining flexibility in pathways for CBC for physicians with careers that combine clinical patient care with significant leadership, administrative, research and teaching responsibilities. 8. Legal ramifications must be examined, and conflicts resolved, prior to data collection and/or displaying any information collected in the process of CBC. Specifically, careful consideration must be given to the types and format of physician-specific data to be publicly released in conjunction with CBC participation. 9. Our AMA affirms the current language regarding continuing medical education (CME): "Each Member Board will document that diplomates are meeting the CME and Self-Assessment requirements for CBC Part II. The content of CME and self-assessment programs receiving credit for CBC will be relevant to advances within the diplomate's scope of practice, and free of commercial bias and direct support from pharmaceutical and device industries. Each diplomate will be required to complete CME credits (AMA PRA Category 1 Credit", American Academy of Family Physicians Prescribed, American College of Obstetricians and Gynecologists, and/or American Osteopathic Association Category 1A)." 10. In relation to CBC Part II, our AMA continues to support and promote the AMA Physician's Recognition Award (PRA) Credit system as one of the three major credit systems that comprise the foundation for continuing medical education in the U.S., including the Performance Improvement CME (PICME) format; and continues to develop relationships and agreements that may lead to standards accepted by all U.S. licensing boards, specialty boards, hospital credentialing bodies and other entities requiring evidence of physician CME. 11. CBC is but one component to promote patient safety and quality. Health care is a team effort, and changes to CBC should not create an unrealistic expectation that lapses in patient safety are primarily failures of individual physicians. 12. CBC should be based on evidence and designed to identify performance gaps and unmet needs, providing direction and guidance for improvement in physician performance and delivery of care. 13. The CBC process should be evaluated periodically to measure physician satisfaction, knowledge uptake and intent to maintain or change practice. 14. CBC should be used as a tool for continuous improvement. 15. The CBC program should not be a mandated requirement for licensure, credentialing, recredentialing, privileging, reimbursement, network participation, employment, or insurance panel participation. 16. Actively practicing physicians should be well-represented on specialty boards developing CBC. 17. Our AMA will include early career physicians when nominating individuals to the Boards of Directors for ABMS member boards. 18. CBC activities and measurement should be relevant to clinical practice. 19. The CBC process should be reflective of and consistent with the cost of development and administration of the CBC components, ensure a fair fee structure, and not present a barrier to patient care. 20. Any assessment should be used to guide physicians' self-directed study. 21. Specific content-based feedback after any assessment tests should be provided to physicians in a timely manner. 22. There should be multiple options for how an assessment could be structured to accommodate different learning styles. 23. Physicians with lifetime board certification should not be required to seek recertification. 24. No qualifiers or restrictions should be placed on diplomates with lifetime board certification recognized by the ABMS related to their participation in CBC. 25. Members of our House of Delegates are encouraged to increase their awareness of and participation in the proposed changes to physician self-regulation through their specialty organizations and other professional membership groups. 26. The initial certification status of time-limited diplomates shall be listed and publicly available on all American Board of Medical Specialties (ABMS) and ABMS Member Boards websites and physician certification databases. The names and initial certification status of time-limited diplomates shall not be removed from ABMS and ABMS Member Boards websites or physician certification databases even if the diplomate chooses not to participate in CBC. 27. Our AMA will continue to work with the national medical specialty societies to advocate for the physicians of America to receive value in the services they purchase for Continuing Board Certification from their specialty boards. Value in CBC should include cost effectiveness with full financial transparency, respect for physicians' time and their patient care commitments, alignment of CBC requirements with other regulator and payer requirements, and adherence to an evidence basis for both CBC content and processes. 1 RESOLUTION 33-20 2 3 Title: Access to Direct Primary Care Physicians 4 5 Introduced by: David Whalen, MD, for the Barry County Delegation 6 7 Original Author: Belen Amat, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, Michigan Compiled Law 500.129 recognizes direct primary care (DPC) and 15 requires DPC practices to charge a periodic fee, avoid billing third-party payers on a fee-for-service 16 basis, and limit any per visit charge to less than the monthly equivalent of the periodic fee, and 17 18 Whereas, DPC practices do not participate with, or bill any insurance companies, allowing 19 DPC practices to provide high quality individualized care at affordable rates for patients, and 20 21 Whereas, the DPC options offers a plan that provides individuals and families with unlimited 22 access to their personal physician for a flat, monthly fee, and 23 24 Whereas, patients choose DPC practices for longer office visits with their physician, 25 increased access via phone calls, text messages, and video chat, all while being cost conscious, and 26 27 Whereas, DPC plans are not health insurance, and DPC patients often carry high deductible 28 insurance plans and are responsible for most of the cost of outpatient testing, medications, and 29 consults, and 30 31 Whereas, DPC physicians are very skilled at finding and negotiating low cost medication, 32 referrals, and studies for their patients, and 33 34 Whereas, some insurance companies consider DPC physicians “out of network,” and will not 35 allow them to order medications, tests, or referrals on patients who have health insurance, even 36 when the medical treatment is being paid 100 percent by the patient due to high deductibles, and 37 38 Whereas, insurance companies will require a patient to visit an insurance-based doctor 39 solely to make the referral, thereby increasing healthcare costs and delaying care, and 40 41 Whereas, unlike traditional insurance-based physicians who may be out of network with 42 particular insurance companies, DPC physicians are, by definition and legal distinction, a unique 43 class of physicians, and out-of-network with all insurances, and 44 45 Whereas, the state of Maine recognized this distinction, and passed legislation prohibiting 46 denial of referrals by DPC physicians; therefore be it 47 48 RESOLVED: That MSMS educate health insurers on the role of direct primary care 49 physicians in promoting high quality care while decreasing health care costs for patients with 50 health insurance; and be it further 51 52 RESOLVED: That MSMS work with health insurers to allow direct primary care physicians to 53 prescribe medications, order tests, and make referrals for patients with health insurance. 54 55 56 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 57 $25,000+

Relevant MSMS Policy:

Resolution 23-15 Resolved: That MSMS study and educate it members regarding alternative payment models for primary care including direct primary care contracts and “concierge” medicine using methods such as email, website, and webinar programs.

Relevant AMA Policy:

Direct Primary Care H-385.912 1. Our AMA supports: (a) inclusion of Direct Primary Care as a qualified medical expense by the Internal Revenue Service; and (b) efforts to ensure that patients in Direct Primary Care practices have access to specialty care, including efforts to oppose payer policies that prevent referrals to in-network specialists. 2. AMA policy is that the use of a health savings account (HSA) to access direct primary care providers and/or to receive care from a direct primary care medical home constitutes a bona fide medical expense, and that particular sections of the IRS code related to qualified medical expenses should be amended to recognize the use of HSA funds for direct primary care and direct primary care medical home models as a qualified medical expense. 3. Our AMA will seek federal legislation or regulation, as necessary, to amend appropriate sections of the IRS code to specify that direct primary care access or direct primary care medical homes are not health “plans” and that the use of HSA funds to pay for direct primary care provider services in such settings constitutes a qualified medical expense, enabling patients to use HSAs to help pay for Direct Primary Care and to enter DPC periodic-fee agreements without IRS interference or penalty. 1 RESOLUTION 40-20 2 3 Title: Tuition Cost Transparency 4 5 Introduced by: Eric James, for the Medical Student Section 6 7 Original Authors: Awais Ahmed, Kaylie Bullock, Amy Cox, Kelly Fahey, Eric James, Benjamin 8 Malamet, Ramiz Memon, Grace Peterson, and Stephanie Wong 9 10 Referred To: 11 12 House Action: 13 14 15 Whereas, in 2018, the Association of American Medical Colleges (AAMC) reported that 76 16 percent of medical students graduated with a median loan debt of $200,000. Compared to the 17 median medical student debt of $50,000 in 1992, there is an approximate 220 percent increase in 18 medical school debt, even after accounting for the rate of inflation, and 19 20 Whereas, the capitalizing interest rates of Stafford Subsidized loans increased from 1.87 21 percent prior to 2006, to a current fixed rate of 6.87 percent, thereby exacerbating the rising debt 22 of medical students, and 23 24 Whereas, MSMS policy advocates for a variety of means in order to decrease medical 25 student debt in the short-term and long-term, and 26 27 Whereas, higher levels of medical school debt are associated with worse academic 28 outcomes in undergraduate medical education, negative effects on mental well-being, and higher 29 levels of stress, and 30 31 Whereas, higher medical school debt influences the way medical students approach major 32 life choices; students with higher aggregate amounts of debt were more likely to delay marriage or 33 having children and disagree that they would choose to become a physician, again, and 34 35 Whereas, medical students with higher debt compared to their peers were more likely to 36 choose a specialty with a higher annual income, were less likely to choose primary care, and less 37 likely to plan to practice in underserved locations, and 38 39 Whereas, the number of graduate medical students exceeds the number of available post 40 graduate year positions. The increasing number of students not matching, and the increase in 41 medical student debt can make medical school seem more of a financial risk, and 42 43 Whereas, the American Medical Association (AMA) supports continued assessment of the 44 value of graduate medical education (GME) and transparency of federal funding, which is received 45 by GME institutions, and 46 47 Whereas, undergraduate medical students are not provided specific breakdowns of tuition 48 costs or reasons for tuition increases, and 49 50 Whereas, the AMA supports improving the systematic reporting of undergraduate medical 51 student expenditures to determine which items are included and the ranges of costs; therefore be it 52 53 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 54 our AMA to collaborate with organizations such as the Association of American Medical Colleges in 55 creating transparency in tuition costs of undergraduate medical education institutions; and be it 56 further 57 58 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 59 our AMA to collaborate with the Association of American Medical Colleges in systematic reporting 60 of itemized tuition cost of undergraduate medical education annually thereby releasing an annual 61 public report; and be it further 62 63 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 64 our AMA to work with other national organizations to support the responsible use of tuition funds 65 by undergraduate medical institutions to improve the affordability of medical education. 66 67 68 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 69 or AMA policy - $500

Relevant MSMS Policy:

Medical School Debt Forgiveness MSMS supports the principle of debt forgiveness for students of Michigan medical schools in return for service in primary care in the state of Michigan.

Resolution 17-12A RESOLVED: That MSMS encourage legislation that would address the burden of medical school debt of future physicians through city, county, or regional purchase of tuition costs of medical students in return for service in these communities upon completion of training; and be it further

RESOLVED: That MSMS seek employment opportunities for medical students with area health systems and/or hospitals affiliated with medical schools to work during breaks, with wages that may be used to significantly reduce the debt burden of medical students.

Resolution 46-08A RESOLVED: That MSMS pursue immediate debt relief for medical students at the statewide level by advocating for tuition freezes upon matriculation at state medical schools, pursuing scholarship and loan repayment options for students who stay to train and practice in the state, and continue to advocate at the state and national level for medical student debt relief; and be it further

RESOLVED: That the Michigan Delegation to the AMA ask the AMA to pursue long-term solutions to the student debt crisis by hiring an economic consulting firm to analyze the feasibility of novel solutions1 including; 1) competency-based curriculums that shorten the length of undergraduate education and medical school, 2) work-study opportunities, 3) paid rotating internships for fourth-year students who have passed initial licensing exams and have the training equivalents of mid-level providers, 4) financial investment funds that match parental savings, 5) relief for dual degrees not covered by the National Institute of Health, 6) pursuit of government Medicare funding for undergraduate medical education funding, and 7) implementing international medical student tuition models, among other viable options.

Relevant AMA Policy:

Cost and Financing of Medical Education and Availability of First-Year Residency Positions H-305.988 Our AMA: 1. believes that medical schools should further develop an information system based on common definitions to display the costs associated with undergraduate medical education; 2. in studying the financing of medical schools, supports identification of those elements that have implications for the supply of physicians in the future; 3. believes that the primary goal of medical school is to educate students to become physicians and that despite the economies necessary to survive in an era of decreased funding, teaching functions must be maintained even if other commitments need to be reduced; 4. believes that a decrease in student enrollment in medical schools may not result in proportionate reduction of expenditures by the school if quality of education is to be maintained; 5. supports continued improvement of the AMA information system on expenditures of medical students to determine which items are included, and what the ranges of costs are; 6. supports continued study of the relationship between medical student indebtedness and career choice; 7. believes medical schools should avoid counterbalancing reductions in revenues from other sources through tuition and student fee increases that compromise their ability to attract students from diverse backgrounds; 8. supports expansion of the number of affiliations with appropriate hospitals by institutions with accredited residency programs; 9. encourages for profit-hospitals to participate in medical education and training; 10. supports AMA monitoring of trends that may lead to a reduction in compensation and benefits provided to resident physicians; 11. encourages all sponsoring institutions to make financial information available to help residents manage their educational indebtedness; and 12. will advocate that resident and fellow trainees should not be financially responsible for their training.

The Preservation, Stability and Expansion of Full Funding for Graduate Medical Education D-305.967 1. Our AMA will actively collaborate with appropriate stakeholder organizations, (including Association of American Medical Colleges, American Hospital Association, state medical societies, medical specialty societies/associations) to advocate for the preservation, stability and expansion of full funding for the direct and indirect costs of graduate medical education (GME) positions from all existing sources (e.g. Medicare, Medicaid, Veterans Administration, CDC and others). 2. Our AMA will actively advocate for the stable provision of matching federal funds for state Medicaid programs that fund GME positions. 3. Our AMA will actively seek congressional action to remove the caps on Medicare funding of GME positions for resident physicians that were imposed by the Balanced Budget Amendment of 1997 (BBA-1997). 4. Our AMA will strenuously advocate for increasing the number of GME positions to address the future physician workforce needs of the nation. 5. Our AMA will oppose efforts to move federal funding of GME positions to the annual appropriations process that is subject to instability and uncertainty. 6. Our AMA will oppose regulatory and legislative efforts that reduce funding for GME from the full scope of resident educational activities that are designated by residency programs for accreditation and the board certification of their graduates (e.g. didactic teaching, community service, off-site ambulatory rotations, etc.). 7. Our AMA will actively explore additional sources of GME funding and their potential impact on the quality of residency training and on patient care. 8. Our AMA will vigorously advocate for the continued and expanded contribution by all payers for health care (including the federal government, the states, and local and private sources) to fund both the direct and indirect costs of GME. 9. Our AMA will work, in collaboration with other stakeholders, to improve the awareness of the general public that GME is a public good that provides essential services as part of the training process and serves as a necessary component of physician preparation to provide patient care that is safe, effective and of high quality. 10. Our AMA staff and governance will continuously monitor federal, state and private proposals for health care reform for their potential impact on the preservation, stability and expansion of full funding for the direct and indirect costs of GME. 11. Our AMA: (a) recognizes that funding for and distribution of positions for GME are in crisis in the United States and that meaningful and comprehensive reform is urgently needed; (b) will immediately work with Congress to expand medical residencies in a balanced fashion based on expected specialty needs throughout our nation to produce a geographically distributed and appropriately sized physician workforce; and to make increasing support and funding for GME programs and residencies a top priority of the AMA in its national political agenda; and (c) will continue to work closely with the Accreditation Council for Graduate Medical Education, Association of American Medical Colleges, American Osteopathic Association, and other key stakeholders to raise awareness among policymakers and the public about the importance of expanded GME funding to meet the nation's current and anticipated medical workforce needs. 12. Our AMA will collaborate with other organizations to explore evidence-based approaches to quality and accountability in residency education to support enhanced funding of GME. 13. Our AMA will continue to strongly advocate that Congress fund additional graduate medical education (GME) positions for the most critical workforce needs, especially considering the current and worsening maldistribution of physicians. 14. Our AMA will advocate that the Centers for Medicare and Medicaid Services allow for rural and other underserved rotations in Accreditation Council for Graduate Medical Education (ACGME)-accredited residency programs, in disciplines of particular local/regional need, to occur in the offices of physicians who meet the qualifications for adjunct faculty of the residency program's sponsoring institution. 15. Our AMA encourages the ACGME to reduce barriers to rural and other underserved community experiences for graduate medical education programs that choose to provide such training, by adjusting as needed its program requirements, such as continuity requirements or limitations on time spent away from the primary residency site. 16. Our AMA encourages the ACGME and the American Osteopathic Association (AOA) to continue to develop and disseminate innovative methods of training physicians efficiently that foster the skills and inclinations to practice in a health care system that rewards team-based care and social accountability. 17. Our AMA will work with interested state and national medical specialty societies and other appropriate stakeholders to share and support legislation to increase GME funding, enabling a state to accomplish one or more of the following: (a) train more physicians to meet state and regional workforce needs; (b) train physicians who will practice in physician shortage/underserved areas; or (c) train physicians in undersupplied specialties and subspecialties in the state/region. 18. Our AMA supports the ongoing efforts by states to identify and address changing physician workforce needs within the GME landscape and continue to broadly advocate for innovative pilot programs that will increase the number of positions and create enhanced accountability of GME programs for quality outcomes. 19. Our AMA will continue to work with stakeholders such as Association of American Medical Colleges (AAMC), ACGME, AOA, American Academy of Family Physicians, American College of Physicians, and other specialty organizations to analyze the changing landscape of future physician workforce needs as well as the number and variety of GME positions necessary to provide that workforce. 20. Our AMA will explore innovative funding models for incremental increases in funded residency positions related to quality of resident education and provision of patient care as evaluated by appropriate medical education organizations such as the Accreditation Council for Graduate Medical Education. 21. Our AMA will utilize its resources to share its content expertise with policymakers and the public to ensure greater awareness of the significant societal value of graduate medical education (GME) in terms of patient care, particularly for underserved and at-risk populations, as well as global health, research and education. 22. Our AMA will advocate for the appropriation of Congressional funding in support of the National Healthcare Workforce Commission, established under section 5101 of the Affordable Care Act, to provide data and healthcare workforce policy and advice to the nation and provide data that support the value of GME to the nation. 23. Our AMA supports recommendations to increase the accountability for and transparency of GME funding and continue to monitor data and peer-reviewed studies that contribute to further assess the value of GME. 24. Our AMA will explore various models of all-payer funding for GME, especially as the Institute of Medicine (now a program unit of the National Academy of Medicine) did not examine those options in its 2014 report on GME governance and financing. 25. Our AMA encourages organizations with successful existing models to publicize and share strategies, outcomes and costs. 26. Our AMA encourages insurance payers and foundations to enter into partnerships with state and local agencies as well as academic medical centers and community hospitals seeking to expand GME. 27. Our AMA will develop, along with other interested stakeholders, a national campaign to educate the public on the definition and importance of graduate medical education, student debt and the state of the medical profession today and in the future. 28. Our AMA will collaborate with other stakeholder organizations to evaluate and work to establish consensus regarding the appropriate economic value of resident and fellow services. 29. Our AMA will monitor ongoing pilots and demonstration projects, and explore the feasibility of broader implementation of proposals that show promise as alternative means for funding physician education and training while providing appropriate compensation for residents and fellows. 30. Our AMA will monitor the status of the House Energy and Commerce Committee's response to public comments solicited regarding the 2014 IOM report, Graduate Medical Education That Meets the Nation's Health Needs, as well as results of ongoing studies, including that requested of the GAO, in order to formulate new advocacy strategy for GME funding, and will report back to the House of Delegates regularly on important changes in the landscape of GME funding. 31. Our AMA will advocate to the Centers for Medicare & Medicaid Services to adopt the concept of “Cap- Flexibility” and allow new and current Graduate Medical Education teaching institutions to extend their cap- building window for up to an additional five years beyond the current window (for a total of up to ten years), giving priority to new residency programs in underserved areas and/or economically depressed areas. 32. Our AMA will: (a) encourage all existing and planned allopathic and osteopathic medical schools to thoroughly research match statistics and other career placement metrics when developing career guidance plans; (b) strongly advocate for and work with legislators, private sector partnerships, and existing and planned osteopathic and allopathic medical schools to create and fund graduate medical education (GME) programs that can accommodate the equivalent number of additional medical school graduates consistent with the workforce needs of our nation; and (c) encourage the Liaison Committee on Medical Education (LCME), the Commission on Osteopathic College Accreditation (COCA), and other accrediting bodies, as part of accreditation of allopathic and osteopathic medical schools, to prospectively and retrospectively monitor medical school graduates’ rates of placement into GME as well as GME completion. 33. Our AMA encourages the Secretary of the U.S. Department of Health and Human Services to coordinate with federal agencies that fund GME training to identify and collect information needed to effectively evaluate how hospitals, health systems, and health centers with residency programs are utilizing these financial resources to meet the nation’s health care workforce needs. This includes information on payment amounts by the type of training programs supported, resident training costs and revenue generation, output or outcomes related to health workforce planning (i.e., percentage of primary care residents that went on to practice in rural or medically underserved areas), and measures related to resident competency and educational quality offered by GME training programs.

Sources: 1. AAMC. An Exploration of the Recent Decline in the Percentage of U.S. Medical School Graduates With Education Debt. https://www.aamc.org/download/296002/data/aibvol12_no2.pdf. Accessed January 13, 2020. 2. Pisaniello MS, Asahina AT, Bacchi S, et al. Effect of medical student debt on mental health, academic performance and specialty choice: A systematic review. BMJ Open. 2019;9(7). doi:10.1136/bmjopen-2019- 029980 3. Craft III J, Craft T. Rising Medical Education Debt a Mounting Concern. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6179784/pdf/ms109_p0266.pdf. Accessed January 13, 2020. 4. Hill MR, Goicochea S, Merlo LJ. In their own words: stressors facing medical students in the millennial generation. Med Educ Online. 2018;23(1). doi:10.1080/10872981.2018.1530558 5. Rohlfing J, Navarro R, Maniya OZ, Hughes BD, Rogalsky DK. Medical student debt and major life choices other than specialty. Med Educ Online. 2014;19(1). doi:10.3402/meo.v19.25603 6. Grayson MS, Newton DA, Thompson LF. Payback time: the associations of debt and income with medical student career choice. Med Educ. 2012;46(10):983-991. doi:10.1111/j.1365-2923.2012.04340.x 1 RESOLUTION 58-20 2 3 Title: Use Term “Intellectual Disability” in Lieu of “Mental Retardation” in Academic 4 Texts, Published Literature, and Medical Education 5 6 Introduced by: Mara Darian, for the Medical Student Section 7 8 Original Author: Samantha Rea 9 10 Referred To: 11 12 House Action: 13 14 15 Whereas, intellectual disability is defined as "a group of developmental conditions 16 characterized by significant impairment of cognitive functions, which are associated with limitations 17 of learning, adaptive behavior and skills," and 18 19 Whereas, people with disabilities have experienced disproportionate burdens during the 20 COVID-19 pandemic and will continue to face disparities moving forward unless equitable solutions 21 are created, including consistent use of terminology that is nondiscriminatory, and 22 23 Whereas, the term “mental retardation” is pejorative and stigmatizing, leading to poor 24 treatment of people with intellectual disabilities, less health care access, and poorer health, 25 employment, and quality of life outcomes, and 26 27 Whereas, physicians are more likely to use the term “mental retardation” than occupational 28 therapists, physiotherapists, nurses, and social workers, and 29 30 Whereas, the Department of Education implemented Rosa’s Law to use the term 31 “intellectual disability” in federal legislation, and 32 33 Whereas, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental 34 Disorders, Fifth Edition (DSM-5) replaced the diagnosis of “mental retardation” with “intellectual 35 disability” for childhood-onset neurodevelopmental disorders, and 36 37 Whereas, the American Medical Association (AMA) already supports using the term 38 “intellectual disability” to replace “mental retardation” in clinical settings (H-70.912), and 39 40 Whereas, the AMA Code of Style and American Psychological Association recommends 41 person-first language in scholarly writing and speaking, and 42 43 Whereas, textbooks, course notes, and published literature in medical education should 44 reflect the same recommendations to encourage appropriate terminology at the earliest stages of 45 physician education as well as continuing medical education for practicing physicians; therefore be 46 it 47 48 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 49 our AMA to amend AMA policy H-70.912 by addition to read as follows: 50 51 Our AMA recommends that physicians adopt the term “intellectual disability” instead of 52 “mental retardation” in clinical settings, academic texts, published literature, and 53 medical education. 54 55 56 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 57 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy:

Eliminating Use of the Term "Mental Retardation" by Physicians in Clinical Settings H-70.912 Our AMA recommends that physicians adopt the term “intellectual disability” instead of “mental retardation” in clinical settings.

Sources: 1. Salvador-Carulla L, Reed GM, Vaez-Azizi LM, et al. (2011). Intellectual developmental disorders: towards a new name, definition and framework for “mental retardation/intellectual disability” in ICD-11. World Psychiatry, 10:175-180. 2. Neece C, McIntyre LL, Fenning R. Examining the impact of COVID-19 in ethnically diverse families with young children with intellectual and developmental disabilities. J Intellect Disabil Res. 2020 Oct;64(10):739-749. doi: 10.1111/jir.12769. Epub 2020 Aug 18. PMID: 32808424; PMCID: PMC7461180. 3. Houtrow A, Harris D, Molinero A, Levin-Decanini T, Robichaud C. Children with disabilities in the United States and the COVID-19 pandemic. J Pediatr Rehabil Med. 2020;13(3):415-424. doi: 10.3233/PRM- 200769. PMID: 33185616. 4. Caldwell, J. (2010). Leadership development of individuals with developmental disabilities in the self- advocacy movement. Journal of Intellectual Disability Research, 54(11), 1004-1014. 5. Caldwell, J. (2011). Disability identity of leaders in the self-advocacy movement. Intellectual and Developmental Disabilities, 49(5), 315-326. 6. Caldwell, J., Arnold, K., & Rizzolo, M. K. (2012). Envisioning the future: Allies in self advocacy. Washington, DC: Association of University Centers on Disabilities. 7. Jones, J. L. (2012). Factors associated with self concept: Adolescents with intellectual and development disabilities share their perspectives. Intellectual and Developmental Disabilities, 50(1), 31-40. 8. Self Advocates Becoming Empowered. (2014). SABE policy statement on the R word. Retrieved from http://www.sabeusa.org/wp-content/ uploads/2014/02/SABE-Policy-Statement-onthe- R-Word.pdf 9. Chris Nash, MD, Ann Hawkins, MD, Janet Kawchuk, MD, and Sarah E Shea, MD. (Feb 2012). What’s in a name? Attitudes surrounding the use of the term “mental retardation”. Paediatr Child Health, 17(2): 71- 74. 10. Federal Register. Rosa’s Law. (July 2017). Retrieved from https://www.federalregister.gov/documents/2017/07/11/2017-14343/rosas-law 11. Harris JC. New terminology for mental retardation in DSM-5 and ICD-11. Curr Opin Psychiatry. 2013;26(3):260-262. doi:10.1097/YCO.0b013e32835fd6fb 12. APA Style. (2019). American Psychological Association. Retrieved on 2/21/21 from https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/disability 1 RESOLUTION: 05-21 2 3 Title: Health Information Card 4 5 Introduced by: Federico G. Mariona, MD, MBA, FACOG, FACS, for the Wayne County 6 Delegation 7 8 Original Authors: Mirna Kaafarani and Federico Mariona, MD 9 10 Referred To: 11 12 House Action: 13 14 15 Whereas, the SARS-CoV-2 novel coronavirus is the third highly transmissible pathogen in its 16 class that has surfaced in the first 20 years of the 21st century and reached the level of a pandemic, 17 causing the clinical disease known as Corona Virus Disease-19 (CoVid-19), and 18 19 Whereas, Covid-19 affects the health, society, education, economy, and security of the 20 United States population, and 21 22 Whereas, accurate and consistent public information is of critical importance to identify, 23 design, and implement programs and processes that are consistent with the needs of the state 24 public health institutions to provide appropriate means to mitigate and implement statewide 25 solutions to health crises and catastrophic events, and 26 27 Whereas, the public lacks confidence in the veracity and the consistency of the health 28 information provided by the health authorities and the media, with conflicting and frequently 29 changing advice increasing the health care, social, and economic uncertainty, and 30 31 Whereas, that a state Health Information Card should be implemented and equipped with 32 programmed encrypted microchip technology to protect the identity of the holder. The card will 33 allow for real time entry of health events and provide access to health information changes and 34 contribute to build the state’s public health system information network, assist in the 35 implementation of strategic plans for public information, individual evidence-based treatment, 36 guide public health advocacy, economic policies, national security integrity, and advanced 37 planning, and 38 39 Whereas, a similar system has been tested, tried, and used in advanced industrialized 40 countries in the world including the United States in Tennessee, and 41 42 Whereas, providing accurate information can be achieved, by the implementation of a 43 system that allows for timely obtainment and recording of pertinent data gathering to construct 44 epidemiological models avoiding poor methodology and variable definitions; therefore be it 45 46 RESOLVED: That MSMS encourage the state’s public health authorities and the state 47 legislature to work towards the implementation of a state Health Information Card, issued to each 48 citizen in the state to contain the demographic and clinical information needed to allow for the 49 building of a standard system of health data collection and facilitate reporting of the state’s 50 population health status. 51 52 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - $25,000+

STATEMENT OF URGENCY: The SARS-CoV-2 novel coronavirus is the third highly transmissible pathogen in its class that has surfaced in the first 20 years of the 21st century and reached the level of a pandemic, causing the clinical disease known as Corona Virus Disease -19 (CoVid-19). Accurate and consistent public information tracking the virus is of critical importance. This resolution is time sensitive as it deals with developing a standard system of health data collection and facilitate reporting of the state’s population health status regarding COVID-19. Similar systems have already been tested, tried and used in advanced industrialized countries. This identification card will allow for real time entry of health events and provide access to health information changes and contribute to build the state’s public health system information network, assist in the implementation of strategic plans for public information, individual evidence-based treatment, guide public health advocacy, economic policies, national security integrity and advanced planning.

Relevant MSMS Policy: None

Relevant AMA Policy: None

Sources: 1. Statista, Cost Drivers where Mobile Health Will Have the Highest Positive Impact Worldwide in the Next Five Years, as of 2016. (accessed on 24 July 2020)]; Available online: https://www.statista.com/statistics/625219/mobile-health-global-healthcare-cost-reductions/ 2. The pharmaceutical record in an emergency department: Assessment of its accessibility and its impact on the level of knowledge of the patient's treatment. Trinh-Duc A, et al. Ann Pharm Fr. 2016. PMID: 33096907 French. In France, the pharmaceutical record (PR) is a shared professional tool arising from the pharmacists lists of all drugs dispensed during the… 3. Derek M Griffith, Andrea R Semlow, Mike Leventhal, Clare Sullivan, The Tennessee Men's Health Report Card: A Model for Men's Health Policy Advocacy and Education. Am J mens health. Sept-October 2019. 13(5) 1 RESOLUTION 07-21 2 3 Title: COVID-19 Vaccine Entry Into MCIR 4 5 Introduced by: Neeli Thati, MD, for the Wayne County Delegation 6 7 Original Author: Neeli Thati, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, the Affordable Care Act of 2010 establishes patient-centered outcomes for all 15 ages, and 16 17 Whereas, the Patient Centered Medical Home is the vehicle to achieve patient centered 18 outcomes, and 19 20 Whereas, the Patient Centered Medical Home is a health care setting where, among others, 21 care is facilitated by registries, information technology, health information exchange, and other 22 means, and 23 24 Whereas, the Michigan Care Improvement Registry (MCIR), through the careful tracking of 25 immunization information provided by health care providers and making this information 26 accessible to authorized users online, strives to reduce the occurrence of vaccine preventable 27 illness, and 28 29 Whereas, patients typically do not keep records of their immunizations, and 30 31 Whereas, immunization information is an integral part of EHRs used in Michigan practices, 32 and 33 34 Whereas, adult immunization, in contrast to pediatric immunization, is not mandated to be 35 entered into the MCIR system within 72 hours, and 36 37 Whereas, Michigan’s COVID-19 vaccine roll out is primarily through the local county health 38 departments, hospitals and pharmacies. Although the number of doses is carefully being 39 accounted for at each distribution center, efforts should be made to update this information in 40 MCIR; therefore be it 41 42 RESOLVED: That MSMS support legislation for Michigan that mandates entry of COVID-19 43 Vaccine into the Michigan Care Improvement Registry (MCIR) system within 72 hours. 44 45 46 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy – $25,000+

STATEMENT OF URGENCY: Adult immunization, in contrast to pediatric immunization, is not mandated to be entered into the MCIR system within 72 hours. COVID-19 Vaccine roll out is through the local county health departments and pharmacies. Although the number of doses are carefully being accounted for at each distribution center, it is crucial that efforts be made to update this information in MICR. This is a very time sensitive matter.

Relevant MSMS Policy: None

Relevant AMA Policy: None

1 RESOLUTION 09-21 2 3 Title Repeal Safe Harbor Provisions 4 5 Introduced by: James Szocik, MD, for the Washtenaw County Delegation 6 7 Original Author: James Szocik, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, group purchasing organizations (GPO) and pharmacy benefits managers (PBM) 15 act as middlemen between producers of drugs and supplies and the consumers, hospitals and 16 patients, and 17 18 Whereas, GPO and PBM propose to add value to the consumers by negotiating contracts, 19 but in reality they extract “rent,” limit innovation distort prices (IV saline is sold at below cost 20 because it is “coupled” with other purchases), and contribute to drug shortage, and 21 22 Whereas, GPO and PBM further offer “rebates” to hospital systems and major consumers 23 that would otherwise be categorized as “bribes” or “kick-backs” and are only allowed under special 24 “safe harbor provisions” of U.S. law, and 25 26 Whereas, this results in increased costs for the end consumer, and 27 28 Whereas, the previous Administration supported and was working on eliminating these safe 29 harbors, the current Administration has suspended all implementation of such changes; therefore 30 be it 31 32 RESOLVED: That MSMS advocate for the repeal of the “Safe Harbors” under 42 CFR 33 1001.952(j) , 42 U.S.C. 1320a-7b(b)(3)(C) and any other state or federal statutes that may apply and 34 support the substitution of rebates directly to the consumer and the public; and be it further 35 36 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) urge 37 our AMA to advocate for the repeal of the “Safe Harbors” under 42 CFR 1001.952(j) , 42 U.S.C. 38 1320a-7b(b)(3)(C) and any other state or federal statutes that may apply and support the 39 substitution of rebates directly to the consumer and the public. 40 41 42 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 43 $25,000+

STATEMENT OF URGENCY: In November 2020, the HHS OIG finalized its previously abandoned 2019 proposal to exclude certain rebates paid by drug manufacturers from the discount safe harbor to the federal anti-kickback statute. The rule is expected to go into effect in January 2021.

Relevant MSMS Policy: None

Relevant AMA Policy: None

Sources: 1. https://www.modernhealthcare.com/article/20190119/NEWS/190119924/are-gpos-pbms-part-of-the- drug-cost-problem-or-the-solution 2. https://www.masimo.com/company/news/media-room/antitrust-litigation/ 3. https://khn.org/wp-content/uploads/sites/2/2016/10/pipelinetoprofits.pdf 4. https://www.gao.gov/assets/590/589778.pdf 5. https://jamanetwork.com/journals/jama/fullarticle/2708613 6. https://www.jdsupra.com/legalnews/trump-administration-revives-rebate-84255/

1 RESOLUTION 12-21 2 3 Title: Standard Practice for Members Joining or Transferring Membership 4 5 Introduced by: Joseph Wilhelm, MD, for the Ingham County Delegation 6 7 Original Author: Joseph Wilhelm, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, Article III, Section 1 of the Michigan State Medical Society (MSMS) Constitution 15 states: DEFINITION—Component societies shall consist of those county medical societies which 16 hold charters from this Society, and 17 18 Whereas, Article III, Section 2 of the MSMS Constitution states: GEOGRAPHICAL SCOPE-Not 19 more than one component society shall be chartered in any county of the State. The House of 20 Delegates may, however, in its discretion, grant a charter to a component society comprising two 21 or more counties, and 22 23 Whereas, Section 2.20 of the MSMS Bylaws states: MEMBERSHIP PREREQUISITE-All 24 members of the several component societies, when in good standing, are thereby and must be 25 members of this Society. All members of this Society must be members of a component medical 26 society or direct members through the Resident and Fellow Section or the Medical Student Section, 27 and 28 29 Whereas, Section 2.30 of the MSMS Bylaws states: ACTIVE MEMBERS-To be eligible for 30 active membership in any component society, doctors of medicine must hold an unrevoked, 31 permanent license that is not currently under suspension in Michigan, or if unlicensed, must be 32 engaged in academic teaching, research or administration. To maintain active membership in any 33 component society, doctors of medicine must maintain active membership in this Society and 34 comply with all the provisions of the Bylaws of this Society and the component society, and 35 36 Whereas, Section 4.10 of the MSMS Bylaws states: MEMBERSHIP AS PRIVILEGE - NOT 37 RIGHT—Admission to membership in any component society is not a matter of right, but one of 38 privilege, to be accorded or withheld at the sole discretion of such society. Each component society 39 may determine the manner of electing its members and shall be the sole judge of the qualifications 40 of applicants for membership therein. There shall be no discrimination on the basis of race, religion, 41 sex, ethnic origin, or sexual orientation, and 42 43 Whereas, Section 4.20 of the MSMS Bylaws states: ADJOINING COUNTY—A doctor of 44 medicine whose principal location of practice is near a county may, with the permission of the 45 Board of Directors of this Society, and upon being duly elected thereto, hold membership in the 46 component society most convenient for the member to attend, and 47 48 Whereas, it is the practice of our county medical societies and our MSMS that new 49 members to the Michigan State Medical Society join the component medical society of the county 50 where they either live or primarily work and the MSMS website states, “When you become a 51 member of MSMS, you also become a member of the county medical society in which you live or 52 work,” and 53 54 Whereas, any current member wishing to transfer membership to another county medical 55 society must first receive a good standing certification from the former county medical society and 56 approval from the new county medical society, and 57 58 Whereas, the county medical societies became aware in July 2020, of physician(s) and/or 59 physician group(s) being allowed to join and/or to transfer membership to inactive counties 60 (counties with no discernable county medical society leadership, structure, operations, or 61 membership dues requirements) in which they did not live and/or primarily work, and 62 63 Whereas, MSMS staff did not notify the county medical societies when these members 64 transferred membership, and 65 66 Whereas, the county medical societies initiated discussion about these aberrant situations 67 with MSMS staff on July 20, 2020, and 68 69 Whereas, following that discussion, the MSMS Board of Directors considered and approved 70 a motion at the October 2020, Board meeting re-interpreting the bylaws stating “that the MSMS 71 Board of Directors acknowledge MSMS Legal Counsel’s interpretation that the MSMS Bylaws do 72 not expressly require a physician to live or work in a county in order to hold membership in that 73 county medical society,” and 74 75 Whereas, this practice of allowing physicians to join and/or transfer to counties in which 76 they do not live and/or primarily work continues to occur since the October 2020, MSMS Board 77 meeting, and 78 79 Whereas, this practice creates an incentive for physicians and/or physician groups 80 regardless of where they live or work to join inactive counties without membership dues to reduce 81 their cost, and 82 83 Whereas, this practice is disruptive and harmful to the integrity and vitality of the county 84 medical societies and MSMS; therefore be it 85 86 RESOLVED: That the MSMS Bylaws be amended as follows: Deletions are indicated by 87 strikethroughs, additions are indicated in bold type. 88 89 2.20 MEMBERSHIP PREREQUISITE-All members of the several component societies, when in 90 good standing, are thereby and must be members of this Society. All members of this 91 Society must be members of a component medical society where they live or 92 primarily work or direct members through the Resident and Fellow Section or the 93 Medical Student Section. 94 95 4.10 MEMBERSHIP AS PRIVILEGE - NOT RIGHT—A doctor of medicine may apply for 96 component membership within the county of their residence or primary location 97 of practice. Any exception would require written, mutual agreement between 98 the physician and/or physician group, the MSMS, and the respective county(ies). 99 Admission to membership in any component society is not a matter of right, but one 100 of privilege, to be accorded or withheld at the sole discretion of such society. Each 101 component society may determine the manner of electing its members and shall be 102 the sole judge of the qualifications of applicants for membership therein. There shall 103 be no discrimination on the basis of race, religion, sex, ethnic origin, or sexual 104 orientation. 105 106 4.20 ADJOINING COUNTY—A doctor of medicine whose residence or principal location of 107 practice is near a county an active, chartered county medical society may, with the 108 permission of the Board of Directors of this Society, and upon being duly elected 109 thereto, hold membership in the nearest active, chartered component county 110 medical society most convenient for the member to attend. 111 112 5.10 CHANGE OF LOCATION – PROCEDURE—When a member of a component society, by 113 reason of change of residence or primary practice location, desires to transfer 114 membership to another component society, such member shall make application 115 thereto accompanied by tender of dues for the remaining half of the current year (any 116 major fraction of a half being regarded as a full half and any minor fraction being 117 disregarded). Thereupon, the secretary of the society to which application is made 118 shall request certification of standing from the Society from which the member desires 119 to transfer and upon receipt of such request the secretary of the latter Society shall 120 supply certification of good standing, provided the following requirements have been 121 met: 122 123 124 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 125 or AMA policy - $500

STATEMENT OF URGENCY: The county medical societies became aware in July 2020 of physician(s) and/or physician group(s) being allowed to join and/or to transfer membership to inactive counties (counties with no discernable county medical society leadership, structure, operations, or membership dues requirements) in which they did not live and/or primarily work. MSMS staff did not notify the county medical societies when these members joined or transferred membership. The county medical societies initiated discussion about these aberrant situations with MSMS staff on July 20, 2020 and, following that discussion, the MSMS Board of Directors considered and approved a motion at the October 2020 Board meeting re-interpreting the bylaws stating “that the MSMS Board of Directors acknowledge MSMS Legal Counsel’s interpretation that the MSMS Bylaws do not expressly require a physician to live or work in a county in order to hold membership in that county medical society.” This practice of allowing physicians to join and/or transfer to counties in which they do not live and/or primarily work has continued to occur since the October 2020 MSMS Board meeting, creating an incentive for physicians and/or physician groups regardless of where they live or work to join inactive counties without membership dues to reduce their cost. This must be addressed at this House of Delegates as the practice is disruptive and harmful to the integrity and vitality of the county medical societies and MSMS.

Relevant AMA Policy: None

Sources: 1. https://connect.msms.org/Membership/Join 2. Source: January 14, 2021 MSMS Board of Directors Meeting Packet

1 RESOLUTION 14-21 2 3 Title: Disposition of Complaints 4 5 Introduced by: Narasimha Gundamraj MD, for the Ingham County Delegation, Christopher J. 6 Allen, MD, for the Saginaw County Delegation, and Evelyn Eccles, MD, for the 7 Washtenaw County Delegation 8 9 Original Author: Evelyn Eccles, MD 10 11 Referred To: 12 13 House Action: 14 15 16 Whereas, MSMS and/or county societies have a duty to investigate complaints brought 17 against one of their members involving ethical or medical behavior, and 18 19 Whereas, in the event that such a complaint is brought, component societies will initiate 20 such investigation with the understanding that should legal advice be needed, they will have the 21 support of MSMS legal counsel, and that their decisions may be reviewed by the MSMS Judicial 22 Committee, and 23 24 Whereas, MSMS and/or county societies do not have a duty to investigate or adjudicate 25 complaints that do not involve one or more of its members, and such complaints if they involve a 26 physician who is not a member of MSMS or county society should be referred to LARA for 27 disposition, and 28 29 Whereas, in the event that a complaint is brought against a member but the complaint is 30 unrelated to and does not involve any aspect of that member’s medical practice, it should not be 31 referred for disposition by MSMS to the county society in which the alleged activity occurred, but 32 should be dismissed by MSMS, and 33 34 Whereas, referral by MSMS of a complaint to the county society for disposition when the 35 dispute does not involve a county society member or is not related to medical practice or patient 36 care, places an unnecessary expectation, administrative, and financial burden on that society; 37 therefore be it 38 39 RESOLVED: That MSMS shall provide legal counsel and knowledgeable staff to the county 40 medical society whenever a complaint is received involving a physician member in said county 41 related to medical practice and/or medical ethics. 42 43 44 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requiring external consultants - 45 $50,000+

STATEMENT OF URGENCY: Complaints are considered as regular medical society business. A standard, clear practice should be developed and communicated to protect the medical societies and members.

Relevant MSMS Policy:

Judicial Commission Complaint Process

Statistics on Complaints

Year Forms Mailed Forms Received Full Complaint Process 2016 2 0 0 2017 1 1 1 2018 3 0 0 2019 1 0 0 2020 3 2 2

Relevant AMA Policy: None 1 RESOLUTION 17-21 2 3 Title: Surrogacy Options for Michigan Parents 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Author: Adam J. Rush, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, the AMA supports surrogate parenting “also termed Third Party Reproduction” as 15 a form of assisted reproduction in which a woman agrees to bear a child on behalf of and 16 relinquish the child to an individual or couple who intend to rear the child, and 17 18 Whereas, such arrangements can promote fundamental human values by enabling 19 individuals or couples who are otherwise unable to do so to fulfill deeply held desires to raise a 20 child, and 21 22 Whereas, gestational carriers in their turn can take satisfaction in expressing altruism by 23 helping others fulfill such desires, and 24 25 Whereas, in the United States, individual states have the power to determine the legality of 26 surrogacy agreements and surrogate compensation, and 27 28 Whereas, the state of Michigan is one of only three states that are outliers on surrogacy law, 29 and 30 31 Whereas, in the state of Michigan statute prohibits compensated surrogacy contracts, and a 32 birth certificate naming both intended parents cannot be obtained, and 33 34 Whereas, the state of New York in February 2021, made compensated surrogacy legal, and 35 36 Whereas, in 1998, MSMS endorsed the need to define and protect the legal status and 37 rights of a child born as a result of surrogate parenting, and 38 39 Whereas, in 2018, Senator Rebekah Warren (D-Warren) introduced Senate Bill 1082 which 40 to repeal Michigan’s current law and replace it with the Gestational Surrogate Parentage Act, but it 41 failed to advance; therefore be it 42 43 RESOLVED: That MSMS work with the Michigan legislature to amend the current law to 44 assist parents and newborns in Michigan, clarify parenting rights, and support compensated 45 surrogacy options. 46

47 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 48 $25,000+

STATEMENT OF URGENCY: This is a timely issue that should be addressed promptly for physicians and patients. In light of recent legislative discussions at the state and/or local level, physicians need to be involved in updating this legislation.

Relevant MSMS Policy:

Surrogate Parenting MSMS endorses the need to define and protect the legal status and rights of a child born as a result of surrogate parenting. MSMS endorsement does not extend to the process of surrogate parenting. (Prior to 1990)

Relevant AMA Policy:

4.2.4 Third-Party Reproduction Third-party reproduction is a form of assisted reproduction in which a woman agrees to bear a child on behalf of and relinquish the child to an individual or couple who intend to rear the child. Such arrangements can promote fundamental human values by enabling individuals or couples who are otherwise unable to do so to fulfill deeply held desires to raise a child. Gestational carriers in their turn can take satisfaction in expressing altruism by helping others fulfill such desires.

Third-party reproduction may involve therapeutic donor insemination or use of assisted reproductive technologies, such as in vitro fertilization and embryo transfer. The biological and social relationships among participants in these arrangements can form a complex matrix of roles among gestational carrier, gamete donor(s), and rearing parent(s).

Third-party reproduction can alter social understandings of parenthood and family structure. They can also raise concerns about the voluntariness of the gestational carrier’s participation and about possible psychosocial harms to those involved, such as distress on the part of the gestational carrier at relinquishing the child or on the part of the child at learning of the circumstances of his or her birth. Third-party reproduction can also carry potential to depersonalize carriers, exploit economically disadvantaged women, and commodify human gametes and children. These concerns may be especially challenging when carriers or gamete donors are compensated financially for their services. Finally, third- party reproduction can raise concerns about dual loyalties or conflict of interest if a physician establishes patient-physician relationships with multiple parties to the arrangement.

Individual physicians who care for patients in the context of third-party reproduction should:

(a) Establish a patient-physician relationship with only one party (gestational carriers, gamete donor[s] or intended rearing parent[s]) to avoid situations of dual loyalty or conflict of interest.

(b) Ensure that the patient undergoes appropriate medical screening and psychological assessment.

(c) Encourage the parties to agree in advance on the terms of the agreement, including identifying possible contingencies and deciding how they will be handled.

(d) Inform the patient about the risks of third-party reproduction for that individual (those including individuals), possible psychological harms to the individual(s), the resulting child, and other relationships.

(e) Satisfy themselves that the patient’s decision to participate in third-party reproduction is free of coercion before agreeing to provide assisted reproductive services.

Collectively, the profession should advocate for public policy that will help ensure that the practice of third- party reproduction does not exploit disadvantaged women or commodify human gametes or children.

Sources: 1. Third-Party Reproduction, The AMA Code of Ethics Opinion 4.2.4. www.ama-assn.org/delivering- care/ethics/third-party-reproduction 2. The United States Surrogacy Law Map. www.creativefamilyconnections.com/us-surrogacy-law-map 3. Surrogate Parenting Act. http://legislature.mi.gov/doc.aspx?mcl-act-199-of-1988 4. The Child-Parent Security Act. http://health.ny.gov/vital_records/child_parent_security_act 5. Senate Bill 1082 (2018). http://legislature.mi.gov/doc.aspx?2018-SB-1082 1 RESOLUTION 19-21 2 3 Title: De-professionalization of the Medical Profession 4 5 Introduced by: David Whalen, MD, for the Kent County Delegation 6 7 Original Author: Patrick J. Droste, MS, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, physicians attend medical school, complete an internship, and residency training 15 before being credentialed as a fully licensed physician, and 16 17 Whereas, physicians complete a rigorous series of board examinations during medical 18 school, internship, and residency to certify their ability to diagnosis and treat patients, and 19 20 Whereas, physicians are regarded as the legal entity that is ultimately responsible for 21 patient care, and 22 23 Whereas, health care workers are encouraged to address physicians by their first name 24 rather than doctor, in order to lessen the "authority gradient" related to patient safety, and 25 26 Whereas, physicians-in-training are being encouraged to perform as active team members 27 in patient care and are not being recognized as medical students or resident physicians, which 28 potentially leads to confusion about leadership and accountability within the team, and 29 30 Whereas, medical schools are utilizing Advanced Practice Professionals as educators for 31 future physicians, implying that the training of Advanced Practice Professionals is equivalent to the 32 training of physicians, and 33 34 Whereas, physicians are still held professionally and legally accountable for outcomes, 35 including adverse outcomes, of team-based care due to the higher level of training involved and 36 the role as the team leader; therefore be it 37 38 RESOLVED: That MSMS supports only the use of titles and descriptors that align with a 39 physician or non-physician provider’s state issued licenses or credentials; and be it further 40 41 RESOLVED: That MSMS actively oppose efforts to diminish the qualifications and training of 42 physicians by hospital administrators, insurance companies, and governmental regulatory agencies 43 who require physicians be referenced as medical providers, team members, health care providers, 44 or any other reference in lieu of the legal title of physician or doctor; and be it further 45 46 RESOLVED: That MSMS seek legislation which provides that professionals in a clinical 47 health care setting clearly and accurately identify to patients their qualifications and degree(s) 48 attained as follows: 49 1. Wear an identification badge which indicates the individual's name and credentials as 50 appropriate (i.e., MD, DO, RN, LPN, DC, DPM, DDS, etc.), to differentiate between those who 51 have achieved a Doctorate, and those with other types of credentials. The font size of their 52 credentials shall be greater than the front size used for their name for the purpose of role 53 definition and patient safety. 54 2. Anyone in a hospital environment who has direct contact with a patient who presents himself 55 or herself to the patient as a "doctor," and who has not received a "Doctor of Medicine" or a 56 "Doctor of Osteopathic Medicine" degree or an equivalent degree following successful 57 completion of a prescribed course of study from a school of medicine or osteopathic 58 medicine, shall specifically and simultaneously declare themselves a "non-physician" and 59 define the nature of their doctorate degree. 60 61 62 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 63 $25,000+

STATEMENT OF URGENCY: We encourage the highest consideration for this resolution to be evaluated and acted upon by the Michigan State Medical Society-House of Delegates-2021. The medical profession has been victim of a well-organized downgrading of professional merit and expertise by providers who want to pay less for physician provided medical services by comparing them to advanced practice providers (APP). Hospital administrators want to decrease the “authority gradient” by removing titles in correspondence and video meetings and calling physicians by their first name. Pharmacists, physical therapists and nurses all offer doctorate degrees and want their graduates to be recognized by the public and hospitals as “Doctors.” This creates a very confusing environment for patient satisfaction and safety and a very disturbing environment for physicians. This movement has been growing for over thirty years, with little tangible resistance by the medical profession and we feel that something legislative needs to be started this year by the MSMS to start reversing this overt devaluation of our profession.

Relevant MSMS Policy:

Calling Physicians by their First Name MSMS discourages policies that require physicians to be called by their first names in professional settings such as their workplace. (Res42-16)

Physician Not Labeled as Provider MSMS opposes the current custom by government and insurance companies of labeling physicians as providers and encourages proper identification of physicians and/or surgeons. MSMS supports physicians who request they be identified as “physicians” apart from other “providers” on any contracts or documents they are asked to sign. (Res38-90A) – Amended 1993 – Edited 1998 -Reaffirmed (Sunset Report 2020)

Relevant AMA Policy:

"Doctor" as a Title H-405.992 The AMA encourages state medical societies to oppose any state legislation or regulation that might alter or limit the title "Doctor," which persons holding the academic degrees of Doctor of Medicine or Doctor of Osteopathy are entitled to employ.

Clarification of the Title "Doctor" in the Hospital Environment D-405.991 1. Our AMA Commissioners will, for the purpose of patient safety, request that The Joint Commission develop and implement standards for an identification system for all hospital facility staff who have direct contact with patients which would require that an identification badge be worn which indicates the individual's name and credentials as appropriate (i.e., MD, DO, RN, LPN, DC, DPM, DDS, etc), to differentiate between those who have achieved a Doctorate, and those with other types of credentials.

2. Our AMA Commissioners will, for the purpose of patient safety, request that The Joint Commission develop and implement new standards that require anyone in a hospital environment who has direct contact with a patient who presents himself or herself to the patient as a "doctor," and who is not a "physician" according to the AMA definition (H-405.969, ?that a physician is an individual who has received a "Doctor of Medicine" or a "Doctor of Osteopathic Medicine" degree or an equivalent degree following successful completion of a prescribed course of study from a school of medicine or osteopathic medicine?) must specifically and simultaneously declare themselves a "non-physician" and define the nature of their doctorate degree.

3. Our AMA will request the American Osteopathic Association (AOA) to (1) expand their standards to include proper identification of all medical staff and hospital personnel with their applicable credential (i.e., MD, DO, RN, LPN, DC, DPM, DDS, etc), and (2) Require anyone in a hospital environment who has direct contact with a patient presenting himself or herself to the patient as a "doctor", who is not a "Physician" according to the AMA definition (AMA Policy H-405.969 .. that a physician is an individual who has received a "Doctor of Medicine" or a "Doctor of Osteopathic Medicine" degree or an equivalent degree following successful completion of a prescribed course of study from a school of medicine or osteopathic medicine) must specifically and simultaneously declare themselves a "non-physician" and define the nature of their doctorate degree. 1 RESOLUTION 23-21 2 3 Title: Licensure of Nutritionists and Dietitians 4 5 Introduced by: Michael Moentmann, for the Medical Student Section 6 7 Original Author: Michael Moentmann 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, Michigan is one of three states which has no formal licensing requirements or title 15 protections for nutritionists and dietitians, and 16 17 Whereas, licensure assures health insurance companies, state, and federal governments that 18 practitioners who are being reimbursed for nutrition care services meet standards of professional 19 competence, and 20 21 Whereas, without proper training, individuals can present fringe nutritional practices as 22 evidence-based, or misinterpret current nutritional research and misapply the findings, and 23 24 Whereas, without formal licensing, individuals who claim to have expertise in nutrition 25 cannot be prevented from making misleading claims regarding nutrition supplements or weight 26 loss plans that could be contraindicated with certain medical conditions, and 27 28 Whereas, registered dietitians have formal professional, educational, and ethical standards, 29 including continuing professional education, and 30 31 Whereas, in previous legislation, licensing requirements and regulation did not apply to 32 business people involved in the distribution of health-related products, so long as they did not 33 identify themselves by the title of "dietitian" or "nutritionist," and 34 35 Whereas, MSMS maintains positions on licensing for other health-related fields, supporting 36 the licensure and definition of scope of practice for legitimate professionals such as genetic 37 counselors and nurse anesthetists, while opposing licensure for unproven health practitioners such 38 as naturopaths; therefore be it 39 40 RESOLVED: That MSMS supports formal educational requirements and subsequent 41 licensure of dietitians and nutritionists. 42 43 44 WAYS AND MEANS COMMITTEE FISCAL NOTE: None

Relevant MSMS Policy:

Licensure and Reimbursement for Certified Genetic Counselors MSMS supports the licensure of certified genetic counselors. (Res36-16)

Certified Anesthesiologist Assistants MSMS supports the licensure of "certified anesthesiologist assistants" (CAA), who would practice anesthesiology under the supervision of an anesthesiologist, consistent with other MSMS policy relative to scope of practice. (Board-Oct17)

Licensure of Naturopaths MSMS opposes the use of licensing as a pathway for expanding the scope of practice of persons practicing naturopathic medicine. (Board-July2018)

Health Profession Boards Need to Protect Patients MSMS opposes efforts by licensing boards of non physicians to establish their own scope of practice, and expansion in non-physicians scope of practice may only occur with approval of the Boards of Medicine, the respective non-physician licensing board, and the Legislature. (Res20-12)

Oppose Scope of Practice Expansion for Allied Health Care Professionals MSMS opposes scope of practice changes for non-physician health care professionals that are not supported by their level of education and training. (Res89-16) - Amended (Res59-18)

Relevant AMA Policy: None

Sources: 1. Licensure and Professional Regulation of Dietitians, Academy of Nutrition and Dietetics, 2020. online https://www.eatrightpro.org/advocacy/licensure/professional-regulation-of-dietitians#state 2. House Bill 4688 committee report; Repeal licensure of dieticians & nutritionists. Michigan State Government, 2014. online http://www.legislature.mi.gov/documents/2013- 2014/billanalysis/House/pdf/2013-HLA-4688-AC9131F3.pdf 3. Noland D, Raj S. Academy of Nutrition and Dietetics: Revised 2019 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition in Integrative and Functional Medicine. J Acad Nutr Diet. 2019;119(6):1019-1036.e47. doi:10.1016/j.jand.2019.02.010 1 RESOLUTION 27-21 2 3 Title: Pictorial Health Warnings on Alcoholic Beverages 4 5 Introduced by: Alangoya Tezel, for the Medical Student Section 6 7 Original Author: Taania Girgla 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, excessive alcohol use is responsible for more than 95,000 deaths annually, making 15 it a leading cause of preventable death in the U.S., and 16 17 Whereas, more than half of alcohol related deaths are linked to a rising number of life- 18 threatening medical conditions - such as liver cirrhosis, cancer, cardiovascular disease, and stroke - 19 with prolonged use of excessive alcohol linked to dementia and neuropathy, and use of excessive 20 alcohol during pregnancy linked to fetal alcohol syndrome, the leading cause of intellectual 21 disability in the U.S., and 22 23 Whereas, nationally, excessive alcohol use leads to a shortened lifespan by approximately 24 29 years, for a total of 2.8 million years of potential life lost, and in Michigan, excessive alcohol use 25 results in 2,945 deaths and 84,215 years of potential life lost each year, and 26 27 Whereas, the economic burden of alcohol misuse is significant, costing the U.S. $249 billion 28 in 2010 alone - of which, three-quarters of the total cost was related to binge drinking - and in 29 Michigan, excessive alcohol use cost $8.2 billion, or $2.10 per drink, in 2010 alone - of which, three- 30 quarters of the total cost was related to binge drinking, and 31 32 Whereas, In 2018, 5.8 percent of adults ages 18 and older nationally had alcohol use 33 disorder, 26.45 percent of people ages 18 or older reported that they engaged in binge drinking in 34 the past month, and 6.6 percent reported that they engaged in heavy alcohol use in the past 35 month, and 36 37 Whereas, binge drinking specifically is responsible for more than half the deaths and two- 38 thirds of the years of potential life lost resulting from excessive alcohol use, and in Michigan, 19.7 39 percent of adults and 17.8 percent of high school students reported binge drinking in 2011, and 40 41 Whereas, in Michigan, the alcohol-induced crude mortality rates have been steadily 42 increasing for the last 40 years, and 43 44 Whereas, these numbers remain so despite a congressional "Alcoholic Beverage Labeling 45 Act" (ABLA) passed in 1988 requiring health warning statements to appear on the labels of all 46 containers of alcohol beverages for sale or distribution in the U.S., signifying that this label failed to 47 warn against several of the medical consequences of excessive alcohol consumption, as it was 48 required to only appear in text, and 49 50 Whereas, only 35 percent of all adults in the summer of 1991 reported having seen the 51 warning label, signifying that these labels have done little to reduce rates of alcohol-related risky 52 behaviors, rates of consumption, or alcohol-related poor health outcomes during this period, and 53 54 Whereas, MSMS current policy supports requiring a text-only warning statement on all 55 advertising for alcoholic beverages regarding fetal alcohol syndrome, and 56 57 Whereas, during this same time, studies repeatedly showed that (1) larger pictorial and 58 symbolic health warnings on tobacco packaging were more effective at reducing tobacco use than 59 smaller text-only warnings, and (2) a mixture of health-related and social-related graphic health 60 warnings on tobacco packaging were most effective at reducing tobacco use, and 61 62 Whereas, experts have recommended and studies have shown that the use of pictorial 63 health warning on alcoholic beverages lead to improve health outcomes, and 64 65 Whereas, in the past decade several studies have predicted and proven that negative 66 pictorial health warnings are associated with significantly increased perceptions of the health risks 67 of consuming alcohol as well as greater intentions to reduce and quit alcohol consumption 68 compared to the control, and 69 70 Whereas, though critics cite the somatic benefits of alcohol in moderation and question the 71 need for health warnings on alcoholic beverages, research shows that there are adverse effects 72 related to cancer at any level of alcohol consumption, and though critics argue that alcohol can still 73 be consumed in bars and pubs without drinkers seeing the packaging, research actually shows that 74 alcohol purchased from supermarkets is more than twice the level of alcohol consumed in 75 bars/pubs, and 76 77 Whereas, MSMS supports a healthy lifestyle related to nutrition and exercise and the 78 avoidance of alcohol and tobacco; therefore be it 79 80 RESOLVED: That MSMS will advocate for the implementation of pictorial health warnings 81 on alcoholic beverages for sale in containers in Michigan, including but not limited to images such 82 as a cirrhotic liver and dilated cardiomyopathy secondary to excessive alcohol use, a car crash, or 83 an animation of a baby in the womb; and be it further 84 85 RESOLVED: That MSMS will advocate for the amendment of current MSMS policy, titled 86 Fetal Alcohol Syndrome, Board-May94, to include language advocating for pictorial warnings of 87 fetal alcohol syndrome from alcohol use during pregnancy; and be it further 88 89 RESOLVED: That MSMS will continue to support the use of health warnings on alcoholic 90 beverages for sale in Michigan. 91 92 93 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 94 or AMA policy - $500

Relevant MSMS Policy:

Fetal Alcohol Syndrome MSMS supports requiring a warning statement on all advertising for alcoholic beverages regarding fetal alcohol syndrome (FAS). (Board-May94)

Relevant AMA Policy: None

Sources: 1. Deaths from Excessive Alcohol Use in the U.S. Centers for Disease Control and Prevention. Published January 14, 2021. Accessed February 2, 2021. https://www.cdc.gov/alcohol/features/excessive-alcohol- deaths.html 2. Alcohol Fact Sheet. World Health Organization. Published September 21, 2018. Accessed February 2, 2021. https://www.who.int/news-room/fact-sheets/detail/alcohol 3. Excessive Alcohol Use - Prevention Status Report in Michigan. Centers for Disease Control and Prevention. Published 2013. Accessed February 2, 2021. https://www.cdc.gov/psr/2013/alcohol/2013/MI- alcohol.pdf 4. Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RD. 2010 National and State Costs of Excessive Alcohol Consumption. American Journal of Preventive Medicine. 2015;49(5):e73-e79. doi:10.1016/j.amepre.2015.05.031 5. Alcohol Facts and Statistics | National Institute on Alcohol Abuse and Alcoholism (NIAAA). Accessed February 2, 2021. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and- statistics 6. Alcohol-induced Crude Mortality Rates , 1980 - 2018. Accessed February 2, 2021. https://www.mdch.state.mi.us/osr/deaths/AlcoholCrudeRatesTrends.asp 7. Alcohol Beverage Health Warning Statement (99R-507P). Federal Register. Published May 22, 2001. Accessed February 2, 2021. https://www.federalregister.gov/documents/2001/05/22/01-12802/alcohol- beverage-health-warning-statement-99r-507p 8. Alcohol Research and Public Health Policy - Alcohol Alert No. 20-1993. Accessed February 2, 2021. https://pubs.niaaa.nih.gov/publications/aa20.htm 9. MSMS Policy Finder. Fetal Alcohol Syndrome, Board-May94. https://www.msms.org/msmspolicies#5256535-advertising 10. Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, Brewer NT. Pictorial cigarette pack warnings: a meta- analysis of experimental studies. Tob Control. 2016;25(3):341-354. doi:10.1136/tobaccocontrol-2014- 051978 11. Park H, Hong M-Y, Lee I-S, Chae Y. Effects of Different Graphic Health Warning Types on the Intention to Quit Smoking. International Journal of Environmental Research and Public Health. 2020;17(9):3267. doi:10.3390/ijerph17093267 12. Ratih SP, Susanna D. Perceived effectiveness of pictorial health warnings on changes in smoking behaviour in Asia: a literature review. BMC Public Health. 2018;18(1). doi:10.1186/s12889-018-6072-7 13. Anshari, D.(2017). Effectiveness of Pictorial Health Warning Labels for Indonesia's Cigarette Packages. (Doctoral dissertation). Retrieved from https://scholarcommons.sc.edu/etd/4059 14. Al-hamdani M. The case for stringent alcohol warning labels: lessons from the tobacco control experience. J Public Health Policy. 2014;35(1):65-74. doi:10.1057/jphp.2013.47 15. Al-hamdani M, Smith S. Alcohol warning label perceptions: Emerging evidence for alcohol policy. Can J Public Health. 2015;106(6):e395-400. doi:10.17269/cjph.106.5116 16. Wigg S, Stafford LD. Health Warnings on Alcoholic Beverages: Perceptions of the Health Risks and Intentions towards Alcohol Consumption. PLoS One. 2016;11(4):e0153027. doi:10.1371/journal.pone.0153027 17. Zahra D, Monk RL, Corder E. "IF You Drink Alcohol, THEN You Will Get Cancer": Investigating How Reasoning Accuracy Is Affected by Pictorially Presented Graphic Alcohol Warnings. Alcohol. 2015;50(5):608-616. doi:10.1093/alcalc/agv029 18. UK Chief Medical Officers' Alcohol Guidelines Review: Summary of the proposed new guidelines-January 2016. :7 19. Institute of Alcohol Studies. Alcohol Consumption Factsheet. 2013 20. MSMS Policy Finder. Support of Healthy Lifestyle, Res36-93A, Reaffirmed (Res34-14). https://www.msms.org/msmspolicies#5256584-public-health 1 RESOLUTION 29-21 2 3 Title: Fertility Treatment Coverage 4 5 Introduced by: Micaela Stevenson, for the Medical Student Section 6 7 Original Author: Micaela Stevenson 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, infertility is defined as the inability to conceive after one year of regular sexual 15 intercourse without using birth control and can affect any age and sex, and 16 17 Whereas, involuntary childlessness due to infertility can profoundly impact people's lives, 18 causing medical, social, economic, and psychological harm, and 19 20 Whereas, lack of insurance coverage often leads some women to take risks that will increase 21 their chances of becoming pregnant such as implanting multiple embryos at one time, and 22 23 Whereas, implanting multiple embryos may cause multiple gestations, increasing the risk for 24 maternal and fetal complications, as well as increased medical care expenditures due to these 25 complications, and 26 27 Whereas, the majority of patients who wish to undergo fertility treatment, such as IVF, must 28 pay out of pocket due to lack of health insurance or having insurance policies that do not cover 29 infertility treatment, with the median price of a cycle of IVF in the United States, including 30 medications, at $19,200, and 31 32 Whereas, Medicaid covers preconception care and contraceptives as part of family planning 33 services, but infertility testing and treatments are rarely considered family planning services and 34 rarely covered by Medicaid, and 35 36 Whereas, 16 states (not including Michigan) have passed laws that require insurers to either 37 cover or offer coverage for infertility diagnosis and treatment. Fourteen of these require insurance 38 companies to cover infertility treatment and two requiring insurance companies to offer coverage 39 for infertility treatment; therefore be it 40 41 RESOLVED: That MSMS supports that Michigan health plans including Medicaid cover 42 fertility treatment, such as in vitro fertilization and other treatments for fertility preservation. 43 44 45 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 46 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy: None

Sources: 1. Treating Infertility. ACOG. https://www.acog.org/womens-health/faqs/treating-infertility Published October 2019. Accessed January 2, 2021 2. Judith Daar, J.D.; et al. Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion. Ethics Committee of the American Society for Reproductive Medicine. ASRM Fertility and Sterility. https://www.fertstert.org/article/S0015-0282(15)01650-7/fulltext#secsectitle0050 Published September 10, 2015. Accessed January 2, 2021 3. SIEGEL BERNARD T. Insurance Coverage for Fertility Treatments Varies Widely. New York Times. July 26, 2014. Accessed December 30, 2020. http://search.ebscohost.com.proxy.lib.umich.edu/login.aspx?direct=true&db=a9h&AN=97208360&site= ehost-live&scope=site 4. Johnston J, Gusmano MK. Why We Should All Pay for Fertility Treatment: An Argument from Ethics and Policy. Hastings Center Report. 2013;43(2):18-21. doi:10.1002/hast.155 5. Skinner E, Garcia A. State Laws Related to Insurance Coverage for Infertility Treatment. National Conference of State Legislators. https://www.ncsl.org/research/health/insurance-coverage-for-infertility- laws.aspx Published June 12, 2019. Accessed January 1, 2021 1 RESOLUTION 32-21 2 3 Title: Access to Affordable Housing 4 5 Introduced by: Laura Carravallah, MD 6 7 Original Authors: Brittany Herron, Jaslyn Morris, Sunny Panh, and Laura Carravallah, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, there is a need among low-income Michigan renters for affordable housing in 15 decent, safe, and sanitary units, as more than 8,000 people in Michigan are experiencing 16 homelessness on any given night; further, more than 61,000 Michiganders experienced 17 homelessness in 2019, and 18 19 Whereas, homelessness is a barrier to primary and emergency health care that is associated 20 with numerous health disparities; as such, more than 40 percent of people experiencing 21 homelessness in Michigan have long term mental and physical health conditions, and 22 23 Whereas, having access to affordable, quality housing helps people with chronic mental and 24 physical health conditions improve and maintain their health and overall well-being, while reducing 25 their utilization of emergency health systems and health related costs, and 26 27 Whereas, the Michigan Housing and Community Development Fund (MHCDF) was created 28 to meet the affordable housing needs of low income, homeless, or disabled households; in 29 addition, funds were used to rehabilitate neighborhoods to increase appeal for local business and 30 habitation, and 31 32 Whereas, the MHCDF did not have strict requirements for allocation of funds for housing 33 versus community rehabilitation, and 34 35 Whereas, the MHCDF was only funded twice (once in 2008 and 2012); in 2012, $3.7 million 36 from the Homeowner Protection Fund was allocated to the MHCDF, but only 9 out of 65 projects 37 submitted were able to receive funding due to the limited resources of the MHCDF, and 38 39 Whereas, in 2008, the MHCDF served more than 130 low-income households and prevented 40 homelessness for 78 households, and 41 42 Whereas, to date, no action has been taken by the U.S. House of Representatives and the 43 U.S. Senate on recently proposed bills to end or mitigate homelessness; therefore be it 44 45 RESOLVED: That MSMS support and advocate for recognition of homelessness as a social 46 determinant of mental and physical health disparities in Michigan; and be it further

47 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) urge 48 our AMA to support and advocate for recognition of homelessness as a social determinant of 49 mental and physical health disparities in the United States; and be it further 50 51 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) 52 support and advocate for timely review of legislation designed to eliminate or reduce 53 homelessness; and be it further 54 55 RESOLVED: That MSMS support and advocate for creation of a permanent funding source 56 for the Michigan Housing and Community Development Fund (MHCDF) with at least 66 percent of 57 that funding allocated for the development, rehabilitation, and maintenance of permanent housing 58 for Michiganders with disabilities or experiencing homelessness. 59 60 61 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions requesting governmental advocacy - 62 $25,000+

Relevant MSMS Policy: None

Relevant AMA Policy:

Sources: 1. Continuums of Care to the U.S. Department of Housing and Urban Development (2019). https://www.usich.gov/homelessness-statistics/mi/ 2. Michigan’s Campaign to End Homelessness Annual Report 2019 (2020). https://www.michigan.gov/documents/mcteh/2019_MCTEH_Annual_Report_713330_7.pdf 3. Housing and Homelessness as a Public Health Issue (2017). https://apha.org/policies-and- advocacy/public-health-policy-statements/policy-database/2018/01/18/housing-and-homelessness-as- a-public-health-issue 4. Living in Michigan, Michigan's Housing and Community Development Fund Annual Report 2008 (2008). http://cedamichigan.org/wp-content/files/MHCDF-2008-Annual-Report-Color.pdf 5. Increasing Access to Affordable Housing (2020). https://mihomeless.org/index.php/2019-2020-policy- priorities/#increaseaccess 6. Michigan’s Housing and Community Development Fund (MHCDF) - CEDAM http://cedamichigan.org/policy/mhcdf/ 7. Ending Homelessness Act (H.R. 1856, S. 2613) (2019). https://endhomelessness.org/legislation/h-r-1856- the-ending-homelessness-act-of-2019/ 8. Housing is Infrastructure Act (H.R. 5187, S. 2951) (2019). https://endhomelessness.org/legislation/housing-is-infrastructure-act-of-2019/ 9. Housing is Infrastructure Act (H.R. 5187, S. 2951) (2020). https://endhomelessness.org/legislation/pathway-to-stable-and-affordable-housing-for-all-act/ 1 RESOLUTION 33-21 2 3 Title: Participation in Alliance for Innovation on Maternal Health Safety Bundles 4 5 Introduced by: Laura Carravallah, MD 6 7 Original Authors: Kathleen Dinh, Irene Lieu, Jennifer Chinchilla-Perez, and Laura Carravallah, 8 MD 9 10 Referred To: 11 12 House Action: 13 14 15 Whereas, pregnancy-related mortality rate per 100,000 live births (PRMR) has peaked in the 16 United States over the past decade and hovers at 17 percent, the highest of any industrialized 17 country, with pregnancy-related mortality defined as ”death of a woman while pregnant or within 1 18 year of the end of pregnancy from any cause related to or aggravated by the pregnancy,” and 19 20 Whereas, Michigan ranks as the eighth worst state for maternal mortality rate and third 21 worst for Black mothers in the entire U.S., with additional disparities existing in age and educational 22 level, and 23 24 Whereas, more than 50 percent of all maternal deaths in Michigan are preventable, with 25 leading causes of death attributable to obstetric hemorrhage, hypertension, pulmonary embolism, 26 amniotic fluid embolism, infection, and a worsening of pre-existing chronic conditions, and 27 28 Whereas, the Michigan Alliance for Innovation on Maternal Health (MI-AIM), pioneered by 29 Robert Sokol, MD; Dawn Shanafelt, MPA, BSN, RN; Jody Jones, MD; Mary Schubert; and Michigan 30 Maternal Mortality Surveillance (MMMS) initiatives have led to the creation of “patient safety 31 bundles” in 2015 to address leading causes of mortality that have led to a 10.5 percent overall 32 decrease in maternal death rates in Michigan by participating birthing institutions, and 33 34 Whereas, despite success at institutions that have implemented MI-AIM’s safety bundles, 35 only 50 percent have complete adoption and no standardization of data collection exists to 36 measure outcomes, and 37 38 Whereas, racial/ethnic disparities in maternal mortality and morbidity for Black and 39 American Native/American Indian mothers in Michigan have improved from five times that of white 40 mothers in 2007-2010 to 2.7 times in 2013-2017, yet still persist, since the startup of MI-AIM, and 41 42 Whereas, Texas has achieved 99 percent of participation from all of its birthing centers into 43 AIM since expanded Medicaid reimbursement to adopting centers, and 44 45 Whereas, California, which currently has the lowest maternal mortality rate, created the 46 California Maternal Quality Care Collaborative (CMQCC), whose fully implemented programs at 95 47 percent of their birthing centers include required implicit bias training for all health care workers 48 involved in perinatal care and ongoing studies assessing racial/ethnic differences in pregnancy 49 outcomes for those with comorbidities, and 50 51 Whereas, the mission of MSMS is to improve the lives of physicians so they may best care 52 for the people they serve in the state of Michigan and advocate on behalf of both physicians and 53 their patients; therefore be it 54 55 RESOLVED: That MSMS will support the participation in Michigan Alliance for Innovation on 56 Maternal Health safety bundles by all birthing institutions in the state of Michigan; and be it further 57 58 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) urge 59 the AMA to recognize the need for all birthing institutions in the United States to participate in the 60 Alliance for Innovation on Maternal Health and implement patient safety bundles; and be it further 61 62 RESOLVED: That MSMS will support Medicaid coverage for birthing centers who become 63 active members of Michigan Alliance for Innovation on Maternal Health in order to improve full 64 participation rates; and be it further 65 66 RESOLVED: That MSMS will support the Michigan requirement of all health care workers to 67 undergo implicit bias training to further close the racial/ethnic gap in maternal mortality. 68 69 70 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 71 or AMA policy - $500

Relevant MSMS Policy:

Relevant AMA Policy: None

Sources: 1. CDC. Pregnancy Mortality Surveillance System | Maternal and Infant Health | CDC. Centers for Disease Control and Prevention. Accessed February 18, 2021. https://www.cdc.gov/reproductivehealth/maternal- mortality/pregnancy-mortality-surveillance-system.htm 2. MDHHS. MDHHS - Michigan Maternal Mortality Surveillance (MMMS) Program - Data Quick Facts. Michigan Department of Health and Human Services. Accessed February 18, 2021. https://www.michigan.gov/mdhhs/0,5885,7-339-73971_4911_87421-474056--,00.html 3. ABEST. Racism and Inequity in Birth Outcomes for Black and Native American Families: A Review of the Literature 4. MI AIM. Michigan Alliance for Innovation on Maternal Health Handbook. Accessed February 18, 2021. https://www.michigan.gov/documents/mdhhs/Michigan_Alliance_for_Innovation_on_Maternal_Health_Ha ndbook_-_6.18.2020_697263_7.pdf 5. Houdeshell-Putt, MPH, DrPH L. MI AIM Interview. Published online February 18, 2021 6. MMMS M. Maternal Deaths in Michigan, 2013-2017 Data Update 7. Texas Health and Human Services Commission. State Efforts to Address Postpartum Depression | Maternal Mortality and Morbidity in Texas. Published online December 2020 8. CMQCC. Toolkits | California Maternal Quality Care Collaborative. Accessed February 18, 2021. https://www.cmqcc.org/resources-tool-kits/toolkits 9. Michigan State Medical Society. First 50 Years of MSMS - In Brief. https://www.msms.org/About- MSMS/News/ID/126 Published July 2, 2013. Accessed February 18, 2021 1 RESOLUTION 34-21 2 3 Title: Use Term “Deaf and Hard of Hearing” in lieu of “Hearing Impaired” 4 5 Introduced by: Laura Carravallah, MD 6 7 Original Authors: Irene Lieu and Laura Carravallah, MD 8 9 Referred To: 10 11 House Action: 12 13 14 Whereas, 7.4 percent of the population in Michigan identify as deaf, deafblind, or hard of 15 hearing, representing a growing community that has been drastically underestimated in the state 16 census, and 17 18 Whereas, the terms deaf and hard of hearing not only describe individuals with the 19 audiological condition of not hearing or mild-to-moderate hearing loss, but more importantly 20 embody the knowledge, beliefs, identity and cultural practices of deaf people, and 21 22 Whereas, the term “impaired” is defined as “being in less than perfect or whole condition; as 23 disabled or functionally defective,” by Merriam-Webster, and 24 25 Whereas, the term “hearing impaired” inherently demeans and labels patients as their 26 disability, focuses on what they cannot do, and establishes “hearing” as the standard and anything 27 different as less than or “impaired,” and 28 29 Whereas, the World Federation of the Deaf and National Association of the Deaf has taken 30 a stance that the term “hearing impaired” is no longer accepted by the Deaf and Hard of Hearing 31 community as they do not see themselves as “less” or “broken,” and 32 33 Whereas, fear, mistrust, and frustration toward health care providers are commonly 34 experienced by deaf and hard of hearing individuals due to lack of provider knowledge regarding 35 sociocultural aspects of deafness, and 36 37 Whereas, other states (Utah, New Hampshire, New York, and Virginia) have adopted a more 38 sensitive and accepted term “Deaf and Hard of Hearing” in lieu of “hearing impaired” in their state 39 laws despite having a smaller deaf population compared to Michigan; therefore be it 40 41 RESOLVED: That MSMS recommends that physicians adopt the term, “deaf and hard of 42 hearing” and/or “persons with hearing loss” instead of “hearing impairment” in clinical settings; and 43 be it further 44 45 RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask 46 our AMA to recommend that physicians adopt the term “deaf and hard of hearing” and/or “persons 47 with hearing loss” instead of “hearing impairment” in clinical settings. 48

49 WAYS AND MEANS COMMITTEE FISCAL NOTE: Resolutions only requesting new or revised MSMS 50 or AMA policy - $500

Relevant MSMS Policy: None

Relevant AMA Policy: None

Sources: 1. MDCR - MDCR Division on Deaf, Deaf, Blind and Hard of Hearing Reveals Results of Year-Long Census and Needs Assessment for Community. Michigan Department of Civil Rights. Accessed February 9, 2021. https://www.michigan.gov/mdcr/0,4613,7-138--507797--,00.html 2. Community and Culture - Frequently Asked Questions. National Association of the Deaf - NAD. Accessed February 11, 2021. https://www.nad.org/resources/american-sign-language/community-and-culture- frequently-asked-questions/ 3. Steinberg AG, Barnett S, Meador HE, Wiggins EA, Zazove P. Health care system accessibility: Experiences and perceptions of deaf people. J Gen Intern Med. 2006;21(3):260-266. doi:10.1111/j.1525- 1497.2006.00340.x 4. Bennett R. Time for Change: Rethinking the Term “Hearing Impaired.” The Hearing Journal. 2019;72(5):16. doi:10.1097/01.HJ.0000559500.67179.7d