Title: Fentanyl ‘Patch for Patch’ Exchange Program
Introduced by: David Whalen, MD, Chair, for Region 8, Kent County Delegation
Original Author: Gerald Lee, MD, Cara Poland, MD
Whereas, fentanyl is a powerful synthetic opioid analgesic that is 50-100 times more potent than Morphine;
Whereas, fentanyl is a Schedule II prescription drug, and it is typically used to treat patients with severe pain or to manage pain after surgery;
Whereas, roughly 28,400 people died from an overdose of synthetic opiates, other than methadone, in 2017 alone;
Whereas, Michigan’s overdose rate of 21.2 per 100,000 is above the national average of 14.6 per 100,000;
Whereas, synthetic opioids, mainly fentanyl, overdose deaths have increased in Michigan from 72 in 2012 to 1368 in 2017;
Whereas, Ontario, Canada, has instituted a successful ‘patch for patch’ exchange program (P4P Program);
RESOLVED: we propose a fentanyl ‘patch for patch’ exchange program in the State of Michigan. If a new fentanyl prescription is written, it should be labeled as a first prescription. This will result in a one-time return of 9/10 patches. The old patches should be stuck to a sheet of paper and returned to the pharmacist when getting a new prescription. When a pharmacy receives a prescription for fentanyl patches but does not collect all used patches or collects fewer than the quantity to be dispensed, they must contact the prescriber. Together the pharmacist and prescriber will make an assessment, consider the circumstances, and determine the best course of action and the quantity to be dispensed. Pharmacists must properly store and then dispose of used patches;
RESOLVED, FURTHER: that the Michigan State Medical Society Board take the proposal of a fentanyl ‘patch for patch’ exchange program to the Michigan State Legislature.
FISCAL INFO:
URGENCY STATEMENT:
A Fentanyl patch exchange may not seem urgent, yet we have postponed this resolution for the past 2 years. During this time thousands have died of opiate overdoses of which Fentanyl is the most common. Over the past decade opiate prescriptions have decreased 40% yet overdoses remain on the rise, which argues we need to take new and novel approaches to this issue.
Title: Non-Stigmatizing Verbiage
Introduced by: David Whalen, MD, for Region 8, Kent County Delegation
Original Author: Cara Poland, MD
Whereas, we are in the midst of the largest manmade epidemic in the history of the United States, and
Whereas, drug overdose is the most common cause of death in Americans under the age of 50, and
Whereas, addiction is a medical disease with effective, evidence-based medical treatment available, and
Whereas, persons who suffer from the disease of addiction are frequently referred to as “drug addicts,” and
Whereas, the verbiage “drug addict” conjures up a somewhat horrific image in the minds of most people, and
Whereas, in reality, addiction is an “equal opportunity destroyer;” therefore be it
RESOLVED: That MSMS encourages the use of clinically accurate, non-stigmatizing terminology when referring to the disease of addiction and shall incorporate such terminology in future communications and publications, as well as update existing policies during the normal process of updating the MSMS Policy Manual; and be it further
RESOLVED: That MSMS recommends all physicians adopt the phrase “person with the disease of addiction” instead of “drug addict” or other stigmatizing verbiage when communicating about substance use and addiction.
WAYS AND MEANS COMMITTEE FISCAL NOTE: $1,000-$2,000 for new MSMS policy and revisions to existing policy.
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.
URGENCY NOTE:
Title: Michigan State Medical Society Judicial Commission
Introduced by: David Whalen, MD, for Region 8, Kent County Delegation
Original Author: Jayne E. Courts, MD, FACP
Referred To: Reference Committee C
Whereas, the Judicial Commission serves to review any concern about the conduct of a physician member that is potentially in violation of the American Medical Association (AMA) Code of Ethics, and
Whereas, concerns may originate from patients or other people and may include, but are not limited to, inappropriate behavior, sexual harassment, or issues of gender identity, and
Whereas, the MSMS Judicial Commission serves as the disciplinary body within MSMS, and
Whereas, the Judicial Commission works through the component county medical societies, often in a slow and potentially inequitable process, and
Whereas, the Official Procedures of the Judicial Commission allow determination of appropriate disciplinary action of a physician member, including possible censure, suspension, or expulsion from MSMS membership, and
Whereas, clear and concise approaches to the judicial and disciplinary process would improve timeliness, consistency, equity, and protection due to standardized processes and expedited decisions; therefore, be it
RESOLVED: That the MSMS Board of Directors consider making the Judicial Commission a Committee of the Board so the Committee may perform its function in a more efficient and equitable manner; and be it further
RESOLVED: That the MSMS Board of Directors study the structure and function of the Judicial Commission and recommend Constitution and Bylaws changes that will be brought to the 2021 MSMS House of Delegates for first reading.
WAYS AND MEANS COMMITTEE FISCAL NOTE: $2,500 -$5,000 to engage in a Board directed study.
Relevant MSMS Policy:
15.00 THE JUDICIAL COMMISSION
15.10 COMPOSITION – QUALIFICATIONS—The Judicial Commission shall be composed of ten members, each of whom shall be a voting member of the Society in good standing. No member of the Judicial Commission shall, during tenure of office, hold any of the following offices or positions: Speaker or Vice-Speaker of the House of Delegates of this Society, or District Director of this Society. Any member of the governing board of a component society which serves in these capacities, shall not, as a Commissioner, participate in deliberations pertaining to a grievance involving a member of that component society or cast a vote in respect thereto.
15.20 JUDICIAL DISTRICTS—There shall be seven Judicial Districts formed by grouping component societies as follows:
District 1—Wayne
District 2—Macomb, Oakland. St. Clair
District 3—Ingham, Livingston, Monroe, Shiawassee, Washtenaw
District 4—Bay, Iosco-Arenac, Genesee, Gratiot, Huron, Isabella-Clare, Lapeer, Midland, Saginaw, Sanilac, Tuscola
District 5—Allegan, Berrien, Branch, Calhoun, Cass, Eaton, Hillsdale, Jackson, Kalamazoo, Lenawee, St. Joseph, Van Buren
District 6—Barry, Clinton, Ionia-Montcalm, Kent, Mason, Mecosta-Osceola-Lake, Muskegon, Newaygo, Oceana, Ottawa
District 7—Alpena-Alcona-Presque Isle, Chippewa-Mackinac, Delta, Dickinson-Iron, Gogebic, Grand Traverse-Leelanau-Benzie, Houghton-Baraga-Keweenaw, Luce, Manistee, Marquette-Alger, Menominee, North Central Counties (Crawford, Gladwin, Kalkaska, Montmorency, Otsego, Roscommon), Northern Michigan (Antrim, Charlevoix, Cheboygan, Emmett), Ogemaw-Oscoda, Ontonagon, Schoolcraft, Wexford-Missaukee
15.80 POWERS AND DUTIES—The Judicial Commission shall have:
15.81 Authority to make binding interpretations of the Constitution and Bylaws of this Society and of the several component societies as they pertain to matters of ethics, mediation, grievance and discipline.
15.82 Authority to make ethical interpretations and decisions in accordance with the standards of the American Medical Association.
15.83 Sole appellate powers at the state level in all matters relating to ethics, professional conduct, mediation and discipline of members of component societies.
15.84 The power to entertain and exercise original jurisdiction in matters pertaining to ethics, mediation, conduct of members or discipline of members when requested to do so by any component society or by any member in good standing of this Society.
15.85 The power and authority to make and promulgate from time to time, rules and regulations governing all procedures pertaining to ethics, grievances, mediation, professional conduct and discipline of members, which rules and regulations shall be binding upon all component societies.
15.86 The power and authority to appoint such committees and to adopt such rules, regulations and procedures as, in the sole judgment of the Commission, are deemed desirable in carrying out the functions and purposes of the Commission.
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:
- Michigan State Medical Society. Constitution and Bylaws, Supplement: Official Procedures for the MSMS Judicial Commission, 2015 edition.
URGENCY NOTE:
Title: Prescription Medication Pill Size
Introduced by: David Whalen, MD, for Region 8, Kent County Delegation
Original Author: David Whalen, MD
Referred To: Reference Committee A
Whereas, dosing of medication frequently requires a patient to cut pills in half to achieve the proper dose recommended by their physician, and
Whereas, these medication types requiring alteration in pill tab size may be to limit the dose of controlled substances which is an advantage to many patients, and
Whereas, these dosage adjustments may be difficult for patients with limited dexterity to cut on their own; therefore, be it
RESOLVED: That MSMS ask the Michigan Board of Pharmacy to pursue pill medication size to be no smaller than six mm in diameter or other size found by research to be best suited for pill cutting by elderly or disabled patients; and be it further
RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask our AMA to request pharmaceutical companies to manufacture pills larger than five mm in diameter for medications most likely to be prescribed to elderly and disabled persons, especially those consisting of controlled substances, to better allow pill cutting to help control dosages, unless research shows this to be unnecessary in this group of patients.
WAYS AND MEANS COMMITTEE FISCAL NOTE: $2,000-$4,000 to engage in outreach efforts.
Relevant MSMS Policy:
None
Relevant AMA Policy:
None
URGENCY NOTE:
Title: Limit Copay on Emergency Department Visits
Introduced by: David Whalen, MD, for Region 8, Kent County Delegation
Original Author: Michelle M. Condon, MD, FACP
Referred To: Reference Committee A
Whereas, some insurance products require a patient to pay an extra or larger co-pay or deductible if an emergency department evaluation does not lead to a hospital admission, and
Whereas, these patients may have waited to confer with their private physician until office hours are open, but are instructed by that physician to go to the emergency department for evaluation; therefore, be it
RESOLVED: That MSMS advocate that insurance companies waive the imposition of higher co-pays or deductibles when a patient is directed by their primary care physician to seek treatment for an acute problem in the emergency department, even if the patient is not admitted to the hospital.
WAYS AND MEANS COMMITTEE FISCAL NOTE: $12,000-$24,000 to engage in regulatory/industry advocacy.
Relevant MSMS Policy:
None
Relevant AMA Policy:
None
URGENCY NOTE:
Title: Enforce AMA Principles on Continuing Board Certification
Introduced by: David Whalen, MD, for the for Region 8, Kent County Delegation
Original Author: David Whalen, MD
Referred To: Reference Committee A
Whereas, the American Medical Association (AMA) Principles on Continuing Board Certification have been developed through the democratic process of various states’ Houses of Delegates and the AMA House of Delegates, reflecting the collective will of state and national medical societies and their physician members, and
Whereas, these longstanding principles clearly demand a continuing board certification process that is low cost, evidence-based, untied to insurance and hospital credentialing, and free of harm to the physician workforce, and
Whereas, the proprietary American Board of Medical Specialties (ABMS) and American Osteopathic Association (AOA) continuing board certification product continues to be high cost, high stress, without evidence over other forms of continuing medical education, required for insurance and hospital credentialing, and harmful to the physician workforce, and
Whereas, ABMS and AOA boards continue to ignore the AMA on nearly every aspect of the AMA policy handbook on continuing board certification, and
Whereas, this failure to protect physicians from recertification harm is having significant effects upon cost of care, physician burnout, and access to qualified physicians, and
Whereas, this failure to advocate successfully for these principles reflects poorly upon the ability of organized medicine to defend physicians and our right to care for patients; therefore, be it
RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask our AMA to continue to actively work to enforce current AMA Principles on Continuing Board Certification; and be it further
RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask our AMA to publicly report their work on enforcing AMA Principles on Continuing Board Certification at the Annual and Interim meetings of the AMA House of Delegates.
WAYS AND MEANS COMMITTEE FISCAL NOTE: $1,000-$2,000 for new AMA policy
Relevant MSMS Policy:
Review Board Recertification and Maintenance of Certification Process
MSMS supports Maintenance of Certification (MOC) only under all of the following circumstances:
- MOC must be voluntary.
- MOC must not be a condition of licensure, hospital privileges, health plan participation, or any other function unrelated to the specialty board requiring MOC.
- MOC should not be the monopoly of any single entity. Physicians should be able to access a range of alternatives from different entities.
- 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
- Changes in specialty-board certification requirements for CBC programs should be longitudinally stable in structure, although flexible in content.
- 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.
- 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.
- 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).
- 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.
- 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.
- 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.
- 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.
- 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).”
- 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.
- 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.
- 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.
- The CBC process should be evaluated periodically to measure physician satisfaction, knowledge uptake and intent to maintain or change practice.
- CBC should be used as a tool for continuous improvement.
- The CBC program should not be a mandated requirement for licensure, credentialing, recredentialing, privileging, reimbursement, network participation, employment, or insurance panel participation.
- Actively practicing physicians should be well-represented on specialty boards developing CBC.
- Our AMA will include early career physicians when nominating individuals to the Boards of Directors for ABMS member boards.
- CBC activities and measurement should be relevant to clinical practice.
- 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.
- Any assessment should be used to guide physicians’ self-directed study.
- Specific content-based feedback after any assessment tests should be provided to physicians in a timely manner.
- There should be multiple options for how an assessment could be structured to accommodate different learning styles.
- Physicians with lifetime board certification should not be required to seek recertification.
- No qualifiers or restrictions should be placed on diplomates with lifetime board certification recognized by the ABMS related to their participation in CBC.
- 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.
- 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.
- 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.
URGENCY NOTE:
Title: Clinical Laboratory Improvement Amendment (CLIA) Requirements
Introduced by: David Whalen, MD, Chair, for Region 8, Kent County Delegation
Original Author: Gerald Lee, MD
Whereas, Clinical Laboratory Improvement Amendment (CLIA) was designed to ensure quality and safety when testing human samples;
Whereas, some manufacturers have sought legal protection by stating all tests need to be confirmed in a laboratory;
Whereas, physicians are trying to make medical decisions based on the results of such tests at the time of appointment and/or for lower costs to the patient;
Whereas, in-office testing should only be done by trained staff in accordance with manufacturer’s directions;
Whereas, physicians should use this information in accordance with the clinical history;
RESOLVED: that any confirmatory lab testing is at the discretion of the ordering physician with the best interests of the patient in mind.
Fiscal Note:
Urgency Statement:
- Alignment with existing AMA policy.
- Recent treatment concerns with new COVID treatments and potential loss of licensure for “misinformation,” which could include medications used off-label and/or dosages off-label.
- There is a need for a clear policy, especially in light of prior authorization restrictions for many medications, whether being used per label or off-label.
Title: Off Label Policy
Introduced by: David Whalen, MD, Chair, for Region 8, Kent County Delegation
Original Author: Gerald Lee, MD
Whereas, “one size does not fit all” and a physician is in a unique position to discuss risk/benefits and evaluate a specific medication/dose for a specific individual;
Whereas, physicians have the best interests of the individual, education to evaluate studies and move more quickly than official channels especially when profits are a determinant of such approval;
Whereas, new data is constantly becoming available affecting new treatments, dosage, conditions and situations;
Whereas, American Medical Association (AMA)policy already states:
AMA Policy: Patient Access to Treatments Prescribed by Their Physicians H-120.988
- Our AMA confirms its strong support for the autonomous clinical decision-making authority of a physician and that a physician may lawfully use an FDA approved drug product or medical device for an off-label indication when such use is based upon sound scientific evidence or sound medical opinion; and affirms the position that, when the prescription of a drug or use of a device represents safe and effective therapy, third party payers, including Medicare, should consider the intervention as clinically appropriate medical care, irrespective of labeling, should fulfill their obligation to their beneficiaries by covering such therapy, and be required to cover appropriate ‘off-label’
- Our AMA supports the dissemination of generally available information about off-label uses by manufacturers to physicians. Such information should be independently derived, peer reviewed, scientifically sound, and truthful and not misleading. The information should be provided in its entirety, not be edited or altered by the manufacturer, and be clearly distinguished and not appended to manufacturer-sponsored materials. Such information may comprise journal articles, books, book chapters, or clinical practice guidelines. Books or book chapters should not focus on any particular drug. Dissemination of information by manufacturers to physicians about off-label uses should be accompanied by the approved product labeling and disclosures regarding the lack of FDA approval for such uses, and disclosure of the source of any financial support or author financial conflicts.
- Physicians have the responsibility to interpret and put into context information received from any source, including pharmaceutical manufacturers, before making clinical decisions (e.g., prescribing a drug for an off-label use).
- Our AMA strongly supports the addition to FDA-approved labeling those uses of drugs for which safety and efficacy have been demonstrated.
- Our AMA supports the continued authorization, implementation, and coordination of the Best l’ uses of drugs on their formulary.
- Our AMA strongly supports the important need for physicians to have access to accurate and unbiased information about off-label uses of drugs and devices, while ensuring that manufacturer-sponsored promotions remain under FDA regulation.
Pharmaceuticals for Children Act and the Pediatric Research Equity Act.
RESOLVED: We at MSMS support this AMA policy as a basic medical right and responsibility of a physician to provide the best care available to our patients;
BE IT FURTHER RESOLVED: We at MSMS support the addition of dosage at a physician discretion as consistent with this policy.
Fiscal Note:
Statement of Urgency:
During the pandemic the right to make a shared informed decision between a physician and their doctor has been threatened. No doubt the constant changing recommendation, observation and policies related to vaccines, masks and such have contributed. This situation set up the opportune time to support this long-standing AMA policy is now.