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Archive for October, 2016

Key Issues Before the State Board of Workers’ Compensation

Friday, October 21st, 2016

By Judge Frank R. McKay and Judge Elizabeth D. Gobeil

A man fell 18 feet off a roof, crushing both ankles and suffering a fractured lumbar vertebrae and a dislocated left shoulder. While tragic, the silver lining for this individual was that his employer had workers’ compensation insurance, and the prompt medical treatment provided to this worker facilitated a nearly full recovery. The roofer returned to a non-roofing job after several surgeries and a period of physical therapy and rehabilitation.

When work injuries happen, the State Board of Worker’s Compensation (“the Board”) wants to get workers feeling better and back to work as soon as they are able. Georgia’s medical professionals play the central, and often pivotal, role in determining workers’ health outcomes and, accordingly, also have a huge impact on the disposition of contested claims.

The Board is considering several pressing policy issues that may have a bearing on your practice, and we appreciate the opportunity to share a few of them with you and enlist your help.

Opioid Overutilization and Response

The Problem and National Response. While recognizing that opioids have a place in medicine, we see far too many instances in Georgia’s workers’ compensation system where prolonged use has ended in tragedy for injured workers and their families. More commonly, it has unnecessarily delayed getting injured workers better and back on the job to the detriment of both the workers and their employers.

We participated in the recent National Prescription Drug Abuse and Heroin Summit, which explored the breadth and depth of the opioid problem. According to CDC data from 2007, unintentional drug overdose deaths in the United States occurred once every 19 minutes. Fueled by the growing use of prescription opioid analgesics, the problem has tripled in the 15 years leading up to 2014, culminating in 28,000 opioid-related overdose deaths in that year.

The Summit unveiled several initiatives aimed to curb the opioid problem, including the CDC’s guideline for prescribing opioids for chronic pain released in March. (See www.cdc.gov/drugoverdose/prescribing/guideline.html) Both the American Academy of Orthopaedic Surgeons and the American Academy of Neurology have also issued position statements on the risks of prescribing opioids.

Among other recommendations, the CDC guideline states that opioids should not be used as first-line or routine therapy for chronic pain. The guideline advises clinicians to consider opioid therapy only if clinically meaningful benefits for both pain and function are expected to outweigh risks to the patient.

Further, the guideline emphasizes the importance of counseling patients on the risks of opioid therapy to help facilitate an informed risk/benefit assessment. When opioid therapy is considered, the guideline specifies opioid selection, duration, followup and discontinuation.

What is the Board doing? Georgia participated in a recent study by the Workers’ Compensation Research Institute (WCRI) examining longer-term opioid use over a two-year time period ending March 2012. According to that study, Georgia showed a slight decrease in longer-term use of opioids (0.2 percentage point change over the study period). That decrease, however, was not statistically significant, and we remain concerned about the level of opioid use in Georgia, especially in non-surgical and longer-term situations.

On the judicial side, the Board is mindful of cases in which opioids appear to be used inappropriately, particularly for long-term use. The Board has the authority to order a change in treatment or change in physician when situations warrant.

While the Board prefers those decisions be made between the parties, often these issues are litigated. When these matters come before us, one of many factors we consider is the impact and propriety of the drug regimen in place under the current treating physician. While the Board lacks treatment guidelines, we do consider prescribing practices (and their effectiveness toward better worker health outcomes) when exercising Board discretion over medical authorization and change in physician decisions.

On the policy side, we are working with stakeholders (including several doctors) on the Chairman’s medical advisory committee to vet potential solutions to target inappropriate and overuse of opioids. Options discussed have ranged from physician education to a drug formulary. We rely upon the advisory committee to help us assess the advantages and disadvantages of various approaches and welcome your input into that process.

Aging Workforce Issues

The Challenges. Like the rest of the country, Georgia’s workers’ compensation system is challenged by aspects of an aging workforce. According to the U.S. Bureau of Labor Statistics, between 1977 and 2007, there was a 101 percent increase in employment of workers 65 and over — a trend that is expected to continue. This trend is associated with an increase in medical and indemnity costs due to the increased risk for injury and larger incidence of comorbidities that can deter recovery.

In addition, an aged worker who is injured often presents practical challenges in claim management. For instance, given the greater incidence of comorbidities in the aging population, it is more difficult to distinguish where the work injury starts and ends as compared to the underlying comorbid condition.

Unlike other states, there is no apportionment of liability. The condition is either compensable or it is not. Georgia’s definition of a workers’ compensation injury includes the aggravation of a preexisting condition by accident arising out of and in the course of employment, but only for so long as the aggravation of the preexisting condition continues to be the cause of the disability; the preexisting condition shall no longer meet this criteria when the aggravation ceases to be the cause of the disability. O.C.G.A. Sec. 34-9-1(4).

Accordingly, this issue is hotly debated and turns on the opinion of the medical professionals involved. If you are attuned at the outset to the significance of the work-related contribution, you can provide more precise medical causation opinions. In turn, having more precise opinions can help facilitate quicker authorization and payment of diagnostics and treatment as well as better assist us in compensability assessments.

What’s New in Physician Panel Requirements?

The Board recently updated its rules in response to marketplace realities that were making it difficult for employers to field a panel of physicians. For background, there are specific rules concerning what constitutes a valid physician panel in Georgia and the consequences for failing to maintain a valid panel. (See O.C.G.A. §34-9-201 and Board Rule 201 for specifics).

Historically, one of those requirements was that no two physicians on the panel be associated with one another. This requirement posed problems both in rural areas where there are fewer physicians and statewide with the growth of medical practice consolidation.

Effective July 1, 2015, there is no longer a requirement that physician panels consist only of non-associated physicians. As a result, you and your associates are eligible to appear on the same employer physician panel.

 Coming Soon: Physician Registry

The Board is working on creating a physician registry linked to the Board’s website that will allow any physician interested in workers’ compensation to register by name and specialty and provide contact information. This will allow users of the website to search for physicians by specialty who accept workers’ compensation patients and allow the Board to send notices of items of interest and changes in rules and statutes germane to physicians. The site will also have a section of frequently asked questions that will be of interest to physicians.

Thank you for the opportunity to comment. We appreciate your service and welcome the chance to work with each of you as we seek continued system improvement.

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Drug-Free Workplace? Medical marijuana and the workers’ compensation system

Friday, October 21st, 2016

By Robert Howell, M.D.

 

Dr. Howell

Dr. Howell

The marijuana plant contains more than 80 different compounds, collectively referred to as cannabinoids. Among these, the main psychoactive compound is tetrahydrocannabinol (THC). It exerts its euphoric effect through activation of the CB1 receptor found within the central nervous system. Another cannabinoid, Cannabidiol (CBD), binds weakly to the CB1 receptor and does not produce euphoria or intoxication.1

The movement toward legalization of medical marijuana dates back to 1996. Between 1996 and 1999, eight states gave approval for the use of marijuana for medicinal proposes. Now 23 states and the District of Columbia have passed some version of medical marijuana legislation. Colorado and Washington were the first to move all the way to legalization, followed by Oregon and Alaska.

The legalization movement in Georgia has taken a piecemeal approach. The decriminalization on “Low THC oil” for medical use was first proposed to the Georgia legislature in 2014. The bill did not pass the Senate but did pass the House. The following year, Haleigh’s Hope Act (HB 1) passed and was signed by Governor Nathan Deal in 2015.

The law allows a patient with cancer, ALS, seizures (uncontrolled), multiple sclerosis, Crohn’s disease, mitochondrial disease, Parkinson’s disease and sickle cell disease (SCD) to register with the Department of Public Health for a waiver. That allows the patient (or caregiver) to possess up to 20 fluid ounces of “low THC oil” without prosecution. “Low THC oil” is classified as containing a THC concentration of up to 5 percent.

In 2016, additional legislation was proposed in the Georgia House. Muscle spasms, Epidermolysis bullosa, terminal illness, PTSD, intractable pain, autism spectrum disorder, Alzheimer’s disease and “any other medical condition or its treatment approved by the commissioner” were to be added to the list of conditions approved to receive medical marijuana. The legislation did not pass the Senate.

The workers’ compensation system in Georgia has yet to be involved with the issue. The diagnoses that are covered simply are very uncommon in worker’s compensation. However, if other states are an indication, the Board will be involved soon.

In Colorado, there is an Employers Clause within Amendment 64 (which legalizes marijuana) that reads :“Nothing in this section is intended to require an employer to permit or accommodate the use, consumption, possession, transfer, display, transportation, sale or growing of marijuana in the workplace or to affect the ability of employers to have policies restricting the use of marijuana by employees.” This language was copied almost word for word into the Georgia law.

The most likely diagnoses to be applied to treatment of injured workers in Georgia are spasms, pain and seizures. The problem with all of these diagnoses is that there is very little quality research into the usefulness of marijuana. The Drug Enforcement Administration (DEA) lists marijuana as a Schedule I drug, which is defined as a drug with no currently accepted medical use and a high potential for abuse. This designation makes research into the potential risks and benefits of medical marijuana difficult.

The courts so far have sent a somewhat mixed message with respect to this issue. In Coats v. Dish Network, the Colorado courts ruled that the employer had the right to fire an employee for marijuana use even though he was registered to use medical marijuana. In a similar case, Garcia v. Tractor Supply, the court ruled that an employee could be fired for legally using marijuana for a medical condition.

However, the New Mexico Workers Compensation Administration has ruled multiple times that the insurer must pay for medical marijuana and include it in the pharmacy fee schedule. A state law to clearly prevent an employer from paying for marijuana did not pass last year in the New Mexico legislature. Evidently this issue remains a moving target.

What do we know about the cost of marijuana to employers? Undeniably, it will present a financial burden: compliance, safety, productivity, flexibility and litigation will all be costly.

What do we know about the health benefits of medical marijuana? High-quality research is sparse. It has clearly been shown that CBD, which does not have hallucinogenic properties, decreases the number of seizures in patients with uncontrolled seizures. Pure Cannabidiol (Epidiolex) is available in Europe. Sativex (CBD and THC in equal concentrations) is approved in much of Europe for the treatment of muscle spasms associated with multiple sclerosis.

There has been very little quality research into the treatment of PTSD, chronic pain, autism or Attention Deficit Disorder and even less research that tries to separate out the effects of THC versus CBD.

Locally, look for issues on two fronts. The Georgia state legislature will take up revisions and or additions to the Haleigh’s Hope Act again this year. It’s expected to add autism and PTSD and possibly Alzheimer’s disease to the list. It may try and increase the legal THC concentration from 5 percent despite the fact that 5 percent is already one of the highest limits in the country.

Also, expect the first medical marijuana case to go before the State Board of Workers’ Compensation soon. No matter what the outcome, expect for it then to be appealed to a higher court.

Medical Marijuana in Georgia

Total doctors registered: 274

Total patients registered: 819

Conditions treated:

Seizures 47%

Multiple sclerosis 11%

Cancer 21%

Mitochondrial disease 5%

Crohn’s disease 8%

Sickle cell disease 3%

Parkinson’s disease 2%

Source: Georgia Department of Public Health

 

Reference

1.Volkow, ND, National Institute on Drug Abuse, NIH. The Biology and Potential Therapeutic Effects of Cannabidiol. Testimony to Senate Caucus on International Narcotics Control, June 24, 2015.

 

Robert L. Howell, M.D.

Dr. Robert Howell is board certified in both plastic surgery and general surgery and holds a Certificate of Added Qualification in Surgery of the Hand. He is a Clinical Assistant Professor of Plastic Surgery at Emory University. Dr. Howell is past chairman of the Medical Advisory Committee for the Georgia State Board of Workers’ Compensation and current chair of a subcommittee investigating implications of medical marijuana in the Workers’ Compensation System.

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Dr. Clay Ackerly named Chief Medical Officer for Privia Health

Thursday, October 27th, 2016

Privia Health, LLC, a national physician practice management and population health company announced today that Dr. Clay Ackerly, former Chief Clinical Officer of naviHealth, Inc., joins Privia Health as the organization’s Chief Medical Officer. Dr. Ackerly has extensive experience driving value in risk-arrangements across the care continuum, and joins Privia to further advance the innovative strategies within Privia’s value-based platform.

“Privia has the right mission and vision – as well as a proven track record – of enabling physicians to successfully care for and deliver personalized care to their patients. In an era marked by uncertainty, change and administrative burden, the arrival of such a simple, patient-centered and physician-driven platform couldn’t be more timely,” said Dr. Ackerly. “I’ve worked in the population health space for more than 15 years, and I’m thrilled to help Privia build upon its current population health platform. Privia exists to help physicians provide high quality, affordable care to their patients, and to help physicians thrive in – not just survive through – a value-driven healthcare world, is a mission I look forward to building upon.”

Most recently, Dr. Ackerly served as the Chief Clinical Officer for naviHealth, Inc., a national post-acute management company. In this role, Dr. Ackerly worked across 26 states, with over 100 hospital partners, and thousands of post-acute partners to improve the quality and experience of care for over 2 million post-discharge patients. Prior to naviHealth, Dr. Ackerly served as Associate Medical Director for the Population Health division of Partners Healthcare, where he was responsible for risk-based contract performance for 500,000 covered lives, as well as the Assistant Chief Medical Officer at Massachusetts General Hospital (MGH). Dr. Ackerly also worked for the Federal Government, including CMS, the FDA, and the White House where he focused on health information technology and quality improvement programs.

As CMO, Dr. Ackerly will collaborate closely with the physicians of Privia Medical Group, one of the fastest growing multispecialty medical groups in the country. Privia Medical Group doctors have a shared vision of improving the quality and cost-effectiveness of care delivered to their patients. This vision is made possible by using sophisticated technology, a team-based approach, and unique population health management programs.

“Clay’s dedication to innovative, value-based care is a great asset to the Privia team as we advance our vision to change the delivery of healthcare in the markets we serve,” said Jeff Butler, Founder & CEO of Privia Health.

“Privia will certainly benefit from Clay’s deep experience in Medicare, Medicaid, and commercial risk programs; but most importantly, Clay’s a good person, and shares a values and mission set that aligns perfectly with that of our team and physicians. We look forward to working with Clay to advance the “quadruple aim” of improved patient experience, better clinical outcomes, lower costs, and enhanced provider satisfaction.”

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Emory Healthcare Network partners with urgent care companies, expands MinuteClinic affiliation to broaden patient access

Friday, October 28th, 2016

Emory Healthcare Network is partnering with two urgent care companies, Peachtree Immediate Care and SmartCare Urgent Care, while expanding its relationship with MinuteClinic, the retail medical clinic of CVS Health, to offer patients more options for their health care needs. These new partnerships, with nearly 60 locations across metro Atlanta, will provide convenient, compassionate, on-demand care.

The urgent care providers will become members of the Emory Healthcare Network, a clinically integrated network of Emory-employed and private-practice physicians who work together to create a single comprehensive care management system.

While staff and physicians at these locations will not be Emory Healthcare employees, the clinics will soon be linked to Emory’s electronic medical records for seamless care and transition. If needed, patients who are referred on to specialists within the Emory Healthcare Network for more complex treatment, will already have a health record in the system.

“We are very excited about this new partnership with our urgent care colleagues and additional MinuteClinic locations, and believe these clinics will help in increasing access by providing alternative health care options,” says Jonathan S. Lewin, MD, president, CEO and chairman of the board for Emory Healthcare. “These clinics will allow patients to get Emory-level care in a timely manner. All of the urgent care clinics coming onboard will have the same quality standards we hold to other members of the Emory Healthcare Network.”

Patients experiencing signs or symptoms of stroke, heart attack or other-life threatening emergencies should always seek care in an emergency room, while less urgent illnesses and injuries are more suitable for urgent care and MinuteClinic.

Peachtree Immediate Care, operated by CRH Healthcare, joins the Emory Healthcare Network with 16 urgent care clinics in the metro Atlanta area and one in LaGrange, Ga. The clinics offer urgent care services for injury, illness, flu, minor surgical procedures, stitches, broken bones, IV fluids and physicals. Lab and digital X-ray capabilities are located at each site.

“The Peachtree Immediate Care team is proud to become part of the Emory Healthcare Network and looks forward to working with them to provide the highest-quality urgent care services seven days a week, and with extended hours to patients throughout the Atlanta area,” says Bill Miller, CEO of CRH Healthcare.

With four convenient urgent care locations throughout Atlanta, SmartCare Urgent Care offers patients an exceptional customer experience with modern, upscale amenities such as an advanced queuing system that allows customers to choose and hold an appointment time that is convenient for them.

“SmartCare Urgent Care is delighted to affiliate with Emory Healthcare and pair our strengths to maintain the health and wellness of all those we serve,” says Kavita Kotte, MD, chief medical officer of SmartCare Urgent Care. “This clinical affiliation broadens our ability to afford our patients easy access to Emory specialists and streamline their continuity of care when necessary.”

In 2011, MinuteClinic entered into a clinical collaboration with Emory Healthcare with 31 of its retail medical clinics. Nurse practitioners continue to staff the clinics and Emory physicians serve as medical directors for the locations. As a result of this growing collaboration, Emory Healthcare Network and MinuteClinic have incorporated additional locations into the partnership, recently expanding to 38 clinics throughout the metro area.

“MinuteClinic and Emory Healthcare Network are both focused on increasing access to high-quality health care for patients,” says Andrew Sussman, MD, president of MinuteClinic. “We are pleased to be able to offer seven additional sites of care to patients in the Atlanta metro area. MinuteClinic offers a wide array of affordable health care services that are convenient for patients and in locations that are close to their homes.”

MinuteClinic providers specialize in family health care and can diagnose and treat common illnesses, injuries and skin conditions. Wellness services (vaccinations, physicals, screenings) are also offered, along with monitoring for chronic conditions.

Depending on a patient’s type of insurance, patients who seek care at one of these urgent care facilities can expect to pay a co-pay similar to that of a primary care visit, rather than an emergency room visit.

Clinical and organizational implementation among all of the companies will be completed over the next few months.

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Northside Hospital offers new tool to detect recurrent prostate cancer

Tuesday, October 25th, 2016

A new molecular imaging agent aims to detect recurrent prostate cancer earlier, when used in conjunction with PET (positron emission tomography) imaging.

Recently approved by the U.S. Food and Drug Administration, AxuminTM (fluciclovine F 18) is the first FDA-approved F-18 PET imaging agent indicated for use in patients with suspected recurrent prostate cancer. Northside Hospital is the first hospital in the country to use the new drug commercially.

Georgia Urology, the largest urology practice in the Southeast, played an important role in Northside Hospital’s becoming the first hospital in the United States to commercially use Axumin, a tool to detect recurrent prostate cancer, according to Dr. Vahan Kassabian, Georgia Urology’s medical director.

More cases of prostate cancer are diagnosed and treated at Atlanta’s Northside Hospital than anywhere else in Georgia. The hospital offers a comprehensive prostate cancer treatment program, which includes screening and advanced diagnostic capabilities, leading-edge treatment and support.

Dr. Kassabian said a “handful” of Georgia Urology’s physicians have used the technology, which has only been available commercially for about six weeks after it received approval from the FDA. Dr. Kassabian said he met with representatives from Blue Earth Diagnostics, the manufacturer of Axumin, which is how he first learned of its existence. Some of the tool’s medical research studies were performed at Emory University, he said.

While most primary prostate cancer can be successfully treated, recurrence occurs in up to one-third of patients. Of those who experience biochemical recurrence (elevated PSA following a prostatectomy or radiation therapy), approximately one-third develop metastatic prostate cancer.

Axumin is designed specifically to target prostate cancer cells. Whereas typical imaging agents (tracers) contain glucose that is absorbed by cancerous cells, prostate cancer cells have a very low sensitivity to sugar. This new agent, rather, consists of a synthetic amino acid that studies show prostate cancer cells prefer.

The drug is administered to patients prior to having PET imaging. The PET scan then detects the tracer and creates an image of the patient’s anatomy. Because more of the tracer is absorbed by the prostate cancer cells, the physician can better see if disease is present, the location and extent of disease and how rapidly it is spreading.

“To date, we have had few imaging tools available for the evaluation of men with biochemically recurrent prostate cancer, said William C. Lavely, M.D., nuclear medicine specialist, Northside Radiology Associates. “The approval of F-18 fluciclovine (Axumin) allows us to have an effective molecular imaging tool to evaluate these patients and assist clinicians in directing further management.”

Urologists use a test known as the Prostate-Specific Antigen (or PSA), which measures the amount of a protein produced by the prostate gland, to detect prostate cancer. At times, the current tests — bone scans and CT scans — can have trouble detecting where the cancerous cells are when PSA is on the rise after definitive therapy, such as surgery or radiation. Axumin provides an important tool for finding where the cancerous cells are located. “So far, it’s excellent,” Dr. Kassabian said of Axumin. “What I can tell is there was a big need for patients whose PSA is rising after prostate cancer treatments and we wouldn’t know where the cancer is with our current imaging. Technetium bone scans or regular CT scans are not very sensitive at picking up small areas of cancer that would otherwise be missed. This is a test that looks at where the PSA membrane may lie in the body and can therefore find cancer earlier and more precisely, which would translate into earlier and more accurate treatment.”

“Our initial experience is positive, demonstrating abnormal uptake in locations of potential metastatic prostate cancer,” Dr. Lavely added.

Early detection is key in successfully treating many cancers. Next to skin cancer, prostate cancer is the most frequently diagnosed cancer in men (1 in 6 men will get it). However, it can be slow growing and take years to develop.

Beginning at age 50, men at average risk (no family history) for developing prostate cancer should begin to discuss the pros and cons of screening with their doctor. Men at high risk for developing prostate cancer should begin discussing screening even sooner.

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New treatment option – naturally dissolving heart stent to patients with coronary artery disease

Tuesday, October 25th, 2016

The Northside Hospital Heart and Vascular Institute is the first in Atlanta to offer patients with coronary artery disease a new treatment option that literally disappears over time.

Abbott’s Absorb bioresorbable vascular scaffold is the world’s first FDA-approved dissolving heart stent. It is a major advance in the treatment of coronary artery disease, which affects 15 million people in the United States and remains a leading cause of death worldwide despite decades of therapeutic advances.

“This is clearly the next era of interventional cardiology, a biological solution, rather than a mechanical one,” says Dr. Jack Chen, interventional cardiologist with Northside Heart.

While stents are traditionally made of metal, the new stent is made of a naturally dissolving material, similar to dissolving sutures. It disappears completely in about three years, after it has done its job of keeping a clogged artery open and promoting healing of the treated artery segment. By contrast, metal stents are permanent implants.

“The bio absorbable scaffolds can potentially make future treatment options easier if the patient needs additional stents or bypass surgery,” explains Dr. Marcus Brown, interventional cardiologist and cardiology section chief at Northside.

Dr. Khalid Shash, interventional cardiologist, implanted the first dissolving stent, Oct. 11, at Northside Hospital’s Atlanta campus.

“After a blockage in a blood vessel is cleared, it only needs support for a matter of months until the vessel heals and can stay open on its own,” said Dr. Shash. “After that, the metallic stent serves no additional purpose, and can, in fact, be a hindrance. The Absorb stent gradually dissolves over time, leaving a healed artery that can flex and pulse naturally.”

“We are pleased to add the Absorb stent to our comprehensive services,” says Patricia Tyson, director, Northside Hospital Heart and Vascular Institute. “The addition of this new tool, combined with the expertise of our heart and vascular team, will help Northside continue to offer patients the best care possible using the most innovative technology available.”

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American Academy of Pediatrics – Georgia Chapter: Fall Meeting of the Ga Pediatric Nurses & Practice Managers

Friday, October 14th, 2016

October 14 at the Cobb Energy Center, Atlanta. For more information, visit American Academy of Pediatrics – Georgia Chapter.

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Georgia Society of Clinical Oncology: 2016 Atlanta Lung Cancer Symposium

Saturday, October 29th, 2016

October 29, Loews Atlanta Hotel. For more information, visit Georgia Society of Clinical Oncology.

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Georgia Pediatric Nurses & Practice Managers Fall Meeting

Friday, October 14th, 2016

October 14

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MAG House of Delegates Meeting

Saturday, October 15th, 2016

October 15-16, Hyatt Regency, Savannah, GA. For more information click here.

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