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NEWS & INFORMATION
AMA HOUSE OF DELEGATES
On February 12, the Washington State Health Care Authority's Health Technology Assessment program published its final report of their re-review of spinal injections. The report is available at the Washington State Health Care Authority Health Technology Assessment Page. A public meeting of the Health Technology Clinical Committee is scheduled for March 18, 2016. The Spine Intervention Society has submitted comments at every stage of this report's development and release.
ATTENTION WASHINGTON PHYSICIANS: Save the Date! March 18, 2016 WA HCA HTCC Meeting (January 20, 2016)
On Friday, March 18 at the SeaTac Conference Center, the WA Health Technology Clinical Committee will meet from 8 am to 5 pm, and preliminary information indicates that spinal injections will be addressed in the afternoon, likely starting at 12:30 pm.Five weeks prior to the March meeting (Feb 12), HTA stakeholders will be notified of the opportunity to present comments at the meeting. Individuals will have three minutes each to make their comments. Groups may “pool” their individual time to allow one or two of their representatives to speak longer. In this case, all individuals whose time is pooled must be present at the meeting whether they speak or not.
Draft WA HCA Health Technology Assessment on Spinal Injections Released (December 16, 2015)
Earlier this year, the WA HCA announced the draft key questions that will frame their re-review of spinal injections. The draft report is anticipated to be released on 12/16/15 at the Washington State Health Care Authority Health Technology Assessment Page. Public comments will be accepted between December 16 and January 14; the Spine Intervention Society will review and comment on the report on behalf of the membership.
Oregon HTAS Drafts Coverage Guidance on Percutaneous Interventions for Cervical Spine Pain (September 18, 2014)
The Oregon Health Technology Assessment Subcommittee (HTAS) has continued to develop their coverage guidance on Percutaneous Interventions for Cervical Spine Pain. On July 28, the Subcommittee reviewed public comment and testimony and forwarded a revised guidance to the Value-based Benefits Subcommittee (VbBS) and the Health Evidence Review Commission for implementation and approval. The VbBS met on August 14 to review the draft coverage guidance; the International Spine Intervention Society is closely monitoring this issue. For more information, see the Health Evidence Review Commission's blog HERE.
Update on the International Spine Intervention Society Response to FDA Statement on ESIs (June 16, 2014)
This message is in response to the FDA statement released on April 23rd, addressing the safety and effectiveness of epidural steroid injections. http://www.fda.gov/Drugs/DrugSafety/ucm394280.htm
The International Spine Intervention Society feels that the alert was misleading in its message regarding the safety of epidural steroid injections and contained inaccuracies regarding the effectiveness of this procedure.
The statement was released by the regulatory division of the FDA and not the FDA Safe Use Initiative (SUI). The FDA SUI has been working with physician experts from multiple organizations, including several Society leaders, over the past two years to help create a set of expert recommendations for the safe administration of epidural steroid injections. It is important to note that the release of the April 23 statement by the FDA regulatory branch was unilateral and unbeknownst to the panel of experts working with the SUI on epidural steroid injections. Following the release of this statement, the expert panel leaders on this project decided to involve the 14 societies represented on the Multi-Society Pain Workgroup (MPW) to craft a set of consensus recommendations for the safe administration of epidural steroid injections.
The MPW was originally formed to assist Medicare contractors in developing more consistent local coverage determinations (LCDs) through multi-society consensus recommendations. Based on its track record in generating consensus and producing multi-society recommendations on interventional pain medicine issues, the MPW was selected to develop multi-society consensus recommendations on the safe use of epidural steroid injections. The MPW process, which results in majority consensus recommendations, is entirely democratic, transparent, and collaborative with no single society having more influence than any other participating society.
The societies represented in the MPW are:
1. American Academy of Neurological Surgeons (AANS) *
2. American Academy of Pain Medicine (AAPM)
3. American Academy of Physical Medicine and Rehabilitation (AAPM&R)
4. American College of Radiology (ACR)
5. American Pain Society (APS)
6. American Society of Anesthesiologists (ASA)
7. American Society of Neuroradiology (ASNR)
8. American Society of Regional Anesthesia (ASRA)
9. American Society of Spine Radiology (ASSR)
10. Congress of Neurological Surgeons (CNS) *
11. International Spine Intervention Society (The Society)
12. North American Neuromodulation Society (NANS)
13. North American Spine Society (NASS)
14. Society of Interventional Radiology (SIR)
* AANS/CNS receive a single vote on the MPW.
The American Society of Interventional Pain Physicians (ASIPP) was involved in the MPW upon its inception, but subsequently resigned from participation.
The intent of this effort is not to mandate policy or write standards of care regarding the performance of epidural steroid injections, but to produce a set of tenable and publishable consensus recommendations regarding the safe administration of epidural steroid injections. We are optimistic that this will be forthcoming from the MPW and the SUI team within a reasonable time frame. The MPW societies that have been integral to this process are effectively progressing in a good-faith effort to produce a positive and sound resolution to address ongoing concerns regarding the safe use of epidural steroid injections. The resulting multi-society endorsed recommendations will undoubtedly be a product held in much higher regard than anything that a single society could hurriedly produce and release, given the time-sensitive nature of this issue.
Oregon HTA Discusses Draft Coverage Guidances on Percutaneous Interventions for Cervical Spine Pain (April 10, 2014)
The Oregon Health Technology Assessment Subcommittee will meet on April 28, 2014 to discuss draft coverage guidances on various topics, including Percutaneous Interventions for Cervical Spine Pain. At the February 24th meeting, the Subcommittee requested additional research on the topic. On April 4th, it was announced that two additional sources would be added to the draft coverage guidance based on expert input. The International Spine Intervention Society members in Oregon are encouraged to become involved and attend the April 28th meeting. Please contact email@example.com if you are planning to attend. For the meeting agenda and materials, see the Health Evidence Review Commission's blog HERE and list of upcoming meetings HERE
WA HTCC Draft Coverage Determination - Facet Neurotomy - Open for Comments (April 10, 2014)
The Washington State Health Care Authority (HCA) Health Technology Clinical Committee (HTCC) has released for public comment its Draft Findings and Decision for Facet Neurotomy, based on a public meeting held on March 21.
Two Society members from Washington State, Drs. Paul Dreyfuss and Alison Stout, attended in person and made very compelling arguments for appropriate coverage. The International Spine Intervention Society also submitted extensive comments on this topic, encouraging the HTA to incorporate best available evidence. As a result, the committee decided to cover some, but not all, of the procedures advocated by the Society.
The International Spine Intervention Society is preparing a response to the draft coverage determination. Society members, particularly those residing in Washington, are encouraged to comment. The deadline for comment submission is April 22.
Society Oregon Members Encouraged to Attend Meeting on Cervical Spine Injections (February 25, 2014)
The Oregon Health Technology Assessment Subcommittee will meet on Monday, February 24; the agenda includes a review of initial draft coverage guidances on cervical spine injections. International Spine Intervention Society members in Oregon are encouraged to become involved and attend the meeting. Please contact firstname.lastname@example.org if you are planning to attend. For the meeting agenda and materials, see the list of upcoming meetings HERE.
Draft WA HCA HTA Report - Comments Solicited! (January 15, 2014)
The Washington State Health Care Authority (HCA) Health Technology Committee has released a draft evidence report on Facet Neurotomy. There are several issues of concern to the International Spine Intervention Society within the WA HCA report; according to the HCA's website, "there are significant questions related to the diagnosis and treatment of facet joint pain including if it is safe, effective and cost-effective and the most effective means of identifying patients who may benefit.” The Society is preparing comments to submit to the HCA later this week, encouraging the Washington HCA to focus on the evidence and the proper application of Society guidelines as the standard for the performance of medial branch blocks, third occipital nerve blocks, and thermal radiofrequency neurotomy.
The draft report is currently available for comments, with a submission deadline of this Friday, January 17th. All Society members, especially those who practice in the state of Washington, are strongly encouraged to submit comments
In a Disturbing Decision, Iowa Supreme Court Allows ARNPs to Supervise Fluoroscopy (June 27, 2013)
Despite strong opposition from medical societies, the Iowa Supreme Court ruled on May 31, 2013 that advanced registered nurse practitioners (ARNPs) in Iowa can legally supervise fluoroscopy procedures. In 2011, a District Court ruled that ARNPs could not supervise fluoroscopy but the Iowa Supreme Court overturned this decision, stating that the District Court made an error in second-guessing the Department of Public Health and the Nursing Board on the adequacy of ARNP training to supervise imaging procedures. The Supreme Court commented that permitting ARNPs to oversee fluoroscopy improves access in rural areas, helps lower costs, and that there are no reports of injuries resulting from ARNP-supervised fluoroscopy.
WA HCA Announces Review of Facet Neurotomy (December 21, 2012)
The Washington State Health Care Authority (HCA) Director has selected a group of health technologies to undergo review and coverage decisions by the Health Technology Clinical Committee (HTCC) beginning in 2013. On this list the HCA placed Facet Neurotomy for Cervical and Lumbar Pain.
To gather information and evidence for consideration in review of the selected topics, public comments will be accepted by the HCA until January 10, 2013 at 5pm. All comments should be submitted to: email@example.com
The International Spine Intervention Society has been very heavily involved with the WA HCA's review of spinal injections and due to those efforts, the majority of the procedures reviewed at the time continue to be covered. We will again do everything possible to assure appropriate coverage and access to facet neurotomy for our patients.
Washington State HTA Issues Final Decision on Spinal Injections (February 3, 2012)
The Washington State Health Technology Assessment (HTA) Program finalized its decision regarding coverage of spinal injections. The decision can be found in the attached document. This concludes a process that took nearly a year to complete, and required arduous work from many dedicated International Spine Intervention Society and other medical society volunteer members; who worked tirelessly trying to assure that appropriate patient access to vital diagnostic and therapeutic spine interventions is preserved. For more information, click HERE.
The International Spine Intervention Society Continues to Fight for the Coverage of Spinal Injections (January 27, 2012)
For the past few months, Society leadership has been diligently working to preserve coverage for appropriately performed spinal injections in the State of Washington and nationally. The Washington State Health Technology Assessment Program (HTA) is charged with assessing the safety, efficacy and cost effectiveness of health technologies to make decisions regarding coverage for state programs, with a possibility of being adopted by private payers who are not contained within the state.
Comments Submitted on WA HCA Health Technology Assessment on Spinal Injections (January 20, 2016)
SIS coordinated the drafting and submission of a letter joined by multiple other organizations to the Washington State Health Care Authority’s (WA HCA) Health Technology Assessment Program in response to the call for comments on their re-review of spinal injections. This review of spinal injections is premature, and according to WA HCA, was prompted by new evidence (i.e. Friedly’s LESS study) and new safety concerns (i.e. the FDA’s labeling changes for epidural injection of steroid). SIS and the other signatories believe that the current draft of the report does not adequately address the key questions posed and is not a satisfactory reference for the topic.
SIS Comments on Oregon Health Authority's Scope Statement for Coverage Guidance Development on Percutaneous Interventions for Low Back Pain (January 20, 2016)
On January 19, SIS submitted comments to the Oregon Health Authority on their Scope Statement for the development of a Coverage Guidance on Percutaneous Interventions for Low Back Pain. The scope statement defined the populations, interventions, comparisons and the outcomes that were considered most important in determining whether changes to the existing coverage guidance are warranted. The current Coverage Guidance indicates that the topic will be reviewed following publication of the AHRQ technology assessment on spinal injections for low back pain. SIS’ comments highlight the AHRQ report's significant methodological flaws and urges Oregon Health Authority to be aware of these errors and not repeat them.
To see the letter, click HERE.
SIS Signs-On to Letter to CMS on MACRA Regulations (November 18, 2015)
A letter signed by more than 100 state and national medical specialty societies has been submitted to the CMS Administrator and to the agency’s regulatory comments site. The letter, laying out principles CMS should follow in designing regulations to implement the Medicare Access and Chip Reauthorization Act (MACRA), can be found HERE.
SIS Expresses Concerns to Congress Regarding Meaningful Use Stage 3 Implementation (November 2, 2015)
On November 2, the Spine Intervention Society, along with dozens of other state and national medical specialty organizations, signed on to letters to Congress expressing displeasure with CMS’ decision to proceed with implementing Stage 3 of the Meaningful Use Program. The overall goal established by Congress in the HITECH Act was to promote widespread adoption of electronic health records by physicians and hospitals. This goal has largely been achieved, though adoption has been followed by problems of interoperability, barriers to the easy exchange of data across care settings, and cumbersome data entry requirements at the exam room level. SIS urges Congressional action to halt the focus on measure thresholds and documentation requirements and instead refocus on promoting better coordinated and high quality patient care. To see the letters, click here: U.S. Senate Letter, House of Representatives Letter.
SIS Coordinates Submission of Comment Letter to the Washington State Health Care Authority (September 16, 2015)
SIS coordinated the drafting and submission of a letter joined by multiple other organizations to the Washington State Health Care Authority’s (WA HCA) Health Technology Assessment Program. Earlier this month, the WA HCA initiated a comment period for review of the draft key questions that will frame their upcoming re-review of spinal injections. This review of spinal injections is premature, and according to WA HCA, was prompted by new evidence (i.e. Friedly’s LESS study) and new safety concerns (i.e. the FDA’s labeling changes for epidural injection of steroid). Their proposed inclusion/exclusion criteria stipulate exclusion of non-RCT evidence (unless related to safety), and their proposed questions fail to require subgroup analyses by diagnosis, use of image guidance, or approach/access to ensure homogeneity of patient populations. With questions and inclusion/exclusion criteria as proposed, the resulting report will do a tremendous disservice to spinal injections, mirroring the recent AHRQ technology assessment. The difference: WA HCA is performing the review expressly to inform coverage determinations.
Society Supports Washington State Physicians' Efforts to Save C2-3 Neurotomy (September 18, 2014)
The International Spine Intervention Society joined in a letter signed by dozens of Washington state physicians, along with American Society of Anesthesiologists, American Society of Regional Anesthesia, and Washington State Society of Anesthesiologists raising questions about the process that resulted in an inappropriate non-coverage decision for C2-3 neurotomy. The Society continues to follow the situation closely and has been working hard to assure appropriate access to valuable procedures for our patients. To view the copy of the letter, please click HERE.
Washington State Health Care Authority Reviewing Facet Neurotomy - International Spine Intervention Society Submits Comments; Public Meeting Scheduled (February 25, 2014)
On December 19, 2013, the Washington State Health Care Authority (HCA) released for public comment a draft evidence report on facet neurotomy. According to the HCA's website, "there are significant questions related to the diagnosis and treatment of facet joint pain including if it is safe, effective and cost-effective and the most effective means of identifying patients who may benefit.” The Society submitted comments to the HCA on Friday, January 17, 2014, encouraging the Washington HCA to focus on the evidence and the proper application of Society guidelines as the standard for the performance of medial branch blocks, third occipital nerve blocks, and thermal radiofrequency neurotomy. The Society comment letter is available here. The public meeting of the Health Technology Clinical Committee (HTCC) in which Facet Neurotomy will be discussed will take place on March 21, 2014.
International Spine Intervention Society Comments on the Washington State Health Care Authority Draft Report on Facet Neurotomy (January 24, 2014)
On December 19, 2013, the Washington State Health Care Authority (HCA) released for public comment a draft evidence report on facet neurotomy. According to the HCA's website, "there are significant questions related to the diagnosis and treatment of facet joint pain including if it is safe, effective and cost-effective and the most effective means of identifying patients who may benefit.” The Society submitted comments to the HCA on Friday, January 17, 2014, encouraging the Washington HCA to focus on the evidence and the proper application of the Society's guidelines as the standard for the performance of medial branch blocks, third occipital nerve blocks, and thermal radiofrequency neurotomy. The Society comment letter is available HERE.
International Spine Intervention Society Joins Medical Specialties in a Call for VHA to Pull Back APRN Independent Practice Requirements (November 22, 2013)
The International Spine Intervention Society joined numerous specialty and state medical associations in a joint letter to the Department of Veteran Affairs protesting the draft Veteran Health Affairs (VHA) Nursing Handbook, which would mandate that all advanced practice nurses (APRNs) within the VHA be designated as independent providers, without regard to state law. The draft handbook would effectively eliminate physician-led, team-based care and require APRNs to attain independent practice by penalizing those who do not wish to attain this status by prohibiting them from practicing within the VHA. To view the letter sent to the VHA, click HERE.
International Spine Intervention Society Responds to the HTA Public Comment Request on Evidence for Cervical and Lumbar Neurotomy (January 24, 2013)
The Washington State Health Technology Authority announced that Cervical and Lumbar Facet Neurotomy would be reviewed in 2013. Preliminary comments on evidence were being sought. The International Spine Intervention Society submitted a summary of new information and will be involved in providing comments as the process progresses. To view the comment letter please click HERE.
International Spine Intervention Society Defends Spine Interventions in Oregon (September 20, 2012)
The Oregon Health Evidence Review Commission (HERC) has issued a draft coverage guidance for percutaneous interventions for low back pain. The draft proposal would drastically limit patient access to valuable spine intervention procedures
The Society alerted all Oregon members and encouraged them to submit comments during public comment period. An official Society letter has been submitted to the HERC, as well. To view the letter, please click HERE.
Urgent Message to International Spine Intervention Society Members in the State of Oregon (September 5, 2012)
The Oregon Health Evidence Review Commission (HERC) has issued a draft coverage guidance for percutaneous interventions for low back pain. There are many points in this document that are very alarming and will drastically limit patient access to valuable spine intervention procedures.
Society members are strongly encouraged to submit comments by September 7, 2012 deadline.
According to the HERC website, below are the requirements for public comments:
"For your comment to be accepted, it must:
Effective June 1, 2012, any submissions not adhering to the above criteria will be returned without an extension of the deadline. Only one submission per person, per topic will be allowed and a separate email must be sent for each topic. Comments should include a full citation to any suggested additional peer-reviewed articles (not counted towards the 1000 word limit). To ensure the suggested articles are reviewed, you should attach copies of the articles with your comments. If we are unable to obtain a cited article, we will not review the study. Comments should not contain links to additional materials. These will not be reviewed.”
For more information please visit: http://cms.oregon.gov/oha/OHPR/pages/herc/coverage-guidance.aspx. If you would like to volunteer to be involved on a greater level and volunteer to attend HERC public hearing (s). Please send an email to firstname.lastname@example.org.
International Spine Intervention Society Receives Multi-specialty Support in Addressing Health Technology Assessment Process for Spinal Injections (January 25, 2012)
Washington State Healthcare Technology Assessment Program (HTA) has announced an evidence review of all spinal injections. The questions proposed by HTA for the evidence review were seriously flawed, mainly in the fact that they did not make any distinction between the diagnostic and therapeutic injections. The WA HTA policies have been cited in the past as basis for denial of coverage by other third party payors, both state and private; therefore it is imperative that any proposed evidence questions for spinal injections be well worded and informed.
The Society has formulated a response and was able to gather multi-specialty support for it: AAPM&R, AAPM, ACR, SIR, ASNR, ASSR, NASS, AANS and CNS signed-on to the comments that were submitted to the HTA.
International Spine Intervention Society Submits Support for the Iowa Board of Medicine Rule (March 29, 2010)
The Society submitted a letter to the Iowa Board of Medicine in support of proposed regulations to define interventional chronic pain management as the practice of medicine.
In accordance with the Society's Position Statement on Prerequisite Training for the Performance of Spine Interventions, proper provider training can only be obtained by completing training at an accredited allopathic or osteopathic medical residency in an ABMS or an AOA accredited specialty with subsequent specialty training in spinal intervention. The comment letter submitted to the Iowa Board of Medicine can be viewed by clicking HERE.
The House of Delegates (HOD) is the principal policy-making body of the American Medical Association. For more information, visit http://www.ama-assn.org/ama/pub/about-ama/our-people/house-delegates.page
Representation at the HOD depends upon the AMA-membership of a society's members. To ensure the Spine Intervention Society's voice at the House of Delegates, please keep your AMA-membership current. If we're not at the table, we're on the menu!
June 2015 HOD MEETING
The International Spine Intervention Society was represented at the June 6-10, 2015 AMA House of Delegates meeting by Drs. Claire Tibiletti and Andrew Yu. Several resolutions and policies addressed at this meeting related to spine interventions and pain medicine, including pain as the fifth vital sign, coverage for chronic pain, opioid-related issues and many more. The Society maintains a delegate seat in order to be eligible for representation at the AMA CPT and Relative Value Update processes and to have input on any topics related to coding and reimbursement of interventional pain procedures.
June 2014 HOD MEETING
Drs. Claire Tibiletti and Andrew Yu represented the International Spine Intervention Society at the AMA House of Delegates meeting June 7-11, 2014. Resolutions and policies addressed at this meeting included issues related to methadone, response to the CMS physician claims data release, and evaluating the advocacy efforts of the AMA. The Society maintains a delegate seat in order to be eligible for representation at the AMA CPT and Relative Value Update processes and have input on any topics related to coding and reimbursement of interventional pain procedures.
June 2013 HOD MEETING
Claire Tibiletti, MD and Andrew Yu, MD represented the International Spine Intervention Society at the AMA House of Delegates Annual Meeting June 15-19, 2013. Some of the key policies that were passed at the meeting were:
Scope of Practice
Comprehensive guidelines on the definition of invasive pain management procedures for the treatment of chronic pain - this was an addition to previously passed policy, which stated that the AMA should actively advocate that interventional chronic pain management is within the practice of medicine and should be performed only by physicians.
Comprehensive policy on compounding pharmacies, including a provision that the AMA supports the view that facilities (other than pharmacies within a health system) that compound sterile drug products without receiving a prescription prior to beginning compounding to be recognized as compounding manufacturers subject to FDA oversight and regulation.
In addition to current policies and a comprehensive report on drug shortages which is developed annually, the AMA HOD voted on a provision to advocate for government stockpiling of oral and intravenous parenteral drug shortage products, or for removal of government policy price controls to mitigate against an unfair manufacturing free marketplace. The AMA will also develop a webpage resource dedicated to drug shortages and continue to evaluate the drug shortage issue.
June 2012 HOD Meeting
Dr. Claire Tibiletti and Dr. Andrew Yu represented the International Spine Intervention Society at the AMA House of Delegates Advocacy Meeting, November 10-13, 2012. Multiple policy issues were discussed, including the delay or elimination of ICD-10 requirement, drug shortages, uniform approach for assessing patients for controlled substances for chronic pain and harm reduction strategies for opioid overdose. The House also established principles for physician employment to protect physicians who enter into employment agreements. To view the principles document please visit: http://www.ama-assn.org/resources/doc/hod/ama-principles-for-physician-employment.pdf
June 2011 HOD Meeting
The AMA House of Delegates Meeting took place in Chicago June 18-22, 2011. The International Spine Intervention Society Delegate to the AMA is Dr. Lee Snook and Alternate Delegate is Dr. Ben Shwachman - both delegates were present at the meeting to represent the voice of pain and interventional physicians as AMA policies are formed.
Despite the growing discord over AMA policies; evident throughout the year and especially during the House of Delegate Meetings; it is crucial that the Society maintains the representation in the House of Delegates. Only societies with House of Delegates representation are eligible to participate in the AMA CPT Editorial Panel process, which makes decisions about CPT coding and the Relative Value Scale Update Committee (RUC), which makes decision about the value of each CPT code. Without the ability for the Society to participate in the CPT and RUC processes we will lose the ability to advocate for proper coding and values for interventional spine procedures.
The Society must prove that a high percentage of our members belong to the AMA in order to keep the representation at these important forums. All members are urged to assure that their AMA membership is up to date to assure that the voice of interventional spine specialists continues to be heard.
June 2010 HOD Meeting
The International Spine Intervention Society AMA Representatives - Dr. Lee Snook and Dr. Ben Shwachman, attended the AMA House of Delegates Meeting, held on June 12-16. In the wake of a Medicare meltdown caused by a 21 percent Medicare physician payment cut, and dissatisfaction with the AMA leadership in addressing the physician payment crisis during the healthcare reform negotiations, it is more important than ever to assure that the specialty society voices, such as the one from the International Spine Intervention Society, are heard. In addition, assuring that the Society keeps the AMA House of Delegates seat is crucial in order to continue our work at the AMA CPT Editorial Panel and the Relative Value Update Committee (RUC) which assigns the value to every CPT code. The only way to continue this important work is to assure that the Society continues its involvement with the AMA House of Delegates.
1/27/2017 » 1/29/2017
Evidence-Based Spine Interventions Seminar - Palm Springs, CA
Inaugural SIS Golf Tournament
2/10/2017 » 2/12/2017
Lumbar Bio-Skills Lab - Phoenix, AZ
3/10/2017 » 3/12/2017
Advanced Lumbar Bio-Skills Lab - Tampa, FL
3/11/2017 » 3/12/2017
European Lumbar Bio-Skills Lab - Amsterdam, NL
4/21/2017 » 4/23/2017
Cervical Bio-Skills Lab - Bethlehem, PA