Jeffrey Davis, ACEP Director of Regulator Affairs, shared the following details regarding the announcement of CMS policies including big wins for emergency medicine: 

• EMTALA: CMS issued the long-awaited revised guidance on EMTALA that will allow medical screening exams to be delivered via telehealth. This has been a major ACEP priority, and we repeatedly asked CMS to issue this revised EMTALA guidance. There are other temporary changes to EMTALA, and Dr. Todd Taylor will send a separate email explaining these. 
• Telehealth: CMS added the ED E/M codes (CPT codes 99281 to 99285) and the critical care codes (CPT codes 99291 and 99292) to the list of approved Medicare telehealth services for the duration of the COVID-19 national emergency. CMS had previously expanded the ability to perform telehealth services but had not allowed emergency physicians to use the ED E/M codes-which most accurately reflect the intensity and value of emergency services. ACEP had identified this issue as a top regulatory priority, and through ACEP's advocacy, CMS has now recognized that ED E/M codes are indeed the most appropriate codes to use when delivering emergency telehealth services.  
• Expanding the Healthcare Workforce: CMS is allowing hospitals to increase their workforce capacity by removing barriers for physicians, nurses, and other clinicians to be readily hired from the local community as well as those licensed from other states without violating Medicare rules. ACEP had urged CMS to relax state licensure requirements. 
• CMS Hospital Without Walls: CMS is allowing hospitals to provide services in locations beyond their existing walls to expand care capacity and to develop sites dedicated to COVID-19 treatment. Under CMS's temporary new rules, hospitals will be able to transfer patients to outside facilities, such as ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories, while still receiving hospital payments under Medicare. Ambulances will also be able to transport patients to a wider range of locations when other transportation is not medically appropriate. These destinations include community mental health centers, federally qualified health centers (FQHCs), physician's offices, urgent care facilities, or ambulatory surgery centers.  
• Waiver of Physician Self-Referral Law: CMS issued blanket waivers of sanctions under the physician self-referral law.  

These are only some of the many policies announced. ACEP is scheduling a webinar with CMS for Friday, April 3rd to discuss EMTALA. More details to follow.  

March 31, Wisconsin Health News

Assembly Speaker Robin Vos, R-Rochester, said Monday that the Legislature will act on a request by the Department of Health Services to waive Medicaid rules in response to COVID-19. 

DHS plans to pursue an emergency 1135 waiver from the federal Centers for Medicare and Medicaid Services. It needs legislative approval to do so under a law enacted after Gov. Tony Evers was elected, but before he took office.

Vos said the Assembly hopes to hold a floor session soon and they’re exploring ways to convene it without “adversely impacting” at-risk populations within their membership and support staff. 

He’s also expecting a final analysis from the Legislative Fiscal Bureau on the federal stimulus law approved last week. 

“We know legislative action will need to be taken, including a request for an emergency waiver from CMS to allow for flexibilities to healthcare providers,” Vos said in a statement. 

He added that they’re having daily discussions with the governor’s office and legislative Democratic leaders. 

DHS officials submitted a request for an emergency waiver to the Legislature’s Joint Finance Committee last week. Spokesman for the committee's leaders said they don't have authority to act on the request.

Evers on Monday called on the Legislature to allow for “greater flexibilities within the Department of Health Services so they can act rapidly and ensure folks are getting the care they need without any unnecessary barriers such as pre-authorization requirements.”

“Lives are on the line here, and we can’t afford being hamstrung by bureaucratic hurdles,” he told reporters.

Governor Evers announced a new public-private partnership among Wisconsin industry leaders to increase Wisconsin's laboratory testing capacity for COVID-19. Prior to today's announcement, the Wisconsin State Lab of Hygiene and the Milwaukee Public Health Lab were leading the Wisconsin Clinical Lab Network labs to bring additional COVID-19 testing online.

The new partnership now includes laboratory support from Exact Sciences, Marshfield Clinic Health System, Promega, and UW Health. These organizations, along with the Wisconsin Clinical Lab Network, will now share knowledge, resources, and technology to bolster Wisconsin’s testing capacity.

The Wisconsin Clinical Lab Network labs have been averaging completion of 1,500-2,000 COVID-19 tests per day. The expanded capacity from the state’s new public-private partnership is expected to double that capacity initially and continue to expand as additional platforms and supplies become available.

Residents who are seeking a COVID-19 test are still required to receive an order from a doctor. These labs are not testing sites. 

The full press release is available online (link).

Andrew Cathers, MD
Associate Medical Director, UW Med Flight
Univ. of WI BerbeeWalsh Dept of Emergency Medicine

UW Med Flight has established an ECMO Transport Program.  Through close partnerships with UW Health’s Critical Care and Cardiothoracic Surgery teams, Med Flight has been able to devise and implement a program wherein these critically ill patients can be safely transported.  In addition, in select situations, the team can travel to the patient, cannulate them at a referring facility, place them on ECMO, and then transport them back to UW Health.

Extracorporeal Membrane Oxygenation (abbreviated as ECMO), is a treatment that is becoming steadily more widespread and prevalent.  It is typically used for patients with severe cardiorespiratory illness.  There are two primary variants – veno-venous (VV) and veno-arterial (VA).  VV ECMO is typically used in patients with intact cardiac function but severely compromised respiratory function, such as ARDS.  VA ECMO is used for patients in cardiac arrest or severe circulatory shock, with the ECMO device supporting both the heart and the lungs.  Typically, large-bore cannulas are placed in the central vessels, and then an ECMO pump and circuit is utilized, which will circulate and oxygenate the blood.  As technology advances and ECMO transport has become more common, the ECMO devices themselves have become smaller and some are even specifically designed for ease of transport in mind.

ECMO has traditionally only been initiated and maintained in large, tertiary centers.  However, recent advances, including more widespread use of percutaneous cannulation techniques, have seen ECMO use spread to the smaller hospitals.  Many of these hospitals lack the capability to longitudinally care for ECMO patients.  In other cases, patients are placed on ECMO in order to “bridge” them to further treatment, such as Ventricular Assist Device placement or lung transplant.  Because of this, these critically ill patients often need to be transferred from the smaller facility to the destination center.  Finally, there are critically ill patients at outlying facilities who may not survive conventional interfacility transport – in these cases, it is actually safer for the patient if they are cannulated and supported by ECMO prior to moving between facilities.

Our teams have completed ECMO transports via both helicopter and ground ambulance.  Mode of transport is flexible and dictated by distance, weather conditions, and most importantly – the needs of the patient. 

Team

• Board-Certified Emergency Medicine Physician with additional transport and ECMO training
• Critical Care Registered Nurse with additional transport and ECMO training
• Board-Certified Cardiothoracic Surgeon with ECMO expertise
• Perfusionist

Vehicle

• EC-145 Helicopter
• Critical Care Transport Ambulances

Patient Population

• Adult Patients already on VA or VV ECMO – either centrally or peripherally cannulated
• Adult Patients who are not yet on ECMO but may benefit from this intervention who are at an outside facility

CMS has released a regulation that added the emergency department (ED) evaluation and management (E/M) codes (CPT codes 99281 to 99285) to the list of approved Medicare telehealth services for the duration of the COVID-19 national emergency.

CMS had previously expanded the ability  to perform telehealth services, but had not allowed emergency physicians to use the ED E/M codes—which most accurately reflect the intensity and value of emergency services .

CMS has now recognized that ED E/M codes are indeed the most appropriate codes to use when delivering emergency telehealth services.

Governor Evers and Wisconsin Department of Health Services (DHS) Secretary-designee Andrea Palm today exercised their authority under Article V, Section 4 of the Wisconsin Constitution and Sections 323.12(4) and 252.02(6) of the Wisconsin Statutes to simplify healthcare license renewals during the COVID-19 public health emergency and to encourage recently retired professionals with expired licenses to re-enter practice. This full order is available online (link).

The order includes the following policy changes:

• Interstate Reciprocity: allows any out-of-state health can provider licensed and in good standing to practice in Wisconsin without a Wisconsin credential. The order requires the out-of-state physician to apply for a temporary or permanent Wisconsin license within 10 days of first working at a Wisconsin health care facility; and the health care facility must notify DSPS within 5 days. The order temporarily suspends the visiting physician practice limitations in Med 3.04. 
• Temporary License: Any temporary licensed to an out-of-state provider during the emergency will be valid until 30 days after the conclusion of the emergency. 
• Telemedicine: Allows physicians licensed and in good standing in Wisconsin, another U.S. state or Canada to provide telemedicine services to Wisconsin residents. 
• Physician Assistants: Suspends several current rules regulating the practice of PAs in Wisconsin. This includes: the requirement of PAs to notify the MEB of changes to their supervising physician within 20 days (order changes it to 40 days); the requirement that PAs limit their scope of practice to that of their supervising physician (the order allows them to practice to the extent of their experience, education, training and abilities. It also allows them to delegate tasks to another health provider); the physician to PA ratio of 4:1 (the order allows a physician to oversee up to 8 on-duty PAs at a time, but there is no limit on how many PAs a physician may provide supervision to over time. It also allows a PA to be supervised by multiple physicians while on duty). 
• Nurse Training and Practice: The order suspends many rules related to nursing. This includes suspending a rule that prohibits simulations from being utilized for more than 50% of the time designated for meeting clinical learning requirements. It also suspends the requirement for nurses to submit an official transcript in order to get a temporary license and allows a temporary license to remain valid for up to 6 months. In addition, it suspends the rule requiring license renewal within 5 years. 
• Advanced Practice Nurse Prescribers: Temporarily suspends the requirement that Nurse Prescribers must facilitate collaboration with other health care professionals, at least 1 of whom shall be a physician or dentist. 
• Recently Expired Credentials: Requires the state to reach out to individuals with recently lapsed credentials about renewal options. The order also suspends many of the late renewal fees and continuing education requirements for most health professions. The order temporarily suspends MED 14.06(2)(a) to allow a physician whose license lapsed less than 5 years ago to renew without fulfilling the continuing education requirements. It also suspends RAD 5.01 (1) and (2) to allow radiographers or LXMO permit holders who have let their license lapse renew without completing continuing education. 
• Fees: The order also gives DHS the ability to suspend fees or assessments related to health care provider credentialing. 

The order is effective immediately and will remain in effect through the duration of the public health emergency.

The full version of the Governor’s press release is available online (link).

Governor Evers released a 65-page draft piece of legislation and a draft joint resolution on Saturday night aimed at addressing COVID-19. The Governor also released a chart outlining the proposal.  The Legislative Fiscal Bureau also provided a Summary of provisions Governor Evers’ proposed legislation and Joint Resolution indefinitely extending public health emergency to state legislators.

The bill includes several healthcare provisions, including language related to out-of-network bills that occur during the public health emergency. The language caps physician payment rates at 250% of the Medicare rate.

Insurance 

• Prohibits health plans from charging patients more for out-of-network services related to the diagnosis and treatment of the condition for which a public health emergency has been declared than they do for in-network services (if an in-network physician is not available).
• The bill requires the plan to reimburse the out-of-network provider at 250% of the Medicare rate. Providers and facilities are prohibited from charging patients more than what they are reimburse by the plan. 
• Creates a process for out-of-state physicians to have liability coverage in Wisconsin during a public health emergency. They would need to provide OCI with a certificate of insurance for a policy of health care liability insurance issued by an insurer that is authorized in a jurisdiction accredited by the National Association of Insurance Commissioners. 
• Requires health plans to cover without cost-sharing any testing, treatment or vaccines related to COVID-19.
• Requires health plans to cover any services provided via telehealth if they cover that service when it is provided in-person. 
• Prohibits health plans from canceling policies due to non-payment during the COVID-19 emergency 
• Prohibits health plans and pharmacy benefit managers from requiring prior authorization for any early refills of prescriptions or restricting the period of time in which a drug may be refilled. 
• Creates a process for pharmacists to extend prescription orders by up to 30 days during public health emergencies. 

Emergency Preparedness 

• Provides $300 million to the Department of Military Affairs to respond to the public health emergency. 
• Provides $200 million to the Department of Administration to respond to the public health emergency. 

Health 

• Creates a public health emergency fund for the Department of Health Services.
• Provides $100 million for a new health care provider grant program specific to planning, preparing for and responding to COVID-19. 
• Provides $17.4 million to local health departments. 
• Creates 64 positions within the Department of Health Services’ Division of Public Health.
• Allows DHS to suspend any premium or cost-sharing requirements for childless adults on BadgerCare in order to qualify for enhanced federal Medicaid matching funds related to COVID-19.  
• Exempts the Department of Health Services, during a public health emergency, from the current law legislative review requirements for submitting waiver requests to the federal government, amending the state Medicaid plan or raising Medicaid reimbursement rates.  
• Expands the definition of public health emergency to include toxins or other threats to health. 

Health Care Workforce 

• Allows former health care providers to receive a temporary license to provide services during a public health emergency. This would apply to physicians, nurses, PAs, dentists, pharmacists, phycologists, social workers and other health providers who have practiced within the last 5 years but do not currently have a license. The temporary license would be valid until 90 days following the conclusion of the health emergency. 
• Allows out-of-state health care providers to receive a temporary license to practice in Wisconsin. The temporary license would be valid until 90 days following the conclusion of the health emergency.
• Allows the state to waive licensure fees for physicians, physician assistants, nurses, dentists, pharmacists, psychologists, and certain behavioral health providers. 
• Exempts certain health care provider credentials issued by credentialing boards in DSPS from having to be renewed during the public health emergency. 

Unemployment Insurance

• Eliminates the one-week waiting period for Unemployment Insurance

Voting

The bill contains several provisions related to voting during public health emergencies. Specifically, for elections held during a declared public health emergency, it would: 

• Require elections held during public health emergencies to be held by mail. 
• Waive the state’s Photo ID requirement.
• Waive the requirement that mail-in absentee ballots need a witness signature.
• Allow mail-in ballots to be counted as long as they are postmarked by Election Day.
• Allow voters to register electronically until 5 days before the election.

March 26, ACEP COVID-19 Communications Hub

After hearing a growing number of reports over the past week of emergency physicians being restricted by their hospital from wearing PPE or even being punished for doing so (whether the PPE was supplied by the hospital or personally obtained), ACEP has been in discussions with the Joint Commissions and OSHA advocating for official guidance or clarification from them to hospitals so that your rights to wear PPE are protected. We've been asked to provide them with specific examples of such occurrences, and are therefore reaching out to you here for your help. 

If you've experienced such PPE restrictions or been sanctioned or punished in any way by your hospital for wearing it, please email me with a short description of what happened at lwooster@acep.org.

Please rest assured that no identifying information will be passed along to the Joint Commission or OSHA; all individual physician names and hospitals will be redacted before I send any collected anecdotes on to them. Please note that while first-hand accounts are greatly preferred, if you do know of such actions against a colleague at your own hospital only, these could be helpful to us as well, as long as they contain sufficient detail that you are confident is accurate.

Thank you, and please stay safe.

Laura Wooster, MPH
Associate Executive Director, Public Affairs
American College of Emergency Physicians
O: (202) 370-9298

Dear Fellow Emergency Clinicians,

During this unprecedented time, the Well-Being Committee and Wellness Section, both want to express our appreciation to all who accepted the call to serve in the field of Emergency Medicine. You are not alone in this. Your passion and dedication to provide care for those in need is noticed and recognized, even more today during this critical time.

We are proud to be your colleagues and stand firm in knowing that you are doing the very best to provide care during these difficult times. Though we are overworked, tired, and stretched thin, we continually answer the call to care for our individual communities during the time they need us most. Selflessly, we put ourselves on the front lines; running towards the problems and work tirelessly to find the solutions that allow us to provide the needed care.

As we work through this pandemic, we want to echo that we hope everyone is able to be safe. In trying times such as these, we as Emergency Clinicians, tend to take care of ourselves last. However, the leadership teams are standing with you to ensure that your wellness is not sacrificed.

In this setting, we recognize the need to provide you with resources to assist you during this time of need. In response, work behind the scenes continues to support the provision of care to patients and their communities, while protecting your work environment, health, and well-being.

ACEP is working closely with Federal Government regulators as an advocate for our profession. In doing so, interstate licensing barriers have been changed, protection of liability measures are being developed, and Dr. Bill Jaquis, ACEP President, has met with the White House Administration advocating for PPE and more testing. A new website has been developed to host all clinical resources for our colleagues. In addition, ACEP has many resources to assist you through difficulties.

ACEP Wellness & Assistance Program

The ACEP Wellness & Assistance Program offers ACEP members exclusive access to THREE (3) FREE CONFIDENTIAL COUNSELING OR WELLNESS SESSIONS in partnership with Mines & Associates. The one-on-one sessions are available 24/7 by phone, text or online messaging. 

Counseling sessions can cover everyday issues including stress, anxiety, depression, family issues, drug and alcohol abuse, relationships, death and grief, and more. Wellness coaching sessions are 30-minute phone calls to help you reach your personal wellness goals. NBME board-certified wellness coaches can help you set specific wellness goals and plan for progress checks along the way to help you reach your objectives. This new program is strictly confidential and is free with your ACEP membership.  

• ACEP members, please log in to learn more about the program
• To learn more about membership, read about ACEP's membership eligibility
• Access ACEP's additional physician wellness resources

ACEP ‘Let’s Talk’ Community on EngagED

This online community was specifically designed to create a safe space where peers can discuss ongoing challenges within their roles, ED’s, and life in general. Here, everyone has a voice and a platform where they can reach out to fellow colleagues for advice and encouragement pertaining to the internal and external factors that affect the balance of our wellness.

If you are interested in having a conversation, all you need to do is click here to sign up. 

Our parting thought to you is simple: Even though we are in a crisis, we can still provide compassion and respect for every person who crosses our path.

ACEP Well-Being Committee

• Arlene Chung, MD, FACEP, Chair
• Rita A. Manfredi MD, FACEP
• Alison Haddock, MD, FACEP

ACEP Wellness Section

• Randall Levin, MD, FACEP, Chair
• Randy Sorge, MD, FACEP
• Pamela Ross, MD, FACEP
• Susan Haney, MD, FACEP
• Angelica McPartlin, MD, FACEP
• Kristen Nordenholz, MD
• Matthew Wong, MD, FACEP
• Michelle Caskey, MD

In response to the COVID-19 outbreak, ForwardHealth is temporarily changing certain policy requirements for services delivered through telehealth.

Beginning March 12, 2020, these altered policy requirements will be in effect during, and only during, the public health emergency declared by the State of Wisconsin in Executive Order 72.

Download the ForwardHealth UPDATE for full details.