WACEP President's Message, January 2020
Ryan Thompson, MD, FACEP

A recent tragic case which occurred in Milwaukee is garnering national media attention. You can read the full story here, but the broad strokes are that a young woman 9 months status post a stillbirth presented to an ED with chest pain, left after waiting 2 hours, and subsequently collapsed and died a short time later -presumably related to postpartum cardiomyopathy. (If you want to brush up on peripartum care, our friends at Wisconsin-ACOG have provided this great reference). Ultimately, this woman’s death was heartbreaking and very likely preventable. 

The immediate and predictable media reaction was to blame the ED for the wait times she experienced. I do not know the physicians who were working at the time, but I’m confident that if the patient had stayed in the ED that she would have received the life-saving care that she needed. To lay the blame solely at the feet of these physicians and other ED staff is unfair and misses the whole host of failures that contributed to this woman’s death. Fortunately, ACEP’s Dr. Howie Mell was able to provide a small amount of context for the story, pushing back against the failed ED narrative.

As emergency physicians, we would like nothing better than to have EDs with enough staff, space, and resources to see every patient with little or no wait times at all. Unfortunately, this is far beyond our control. Innumerable forces contribute to ED crowding: a woefully overwhelmed mental health system that leaves patients boarding for days in the ED, inadequate Medicaid funding which leads to a lack of primary care availability and budget shortfalls in EDs, hospital system failures to decompress ED boarding through creative surgical scheduling and inpatient hallway beds, and many more.  

I originally joined the WACEP board to head up the planning of the annual Spring Symposium (this year occurring April 15-16th in Madison, sign up here), but I have come to increasingly recognize the value WACEP offers in addressing the systemic issues we struggle with every day. National ACEP simply doesn’t have the resources or awareness of state-level problems to intervene effectively, but by working on the local level we can do so much. Dedicated members of our board monitor for state legislation relevant to EM so we can provide our perspective to legislators, sit on a multi-specialty task force dedicated to fixing ED psych boarding, have designed opiate-alternative guidelines to attenuate the opiate crisis, meet with state regulators to push for increased Medicaid reimbursement for EM so we can recruit more docs, and help craft position statements that EM physicians can use to advocate for change within their own institutions. I am constantly humbled by the passion and dedication displayed by our membership.

In the hustle and bustle of our lives it can become all too easy to lose sight of the challenges that face our specialty and our patients on a daily basis. WACEP has been working for years to give EM docs a voice so we can advocate for ourselves and our patients. As your new president, I will strive to continue that mission, but we need your help as well. Please reach out to us if you have an issue you are passionate about, tell an EM friend about the work we are doing on their behalf, and contribute to our PAC so we have the clout to push for legislative change in the state. WACEP is nothing without its members, so please help us help you!

Nathan Houdek was appointed deputy commissioner of insurance in January of 2019. He's chairing the Governor's Task Force on Reducing Prescription Drug Prices and is vice chair of the Group Insurance Board.

Mr. Houdek will detail the work of both groups at a Wisconsin Health News Newsmaker Event on Monday, February 10 at the Madison Club in Madison. He'll also discuss the future of the ACA market, protections for people with pre-existing conditions, surprise medical bills and more.

Learn more and sign up here.

January 21, Wisconsin Health News

A new proposal would create a pilot program in western Wisconsin so law enforcement wouldn’t have to transport those in mental health crisis across the state.

The bill would require that the Department of Health Services reimburse hospitals located in Barron, Burnett, Dunn, Pierce, Polk, St. Croix and Washburn counties for housing patients for emergency detention.

Bill author Rep. Rob Stafsholt, R-New Richmond, said at an Assembly Committee on Mental Health hearing last week that those in crisis in his district are often transported to Winnebago Mental Health Institute in Oshkosh.

“It’s a roughly five-hour trip, often in handcuffs, across the state while you’re in a mental health crisis,” Stafsholt said. “And the reason we do that is there’s not access to those types of facilities in northwestern Wisconsin.”

Participating providers would be able to opt into the program. DHS would cover up to 80 percent of the difference between the hospitals' average cost per bed per day and the average rate received per bed per day. Counties would have to pay the remainder.

St. Croix County Sheriff Scott Knudson said that emergency detentions can impact law enforcement staffing, calling it one of their more “draining duties." Any additional resources would help, he said.

Sarah Diedrick-Kasdorf, Wisconsin Counties Association deputy government affairs director, said the plan isn’t specific on how much of the difference DHS would cover, making it difficult for counties to budget.

She questioned how the bill would relate to federal law and county contracts for emergency detention services.

“These are all things we can sit down and talk about and come to some sort of resolution on,” she said. 

Nominations are now being accepted for the WACEP 2020 Distinguished Service Award.

This award annually recognizes a WACEP member in good standing who has demonstrated exceptional commitment and service to the organization, and/or made a significant contribution toward the advancement of emergency medicine in Wisconsin or beyond.

If you know of an emergency physician who is deserving of this award, submit your nomination today.

The deadline to accept nominations is March 1^st and the selected award recipient will be recognized during the WACEP Annual Spring Symposium.

Interested in taking a deeper dive into federal and state legislative issues important to emergency medicine? Plan to attend ACEP’s Leadership and Advocacy Conference (LAC), April 26-28, 2020 at the Grand Hyatt in Washington DC.

At LAC, you will learn tips and tools to advocate on issues at both the federal and state levels, hear updates on proposed legislation that could impact you and your patients, and have an opportunity to meet with your federal legislators in person. 

The Wisconsin Chapter, ACEP has earmarked funds to support travel and conference registration expenses for up to four residents and four members in practice. Simply submit your brief statement of interest no later than January 31^st explaining your why you’d like to attend and what you hope to do with information you obtain at the conference.  Notice of funding will be made by mid-February. 

Jeffrey Pothof, MD, FACEP
WACEP President

Dear WACEP members,

As we close out yet another year it seems a brief reflection of the previous year is the natural starting point as we start to focus on what we aim to accomplish in the upcoming year.  2019 was a busy year for Wisconsin emergency physicians. 

Top of my mind is that we lost a friend and colleague in Eric Jensen who passed away after a courageous battle with cancer.  His enthusiasm and passion to leverage his skill and talent to improve the lives of others was self-evident in the work and guidance he provided our organization and will not be forgotten.

Legislatively there were a multitude of issues we worked on to ensure patients had access to the great care all of you deliver while advocating for fair remuneration for our work while ensuring patients continue to receive high quality and safe care.  Most recently the call went out to contact your representatives about an out of network balance billing (insurance network inadequacy) legislation that would have been attached to the year end funding package.  This legislation was incomplete and unfavorable.  As of this writing it appears your engagement and advocacy was able to help us and others concerned about the impact of this language on patients put a hold on this so that all stakeholder have a chance to be heard and all implications understood.  Thank you to all of you who took the time to contact your legislators in Washington as your efforts were not in vain.

We continue to be engaged in proposed legislation that looks to address the mental health crisis that burdens our emergency departments and inhibits out ability to provide the care we think Wisconsin citizens deserve in our emergency departments.  We also continue to closely follow the CARES Act and have not slowed our focus on drawing attention and action to Medicaid reimbursement rates for emergency physicians as Wisconsin continues to maintain the record of worst in the United States.

We look forward to another exciting Doctor Day where your voice can be heard at the State Capitol in Madison. WACEP will be having a policy primer the evening prior, Tuesday,  January 28, which I promise will be informative and a great way to meet other emergency physicians passionate about our specialty. The main event will take place on Wednesday, January 29 before. For more information and to register, visit www.WIDoctorDay.org/schedule.

This spring will bring another WACEP Spring Symposium to be held in Madison.  The committee has secured top talent in emergency medicine to come speak, and I encourage you to drop by the research forum to see how impressive our EM residents in the state are as they look to advance emergency care.  You can learn more or register by visiting www.WisconsinACEP.org/WACEP2020.

As my time as WACEP president is drawing to a close I look forward confidently knowing that committed emergency physicians will continue to step forward to meet the challenges we face as a specialty and promote the interests of the patients whose lives we have the privilege of being part of.  Dr. Ryan Thompson, the incoming WACEP president, is a strong leader and certain to advance our organization.

In closing I can’t express how thankful I am for a WACEP board of intrinsically motivated and engaged colleagues and friends. Kudos to Badger Bay and Sally Winkelman for their commitment and leadership to our organization, and to all of you, the emergency medicine providers in our state who every hour of every day are there for anyone who needs our help without caveat or exclusion.  Thank you for everything you do.

~Jeff 

December 12, Wisconsin Health News

An Assembly committee plans to vote next week on a bill that would make it clear that law enforcement agencies can contract with others to transport those in mental health crisis for emergency detention.

The plan also directs the Department of Health Services to pursue federal approval to reimburse transport for Medicaid recipients.

Rep. Mark Born, R-Beaver Dam, said some agencies already contract for emergency detention transports. But the majority don’t because their attorneys feel that state law may not allow it.

“We want to make it clear that this is an option for local governments to work with third-party vendors, ambulance services or other law enforcement agencies to help in this process,” Born told members of the Assembly Committee on Mental Health Tuesday.

Law enforcement testified in support of the plan. Dodge County Sheriff Dale Schmidt said transferring those in crisis is time-consuming.

“We have an epidemic in the state of Wisconsin with emergency detentions,” Schmidt said. “My opinion, and I think the opinion of many law enforcement executives is that emergency detentions by far take up the most time of any incident that we deal with on a daily basis.”

Schmidt said he’s waiting for the passage of the bill before contracting for emergency detention transports.

Disability Rights Wisconsin Milwaukee Officer Director Barbara Beckert wrote in testimony submitted to the committee that they respect the intent of the bill.

But the plan doesn’t provide criteria for providers like requirements that they are trained on safety, mental illness, trauma and other topics.

“Currently the law enforcement personal who provide transport are public employees and as such have greater accountability,” Beckert wrote. “It is unclear how accountability would be addressed for third-party contractors. Use of a third party potentially leaves the door open to abuse.”

Born said it’s the responsibility of law enforcement agencies to vet their contract providers and to have solid contracts.

The committee is scheduled to vote on the measure next Tuesday. 

December 10, Wisconsin Health News

A new legislative package aims to support rural emergency medical service providers.

Sen. Howard Marklein, R-Spring Green, began circulating the measures last week for co-sponsorship with Sen. Steve Nass, R-Whitewater, and five GOP Assembly lawmakers.

Marklein said in a statement that the bills are based on four summits he held with local EMS volunteers this fall.

“This package of rural EMS legislation is a small step toward supporting our local, rural volunteer EMS providers,” Marklein said in a statement. “It removes some obstacles, improves state-level regulation and makes the funding whole.”

One plan would provide an additional $239,800 in state money annually to the Funding Assistance Program, which gives ambulance service providers the only state money they receive. The increase will allow EMS services to buy equipment and compensate members for training.

Another bill makes a series of changes, like clarifying a recent state law allowing an ambulance service provider to upgrade its service level to the highest level of an EMS practitioner staffing the ambulance. The plan would clarify that a practitioner can perform up to their certification, but the ambulance doesn’t have to be stocked to that highest level.

The bill also allows ambulances to be staffed with one emergency medical technician and a driver with CPR certification for low-risk transports, like transporting patients between nursing homes and hospitals for dialysis.

Another part of the bill streamlines the process of applying for the Funding Assistance Program. And it also bars EMS departments from prohibiting their employees or volunteers from working with another department.  

Marklein said he was "shocked" to hear that some large EMS departments bar their employees from volunteering for volunteer departments.

“They say that they worry about the person getting hurt," he said in a statement. "I would wager that a person is more likely to get hurt playing church league softball than dedicating their considerable skill, talent and knowledge to saving the life of their neighbors.”

A final bill would make passing the National Registry of Emergency Medical Technicians exam optional for emergency medical responders, the lowest EMS licensure level in the state. Individual departments would be able to decide whether the test is required.

Responders would have to complete a DHS-approved training course and pass all tests and hands-on learning experiences to receive a license.   

Jeff Pothof, MD, FACEP
President's Message, November 2019

Dear Wisconsin Emergency Physicians,

I wanted to use this month’s column to update you on our participation in the 2019 Annual ACEP Council Meeting that occurred late last month.

For those that may not be aware ACEP’s annual council meeting is the process by which the college determines both it’s leaders for the next year as well as the direction of the college by listening to and adopting resolutions that direct the board of directors as to what they should be committing resources to and working on.  The council is made up of councilors from every state.  Each state has councilors allocated based on total state chapter members.  The council also includes representation from the college’s sections as well as EMRA.

This year our Wisconsin Chapter co-authored two resolutions.  The first resolution was aimed at increasing awareness of implicit bias among physicians and requiring ACEP to create and make available online implicit bias training free to all ACEP members.  The second resolution we co-authored was aimed at requiring ACEP to develop a policy statement in favor of physician salary and benefit package equity and transparency.  Both resolutions were adopted by the council.  The WACEP board became involved with these two resolutions based on recent data that continues to show disparities in medicine especially as it pertains to compensation of women and minorities.  We feel this issue is important to providers practicing in Wisconsin and were please that the council agreed to devote more attention and training of providers on this issue.

There were many other important discussions this year on an array of topics from private equity companies acquiring medical practices and the impact on the practice of emergency medicine to ACEP supporting emergency physician’s compensation during contract transitions.  We also adopted a resolution that would require ACEP to issue a statement that strongly supports vaccination by any person detained by ICE or ICE contracted facilities and a resolution that opposed legislation requiring reporting of naloxone prescriptions to state PDMPs. 

This year the council elected the president elect Dr. Mark Rosenberg as well as the college’s new board members and council vice speaker.

If you are interested in learning more about ACEP council I encourage you to visit this site: https://www.acep.org/how-we-serve/council/.

If any of you are interested or have questions about how your Wisconsin chapter interfaces with national ACEP, or desire to become more involved in setting the direction of our specialty and improving our professional lives please reach out to myself or any of our board members “HERE” (insert email link).  Likewise, please share with colleagues of your group who are not yet ACEP members the work the college does to preserve and promote our specialty.  We’d be happy to discuss ACEP council or any of our other initiatives we are working on to improve our specialty with any of you.

AJ Wilson and Greg Hubbard
Hubbard Wilson & Zelenkova Government Relations

Legislative News

The state legislature had its most active period thus far in the 2019-2020 legislative session during the fall months.   Several bills of interest were introduced or saw action.  Other bills continued to lay dormant. 

AB 267/SB 249 creates an additional system of licensure for advanced practice registered nurses (APRNs), has received no legislative action.   WACEP is registered opposed to this bill and there is no expectation it will be moving forward this session. 

AB 575/SB 515 changes the relationship between physician and physician assistant to that of collaboration rather than supervision. This bill transfers licensure and regulation of PAs to a newly created Physician Assistant Examining Board and makes changes to licensure requirements.  WI Medical Society is working against this bill.  The Wisconsin Hospital Association is working for it.  WACEP has not taken a position to date.

AB 329/SB 313 addresses the issue of “surprise billing” for patients brought to an out of network ER.   This bill does not appear to be moving this session. Insurance interests have registered “undisclosed” but it is widely known that they oppose.  WACEP should be sure it agrees with how the bill addresses the issue.   Federal action is still a slight possibility. 

AB 526/SB 520 requires all continuing medical education to include two hours of instruction on suicide prevention.  The bill was amended to require it only once for a physician.   The bill passed the Assembly but no action thus far in the Senate. WMS is opposed. 

AB 573/SB 540 – “Red Flag Law” – this bill covers two subjects – Extreme Risk Protection Orders and Universal Background Checks for gun purchases.   The Governor called a special session to take up such legislation but the Legislature did not move forward.  This bill, that was introduced prior to the special session call, is authored by Rep. Sargent and Sen. Taylor.  No legislative action is expected. 

The Emergency Psych taskforce met with the Attorney General’s office in September and led a break out session at the Attorney General’s Summit on Emergency Detention on Medical Clearance Process Improvements on October 31^st.   The group (Dr. Repplinger and psychiatrist Dr. Thrasher) also met with WI Sheriffs Association to discuss shared issues and concerns.   The Sheriffs Association shared a bill on private transport that has since been circulated for cosponsors (LRB 1247).  This bill is authored by Rep. Mark Born (R) has yet to be introduced.

AB 443/SB 405 creates a $15 million grant to an Eau Claire County hospital to fund an expansion of psychiatric bed capacity.   This bill provision was included in the budget that passed the legislature but was vetoed by the Governor.  Further, legislative republicans attempted to override the governor’s budget veto but failed.  If this bill is passed, it will likely be vetoed again.

AB 433/SB 392 requires DHS to award grants totaling $5 million to regional crisis stabilization facilities for adults based on criteria established by DHS established in five regions of the state.  While this bill has bipartisan support, it is unlikely to move this session. 

We continue to work towards the goal of increased Medicaid reimbursement rates.  At present we are scheduling a WACEP meeting with the Division of Medicaid Services that will hopefully take place in December.

Political News

A special election will be held for the 7^th Congressional District seat vacated by Sean Duffy (R).  The seat leans republican and because it will have to be defended again in November 2020, democrats have not made it a priority despite success in recent special elections.   The primary will take place on December 30 and the general is scheduled for January 27^th.   On the Republican side, current State Senator Tom Tiffany, Jason Church, a retired Army captain and current staffer for US Senator Ron Johnson, and Michael Opela, a hobby farmer, will face off.   On the Democratic side, Lawrence Dale, a businessman who actually lives in Michigan and Tricia Zunker, the Wausau School Board president and associate justice in the Ho Chunk nation will compete.  

In the 5^th Congressional District to replace the retiring Jim Sensenbrenner, current Senate Majority Leader Scott Fitzgerald appears to have cleared the field in this heavy GOP district. (This is also significant because it pretty much guarantees there will be a new Senate Majority Leader next session.)  Fitzgerald at present is expected to face Tom Palzewicz, a Waukesha County democrat. 

The most significant political news on the local level at present is that Chris Abele announced he will not run for reelection as Milwaukee County Executive this spring.   Several candidates have announced their interest or intention to run including: David Crowley (current state representative), Chris Larson (current state senator), and Theo Lipscomb (Milwaukee Co. Supervisor and Board Chair).