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). 

A letter to Congressional leadership is circulating with an aim to obtain signatures from several hundred smaller and independent groups from various impacted specialties, providing maximal visual impact and local connections related to surprise billing.  The turn-around is very quick with a planned deadline to sign on by mid-day on Thursday, December 5.

Please share notice of this effort with as many smaller and independent groups as possible. The more sign on, the more compelling in its impact. Each specialty is defining "smaller group" for themselves, since there's such variation on relative group sizes across specialties. For EM, ACEP is requesting groups that serve 10 hospitals or less to sign-on, which is consistent with the EM smaller group letter that went to the Hill in early September.

Download, review and sign your group to the letter at bit.ly/SmallIndGrpLetter.

ACEP is requesting additional action on Out of Network Billing/Surprise Billing. Several Congressional champions (Reps Morelle, Shala, Roe, and Taylor) are circulating a bipartisan letter in the House to leadership to collect Congressional signatures. Anything members can do to encourage more Congressional offices to sign on would be a big help. The turn-around time is pretty tight--signatures are due Dec 5. Please see the letter below, and if you have good relationships with any House offices, please encourage them to sign on.

To sign on, please contact:

Maria Oparil, Legislative Assistant
Office of Congressman Joseph D. Morelle (NY-25)
1317 Longworth House Office Building
202-225-3615 | maria.oparil@mail.house.gov

The Honorable Nancy Pelosi
Speaker of the House
H-232, U.S. Capitol
Washington, DC 20515

The Honorable Kevin McCarthy
House Minority Leader
H-204, U.S. Capitol
Washington, DC 20515              

Dear Speaker Pelosi and Leader McCarthy,

Thank you for your leadership on addressing the unfortunate practice of "surprise billing," which leaves patients with unexpected charges after they receive emergency or out-of-network medical care. Many of our own constituents have been left helpless in disputes between health care providers and insurance plans, saddled with untenable out-of-pocket costs after receiving potentially life-saving care.

As you know, ongoing bipartisan, bicameral negotiations continue with the goal of addressing this critical issue in a larger legislative package before the end of this year. We are supportive of these efforts, and unequivocally believe Congress should complete legislation that will hold patients harmless in unplanned out of network care. However, we also believe it is critical that this legislation includes a balanced independent dispute resolution system between providers and insurers. We are committed to ensuring that our local doctors, hospitals, and communities are not disproportionately impacted by an approach that fails to include true measures of accountability.  

Patients, doctors, and hospitals are relying on us to address this issue without harming the quality of our health care system or hurting our local economies. A benchmarked, one-size-fits-all, approach would hinder network adequacy and access to care, particularly in rural and underserved areas. In contrast, instituting a neutral, independent review process after direct negotiations between the parties can lower health care costs without massive disruptions to the health care market. 

An accessible and meaningful appeals process would also ensure that the playing field is not tilted toward health insurance companies at the expense of our local hospitals or doctors, especially those who are already in-network, while still ensuring that the patient is out of the middle and not financially responsible for a surprise medical bill.

We look forward to working with you to end the practice of surprise billing through balanced legislation. This is a tremendous opportunity to ensure that no American family is faced with an unaffordable bill for unexpected out-of-network care ever again, without threatening the quality of care they receive from physicians and hospitals across the nation or increasing the cost of care for anyone.

Thank you again for your work to address this pressing issue-we are confident we can achieve a fair result to protect patients, providers, and insurers.

Sincerely,

Joseph D. Morelle
Donna Shalala
Phil Roe
Van Taylor

Lisa Maurer, MD
WACEP Legislative Chair

Wisconsin is one of many states that has received federal approval to change our Medicaid program, called a waiver project, in some substantial ways that will affect our patients in the emergency department. 

There are several characteristics of the changes that will affect our patients.  Namely, there will be a new work requirement for some Medicaid enrollees in order to maintain their eligibility for coverage, new Medicaid coverage for inpatient substance use disorder treatment, and some mandatory screening for substance abuse disorders.  Most impactful for our patients and workflow, the waiver also contains a new potential for copayment for Medicaid patients for ED visits.  As these new laws are implemented in Spring of 2020, it is our responsibility as advocates for our patients to ensure that we maintain protections under the Prudent Layperson Standard. 

This waiver project starts a new $8 copay for ED patients who receive care in the ED for non-emergencies as of February 2020.  This is not a new concept, whereby fourteen other states already charge copays to Medicaid enrollees who receive non-emergent care in the ED.  A minority of states have even gotten federal approval to charge more than the historic maximum of $8 copayment.  The real risk to emergency patients lies in the variance among the states in how they define a “non-emergency,” and what direction Wisconsin moves in this regard.  Scarily, some states’ Medicaid departments chose to define non-emergency based on final diagnosis.  Choosing to define non-emergency in this way is a clear violation of the Prudent Layperson (PLP) Standard as defined by federal law, which protects patients who present with symptoms concerning for emergency, even though ultimately, they might not be diagnosed with a life- or limb-threatening condition. 

Thankfully, the Wisconsin Department of Medicaid has chosen to define emergency (and therefore non-emergency) based on the PLP.  What’s more, this definition of non-emergency is as determined by the physician caring for the patient.  Hence, our judgement is paramount, as it should be, as we are the ones who have the best sense of the patient’s concerns at the time of presentation.  Of note, in Wisconsin, this copayment will be applied to the facility charges, not the professional fee charged by the physician.  Therefore, each hospital system will need to determine what the workflow will be to assess for non-emergency and then somehow alert the registration staff so they can apply the copay to the patient’s cost-sharing responsibilities.  In other states that have implemented a copay for non-emergent services in the ED, actual utilization of the copay by the hospitals has been low.

In the coming months, DHS will be rolling out pre-implementation outreach and communication activities about the program.  Thank you in advance for making sure the implementation of this copay makes sense for emergency physicians and our patients at your hospital.

Your Medicare reimbursements will be cut unless Congress acts before the end of the year. Help us urge Congress to take action to improve MACRA and to stop the upcoming cuts to ensure Medicare patients continue to have access to high quality emergency care. Click here to learn more and send a message to Congress today.

Recently, CMS released its final 2020 Medicare Physician Fee Schedule (PFS) rule that includes changes that will affect Medicare physician payments and MIPS starting Jan. 1. ACEP's Regs & Eggs blog breaks down the final rule, emphasizing policies that apply to EM.

November 20, Wisconsin Health News

Gov. Tony Evers signed into law three health-related bills Tuesday. The measures will:

• Allow pharmacists with appropriate training to administer vaccines to young children. 
• Make technical changes so that EMS providers can apply for a Medicare pilot program. 
• Create a grant program to update 911 service infrastructure. Grants could go to staff training, equipment updates and consolidation of public safety answering points.

Evers said in a statement that the measures will help "promote safer and healthier communities in Wisconsin."

ACEP has developed new resources specifically to benefit small groups.  A new Small Group Advisory Group is a team of seasoned small group members who have volunteered to support the small group practice model by sharing their expertise with other small group members who are looking for guidance or wanting to tap into the experience of others as they face various challenges unique to small groups. If your small group is dealing with an issue that you’d like to ask the advisory group about, just send us an email at smallgroups@acep.org.

ACEP has also developed an online community for small group members to share ideas and discuss issues. To joint that group and see the other small group resources available, go to www.acep.org/smallgroups.

ACEP’s new first responder training program, Until Help Arrives, was officially unveiled during ACEP19 in Denver with a series of events to highlight how emergency physicians can positively impact their communities by conducting training sessions to teach the public basic life-saving skills. Learn more.

New ACEP member benefit now available

ACEP members care for their patients 24-7-365… but are you are taking care of yourself?  At ACEP19 in Denver, ACEP launched the ACEP Wellness & Assistance Program., a service available to all members that provides access to three confidential counseling or wellness coaching sessions, free of charge.

Call 1-800-873-7138 to register and receive support whenever, however iyou need it.

• Counseling is available 24 hours a day, 7 days a week
• Sessions can cover stress, anxiety, depression, family issues, drug and alcohol abuse, relationships, death, grief, and more
• The service is strictly confidential and can be scheduled face-to-face, over the phone, via text, or through online messaging 
• Wellness coaching sessions are 30-minute phone calls to help reach your personal wellness goals which can include weight loss, nutrition, healthy habits, stress, caffeine reduction, injury recovery, relationships, sleep, smoking cessation, and more

Members may choose three free sessions in any combination of counseling and wellness coaching, up to the session limit.

An additional resource is available at a nominal fee of $15/year that will help members manage legal and financial issues through ACEP’s partner, Mines & Associates. Participants will have unlimited access to an extensive online resource library and unlimited 30-minute in-person consultations for each individual legal or financial matter and a 25% discount on legal and financial services within the Mines network.