After weeks of speculation and media coverage, the Republican-controlled Legislature passed a number of bills in a “lame duck” Extraordinary Session.  All bills were passed on party-line votes, and while Governor Walker has signaled his willingness to sign the legislation, he has provided no details.

Evident by the media reporting on the Extraordinary Session, these proposals were by and large forgone conclusions; they were destined to pass regardless of outside support or opposition.  While the Senate Republican caucus, in particular, was divided on key items in the various bills, ultimately they were able to make amendments sufficient to secure votes for final passage of the legislation.  (Though unrelated to healthcare, the controversial proposal to change Wisconsin’s presidential primary election date was not taken up.)

Of particular interest to WACEP and other health organizations is Senate Bill 886, which makes a variety of changes to how the Department of Health Services (DHS) can make or recommend changes to the Medicaid program.  In advance of yesterday’s votes, and to no avail, a group of 20+ healthcare organizations and systems (led by the Wisconsin Medical Society and Wisconsin Hospital Association) wrote a joint letter to the Legislature expressing concerns about the breadth of SB 886, the lack of time for a full analysis of the legislation and the potential for unintended consequences.

Among other things, the original SB 886 solidified in statute items contained in the most recent Medicaid Waiver approved by the Federal Government related to Wisconsin’s Medicaid/BadgerCare coverage for childless adults, including new work and premium requirements for eligibility.  Among those items, the Waiver contained a new $8 copay for non-emergency visits to Emergency Rooms – quoting SB 886’s official Analysis:

DHS must charge recipients an $8 copayment for nonemergency use of the emergency department and must comply with other requirements imposed by the federal DHHS in its waiver approval effective October 31, 2018. The requirements in the bill must end no sooner than December 31, 2023, and the bill prohibits withdrawal of the requirements and DHS from requesting withdrawal, suspension, or termination of the childless adults demonstration project requirements before that date unless the legislation has been enacted specifically allowing for withdrawal, suspension, or termination.

In addition, the original SB 886 limits DHS’s ability to make other changes to Medicaid programs including changes to provider reimbursement – again, quoting SB 886’s official Analysis:

This bill prohibits DHS from submitting an amendment to the state's Medical Assistance plan or implementing a change to the reimbursement rate for or making a supplemental payment to a provider under the Medical Assistance program without first submitting the proposed state plan amendment, rate change, or payment to JCF. If the state plan amendment, rate change, or payment has an expected fiscal effect of less than $1,000,000 from all revenue sources over a 12-month period following the implementation date of the amendment…

Ultimately, to secure agreement on SB 886, the Senate adopted (and the Assembly concurred) an amendment raising the original $1,000,000 fiscal effect to $7,500,000.  In other words, DHS may still make changes that cost less than $7,500,000 for the immediately following 12-month period without Legislative approval.

Nicole Forbord, PA-C is the winner of the FitWell contest, WACEP's most recent wellness initiative. Nicole, a PA with Emergency Medicine Specialists, SC who contracts for Ascension, posted her activity and fitness images on WACEP's social media accounts during the summer. She was selected as the winner in a random drawing from among contestants, and has been awarded a WACEP branded fleece and $200 towards a gym/club membership of her choice. Congratulations Nicole!

Eric Jensen, Jensen Government Relations, LLC

Searching for a word to summarize last night’s Wisconsin state elections this morning (including early this morning as I obsessively watched the final results trickling in!), all I could come up with was:  Wow.

Neck and neck all night, at about 1:00 am came an announcement that nearly 50,000 absentee ballots from Milwaukee County were still being counted and would be reported shortly.  With the Governor and Attorney General races very close at that point, the announcement of those ballots yet to come from the traditional Democratic stronghold signaled that both races were likely over, and indeed they were.  Those ballots gave Tony Evers a nearly 30,000-vote lead over Governor Walker, and gave Josh Kaul a nearly 15,000-vote lead over Attorney General Schimel.  Despite possible recounts, barring any unanticipated irregularities most insiders agree those totals will be sufficient to sustain victories for both Evers and Kaul.  (Of note, Democrats also won all three other statewide races – US Senate, Secretary of State and State Treasurer.)

While the statewide races were swept by Democrats, with results that were quite close to the closely watched Marquette Law School poll results leading into Election Day, the real “wow” factor came through in the races for State Senate and State Assembly. 

Democrats entered Election Day optimistic that high turnout for the statewide races would help their causes in both the State Assembly and Senate.  In the end, it did not.  In fact, Assembly Republicans did not lose a single seat – including several seats they hold in what have long been viewed as traditionally strong Democratic areas – and will maintain a 64-35 majority.  Meanwhile, Senate Republicans, viewed by many as quite vulnerable after losing two GOP-held seats during Spring Special Elections, actually expanded their majority by holding all of their seats and winning back the 1st Senate District up in Door/Kewaunee Counties they had lost during the June Special Election.

Drawing conclusions from all of this will be an interesting political and social science discussion for some time to come, but what the numbers showed is fairly simple:  the very high concentration of Democratic voters in Dane and Milwaukee Counties voting in large numbers is sufficient to win statewide races (borne out during this Spring’s Supreme Court race as well).  Meanwhile, there remain more areas of the state where Republican voters appear to outnumber Democratic voters by smaller percentages (compared to the Democratic advantages in Dane and Milwaukee Cos.) allowing Republicans to out-perform their statewide candidates by just enough to win the smaller Assembly and Senate districts and control the Legislature.

The Governor, Attorney General, State Senators and State Representatives will be sworn in the first week of January, and action will commence soon after.  What the dynamic will be between the new Governor and the existing Legislative majorities will be interesting to see.  Also interesting, will be watching the dynamic between the two Republican majorities that did not see eye-to-eye on several major policy areas last session.

Eight hours of training on medication-assisted treatment (MAT) is required to obtain a waiver from the Drug Enforcement Agency to prescribe buprenorphine, one of three medications approved by the FDA for the treatment of opioid use disorder. Providers Clinical Support System (PCSS) offers free waiver training for physicians to prescribe medication for the treatment of opioid use disorder. PCSS uses three formats in training on MAT:

• Live eight-hour training
• “Half and Half” format, which involves 3.75 hours of online training and 4.25 hours of face-to-face training.
• Live training (provided in a webinar format) and an online portion that must be completed after participating in the full live training webinar

Trainings are open to all practicing physicians. Residents may take the course and apply for their waiver when they receive their DEA license. For upcoming trainings consult the MAT Waiver Training Calendar. For more information on PCSS, click here. Please email Sam Shahid at ACEP for more information on MAT training.

October 18, STAT

When I walk through my hospital’s emergency department, I’m sometimes overwhelmed by the number of people languishing there as they wait for help with a mental health issue, like the woman clutching her chest as if she’s having a heart attack but is really suffering from a panic attack. It’s her third time here in a week.

She is just one of the hundreds of patients who will be admitted this year to my emergency department in the Mat-Su Regional Medical Center in Palmer, Alaska, experiencing psychiatric emergencies.

Many stay in the emergency department for hours; some even stay there for a few days. The practice, called psychiatric boarding, occurs when an individual with a mental health condition is kept in an emergency department because no appropriate mental health care is available. It’s rampant around the country.

Millions of Americans with mental health issues are not getting the care they need. It’s a crisis so profound that it is overwhelming emergency departments and the entire health care system. The causes? Too few outpatient resources and inpatient treatment options for mental health issues; separate systems for treating mental health and physical health; and a shortage of specialists able to respond to patients in the midst of mental health crises, to name just a few.

I believe hospitals can curb this trend by doing a few key things, beginning with improved collaboration.

The statistics are staggering: Nearly 1 in 5 U.S. adults — about 44 million — experiences mental illness in a given year, a number that is certain to increase. And it comes at a time when the demand for mental health professionals is outstripping the supply. For psychiatrists alone, a 2017 report published by the National Council for Behavioral Health estimates the shortage will be between 6,100 and 15,600 practitioners by 2025. That same report points out that lack of access to psychiatric services in hospital emergency departments is especially problematic. 

Read full article.

Eric Jensen, WACEP Lobbyist

In less than three weeks, on Tuesday, November 6^th, Wisconsinites will go to the polls to vote in races for the U.S. Senator, Governor, 17 of Wisconsin’s 33 State Senate districts, all 99 of Wisconsin’s State Assembly districts and a variety of local elections and referenda.  Between now and then, we’ll be inundated with radio and TV ads, campaign flyers (and maybe candidates) at our front doors, political “robocalls” and media reports about candidates, races, polls and predictions.  ‘Tis definitely the season!

Political insiders watch political polls like hawks, hoping to glean from them predictions of election outcomes.  But in 2016 we learned a powerful lesson about political polling in modern times – not one national pollster predicted victory by President Trump, either in Wisconsin or nationally.  More and more, people of different demographics are moving from landlines to mobile phones increasing the difficulty of getting a representative population sample in a poll.  That simple fact, along with how questions are asked, who asks the questions and a variety of other factors increase the difficulty of getting statistically accurate poll results.

For WACEP, our attention is primarily on the races for Governor, State Senate and State Assembly as the outcomes of those races can have a profound effect on health care policy making for the next two years and beyond.

The Governor’s race is the one most discussed in the state’s media.  Governor Walker has served two four year terms, yet won election as Governor three times.  Tony Evers, his Democratic challenger, has served as Wisconsin’s State School Superintendent, himself winning multiple statewide elections.   As divided as Wisconsin’s voting population has become, and both candidates holding strong name recognition throughout the state, this race figures to be close to the end.

In the State Senate, after Democrats won two previously Republican-held seats during Spring Special elections, Republicans hold a 18-15 majority heading into November.  Democrats are focusing on two key Republican seats (one in the Appleton area, one in the large rural district west of Madison) in an effort to win the majority.  But Republicans see opportunities of their own to win back one of the Special Election seats in the 1^st Senate District in Door/Kewaunee County, as well as a far northern seat that includes Superior, Ashland and Rice Lake.

In the State Assembly, Republicans hold a far larger 64-35 majority.  To win the majority, Democrats must hold all their current seats and win 15 more.  It’s a daunting challenge, and while anticipated high voter turnout in places like Democratic stronghold Dane County may have a big impact on the Governor’s race, it won’t affect Assembly races in central and northern Wisconsin.

The outcomes of these 2018 elections will come down to voter turnout for both parties – throughout the state, not simply in party stronghold areas.  As you see polls being reported in the media, remember 2016.  Elections aren’t won by polls or pundits, they’re won by votes – so get out and cast yours on November 6^th!

WACEP President's Message, October 2018
Lisa Mauer, MD

Emergency physicians do not typically think of cannabis as pertinent to our typical clinical practice.  This is demonstrated by the fact that ACEP has not adopted any of 14 resolutions (both in favor of and in opposition to recreational marijuana) that have been proposed in the last 10 years.  On the other hand, our practice is, in some ways, is defined by the failures of the healthcare system, from chronic intractable conditions in need of a novel treatment to the unanticipated side effects of increasing exposure to a recreational substance.  We may get pulled into this debate on the national level.  

But what about at the state level?  Marquette Law School poll done in August showed that 61 percent of Wisconsinites say marijuana should be fully legalized and regulated like alcohol while 36 percent oppose legalization.  Advisory referendum questions on marijuana will be included on ballots in 16 different counties and 2 cities next month.  With all of this local action, I was recently faced with the question of “What would you say to a reporter who asked what emergency physicians of Wisconsin think about marijuana?”  While our state chapter of ACEP does not form individual policy apart from our national organization, it is important that our chapter reflects our local environment.  I believe there are likely low-hanging fruit that would reflect commonalities among WI emergency physicians’ opinions on how we could best represent our patients in this public debate.  Read below for background information on what pertinent policy exists, and then email me with how you think emergency physicians in Wisconsin should publicly regard marijuana for recreational use, medical use, research, or other!  

Recreational use: Nine states and the District of Columbia have legalized recreational use of marijuana for adults over the age of 21.  Twenty-two states and the District of Columbia have decriminalized small amounts of marijuana.  AMA has policy on recreational use or legalization of marijuana:

• Initially established in 1997 and modified several times until it was reaffirmed last year, the AMA urges legislatures to delay initiating the legalization of cannabis for recreational use until further research is completed on its consequences.
  
• Advocates for point of sale warnings and product labeling regarding potential dangers of cannabis-based product use during pregnancy and breastfeeding.
  
• For states that have already legalized cannabis, they should take steps to regulate it.  If taxed, a substantial portion of the revenue should be used for public health purposes.
  
• Public health based strategies, rather than incarceration, should be used to handle individuals possessing cannabis for personal use.
  
• Supports continued educational programs on substance abuse to include marijuana
  

It is notable that ACEP does not have policy on legalization of recreational marijuana.  This also includes a proposal last month in San Diego at ACEP18 Council to approve policy language mirroring the first AMA policy listed above.  Discussion on the ACEP council floor in opposition to policies regarding recreational marijuana often centers around the idea that recreational marijuana is not within the scope of emergency medicine, although emergency physicians may have opinions on recreational marijuana as individuals.

Medical use: Thirty-one states have legalized marijuana for medicinal use.  In addition, 15 other states, including Wisconsin, only allow use of low THC, high cannabidiol products for limited medical conditions such as seizure disorders.

Much of existing AMA policy about medical use of marijuana focuses on the basis of physician-patient relationship being free from interference by the government:

• Cannabis products for medicinal use should be considered for approval by the FDA, not legalized through legislative, ballot, or referenda initiatives.  Any FDA-approved cannabidiol medications should be regulated as other prescription products are, rather than state laws that may apply to unapproved cannabis products.
  
• Cannabis products not approved by the FDA will have warning labels indicating such
  
• Supports protection against federal prosecution for physicians who discuss cannabis with patients or recommend cannabis in accordance with state laws

The Wisconsin Medical Society (WMS) policy affirms the third point above, and also goes on to state that smoked marijuana should only be used for therapeutic reasons for which we have scientific data regarding safety and efficacy. 

Again of note, ACEP has a noticeable lack of policy in this realm, and in fact did not adopt 3 proposed policies over the last few years, including proposal to protect the right of emergency physicians to prescribe medical marijuana and a proposal to officially take no position on the medical use of cannabis products. 

Research: AMA again takes the lead in ample policy regarding research of cannabis use. They encourage public health agencies to improve data collection of effects of cannabis.  The AMA and WMS have the same following policy:

• Urge that marijuana’s status as a schedule I controlled substance be reviewed with the goal of facilitating the conduct of research and potential development of medicines
  
• Call for adequate studies of cannabinoids
  
• Urge federal agencies to fund and facilitate the conduct of research

Interestingly, although the ACEP Council voted to not approve a resolution in 2014 to specifically promote research of medical marijuana, they did just last month approve the very first ACEP resolution regarding cannabis, mirroring language of the first above AMA/WMS policy point.

Wisconsin statute includes a provision that a psychiatric bed locator be maintained as a single point of reference of psychiatric bed availability. The bed locator website was developed, and is maintained, by the Wisconsin Hospital Association. The site is meant to assist emergency departments when seeking to transfer and admit patients for psychiatric reasons.

In an effort to work with WHA to identify possible areas of improvement for the bed locator, WACEP has developed a short survey for its members regarding the site’s usage. Please take a moment to answer the survey.

Is psychiatric boarding out of control in your ED too? WACEP hears you! 

Drs. Redwood and Repplinger visited Kaye Zwiacher, MD, director of Winnebago Mental Health Institute, to discuss the SMART protocol. The SMART protocol decreases ED length of stay and costs by eliminating unnecessary diagnostic labs in 65% of psychiatric medical clearances.

WACEP President's Message, September 2018
Lisa Maurer, MD

You’re working a busy 12 hour shift, and a patient with chief complaint of “SI” pops up on the board.  Gulp.  The evaluation is uniquely straightforward: this 54 year old female has a history of depression and is having passive thoughts of suicide in a stressful time, very clearly presents with her husband for voluntary admission.  No ED hold needed.  You find no other medical concerns and even get her accepted at the nearest psych hospital promptly, which happens to be 50 miles away.  Bingo bango, you’re on a roll!  

Then comes the question of what “mode of transportation” are you going to fill out on the EMTALA form?  The patient just assumes that her husband can drive her there, but your hospital has a policy that all psych transfers must go by ambulance, sticking this family with a hefty bill.  Your gut is that she is extremely low risk for harm or non-adherence to the care plan during private transport.  Is there merit to insisting on ambulance transfer?

We had this exact question presented to our chapter by our members.  Certainly, there is a time and place when your spidey sense tells you to opt for ambulance transfer even for voluntary admissions.  However, for the seemingly low risk patients, we wanted to supply our members with data who wish to have discussions with their hospital administrators if you want to pursue more flexible standards for transportation in voluntary psych transfers.  See here for a seven-page legal summary concluding that the mode of transportation should be left to the judgement of the physician, done by our contracted attorney, Guy DeBeau from Axley Brynelson, LLP.  It includes an interesting summary of pertinent case law, and tips for how to safely document characteristics you may have considered when assessing your patient’s level of risk for harm during transfer. It is worth pointing out that the memo does not include any examples of civil suits for harm that occurred during a similar transfers in Wisconsin, because there aren’t any such lawsuits. 

For other points of discussion, WACEP has received some helpful tips from our partners in the WI Psychiatric Association.  They refer to the CMS booklet on Non-Emergent Medical Transport for the “standard of care” for transportation of psychiatric patients, which comments on the difference between clinical scenarios that necessitate emergent transport and those that are non-emergent.  For potential discussions of other transportation options, keep in mind non-ambulance secure transport choices as well, such as JBM, Able- Access, or Lock n Load.

Does your hospital have a policy to mandate that all patients being transferred for voluntary inpatient psychiatric care go by ambulance?  Do you feel that this is appropriate, or are you looking for a change?  We are interested in how we can further help with this issue in Wisconsin EDs.