March 21, Wisconsin Health News

The Senate approved more than a dozen bills during its final planned floor period of the session Tuesday, sending them to Gov. Scott Walker’s desk for approval.

The bills range from creating an intensive care coordination program in Medicaid, supporting efforts to fight the opioid epidemic and providing grants to increase awareness of Alzheimer’s and dementia.

But the chamber didn’t take up some proposals approved by the Assembly in recent weeks. That includes bills that would define direct primary care in state law and allow small businesses to band together and self-insure their health plans.

The bills approved by the Senate and heading to the governor would:

• Create an intensive care coordination pilot in the Medicaid program.
  
• Provide funding to fight drug trafficking, support prevention, establish treatment courts and offer medication-assisted treatment to those leaving jails.
• Boost treatment and prevention efforts to combat the opioid epidemic.
• Allow first responders, emergency medical technicians and ambulance services providers to renew their certifications or licenses every three years instead of two years.
• Allow podiatrists to supervise physician assistants and advanced practice nurse prescribers.
• Axe a state law requiring the Milwaukee County Mental Health Board to appoint a board of trustees to manage its mental health facilities and modify how members are appointed to the board.
• Guarantee pharmacists can delegate duties to pharmacy technicians, following confusion about current state regulation.
• Allow the Department of Health Services to expand a dental reimbursement pilot program to additional counties. 
• Provide $500,000 to award grants to increase awareness of Alzheimer’s disease and dementia in rural and underserved areas. 
• Require 911 dispatchers to provide assistance on administering CPR over the phone. 
• Recognize supported decision-making agreements, which allow older adults and those with disabilities to designate another person to help them make a decision. 
• Prohibit the sale of dextromethorphan, an ingredient in over-the counter cough medicine, to children without a prescription.
• Require the Department of Veterans Affairs to administer a program providing outreach and mental health services to at-risk veterans.
• Make it easier for physicians licensed in other states to treat patients at certain sporting events.
• Change how high an applicant has to score on an examination to be granted a chiropractor license. 
  
• Allow unaccompanied youth access to outpatient mental health treatment without parental consent.
• Require health plans to cover refills of prescription eye drops

by Dana Resop, MD

After reviewing some ultrasound images, I recently noted that we have few archived images of procedures, although we use ultrasound in procedures often.  Likely we get distracted by the procedure and forget to record screen images, but the images required vary by the procedure and this may be part of the issue.

If you have an ultrasound machine in your department, most likely this is at least partly due to the Agency for Healthcare Research and Quality (AHRQ) recommendation to use dynamic ultrasound guidance for central lines. You have devoted time and money to learn to use the ultrasound and stay proficient at it. It also costs money to keep that machine working, supply sterile probe covers and gel, as well as to support the infrastructure to get the images into the patient medical record.  To reimburse you for this additional knowledge, materials and practice, there is an additional reimbursement for use of ultrasound for procedural guidance in central lines (and codes for peripheral lines, procedures, etc.)

The current CPT description for Code (76937) applies to central venous access with ultrasound guidance. The description follows.

"Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting."

Dynamic guidance recommended for vascular procedures is different from static ultrasound guidance required for paracentesis, thoracentesis or other stable, larger targets. To document static ultrasound guidance, such as for a paracentesis, ultrasound to identify the location appropriate for procedure, archive an image for the record, mark the site, then put the probe down, prep the patient and do the procedure.

In contrast, due to the dynamic nature of venous access, ultrasound is used throughout the needle placement. In a perfect world (CPT), we capture an image of the needle entering the vessel.  However, attempting this may result in one of the following: broken sterile field, dropped probe, guidewire knocked off the bed, or losing the vein. Even the ACEP Ultrasound Section experts admit obtaining this image is unlikely in most ED patient settings.1

To safely document dynamic guidance during the central line procedure, use ultrasound to identify the vein, confirm patency (squish it) and then guide needle insertion. Now feed the wire into the vessel and remove the needle from the vein. Now there is nothing sharp in the patient or in the provider’s hands. Record two images of the inserted wire in the vessel: one in short-axis and one in long-axis (See figures). This is intra-procedure documentation of dynamic guidance. It also proves that the blood vessel that will shortly be dilated with a 7-French introducer (in the hypotensive patient on blood thinners) is NOT the carotid. Two wins! Remember to save the images to the patient’s chart per your department’s practice.

For further information about use of ultrasound, including guidelines about documenting and billing, please refer to Ultrasound the ACEP website. Experts in the ACEP Ultrasound interest group have put together multiple guidelines Multiple specialties refer to these guidelines in their own literature. I’m not a billing expert, please discuss your institution’s practice with your specialists!

1: Ref: Ultrasound FAQs (2017, Feb. 13). ACEP.org. https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Ultrasound-FAQs

Dr. Dana Resop is an EM Clinical Assistant Professor at the Univ. of WI Madison and a Board Member of WACEP. She obtained her MD at University of Wisconsin School of Medicine and Public Health, and her EM Residency and Ultrasound Fellowship training at the University of Massachusetts. She now focuses on residency education and point of care bedside ultrasound.

As part of the Wisconsin Hospital Association's Antimicrobial Stewardship Journal Club Series, Bobby Redwood, MD, MPH, FACEP, Immediate Past President of WACEP, will be presenting a four-part webinar series focusing on hot topic issues affecting health care antimicrobial stewardship.

The Antimicrobial Stewardship Journal Club is a four-part series of education and conversation focused on clinical decision making and population health considerations in Antimicrobial Stewardship. Each Club includes a review of current literature, discussing case scenarios, and a time for questions. The series is intended for physicians, mid-level providers, quality improvement leaders, and others with a special interest in the Club topic being discussed.  

All sessions are 12:00 pm - 1:00 pm via webinar:

• Journal Club #1: When to Test and When to Treat—A Deep Dive on Asymptomatic Bacteriuria Thursday, April 12, 2018 
  
• Journal Club #2: Evidence-based Strategies to Avoid Prescribing Unnecessary Antibiotics Monday, June 11, 2018
  
• Journal Club #3: Evidence-based Strategies to Prescribe Antibiotics More Effectively Monday, August 13, 2018 
  
• Journal Club #4: Pre-op Urinalysis Before Orthopedic Surgery—What is the Current Evidence? Monday, October 15, 2018

Learn more. 

Coordinating Clinical and Public Health Responses to Opioid Overdoses Treated in Emergency Departments

Join the 20th US Surgeon General, Acting CDC Director, a CDC subject matter expert, and other clinical and public health professionals for a webinar discussing new data and coordinated efforts by clinicians, public health government, and communities to respond to increasing opioid overdose emergency department visits. This combined webinar joins these two audiences together to provide a discussion on how clinicians and public health communities can work together in coordinating a more robust response to the opioid overdose epidemic.

The nonmedical use of prescription opioids and illicit opioids causes significant morbidity in the United States. The latest data indicate that rates of overdoses treated in emergency departments are rising across all regions and require a coordinated response between public health, clinicians, public safety, and community organizations.

During this call, clinicians and public health practitioners will learn about the increases in opioid-related morbidity and steps they can take together to reverse these trends.

Date: Tuesday, March 13, 2018
Time: 2:00 - 3:30 PM (Eastern Time)

Join the webinar here: https://zoom.us/j/662731210

Or iPhone one-tap: US: +16699006833, 662731210# 

Or Telephone: 1 669 900 6833 or +1 408 638 0968

Webinar ID: 662 731 210

The webcast (slides with audio) for this call will be posted on the webpage a few days after the COCA Call. The transcript will be posted a few weeks after the call.

Follow these steps to earn free continuing education

Wisconsin Voices for Recovery at the UW-Madison Division of Continuing Studies will provide re-grant awards for organizations to employee Recovery Coaches and Certified Peer Support Specialists. Peer support providers will begin providing recovery support in the hospital-based setting (Emergency Department) with individuals who have survived an opioid overdose. This statewide peer support network will function as a portion of the State Targeted Response to the Opioid Crisis. The ultimate goal of the program is to create sustainable peer support models across the state that will:

1. Increase treatment and recovery support service utilization of the target population
2. Reduce Emergency Department recidivism
3. Decrease the number of overdose fatalities in Wisconsin

Read the article, Wisconsin Voices for Recovery receives $1.4 million grant to combat opioid abuse.

Please consider applying for this amazing opportunity to help address the opioid crisis in Wisconsin! If you would like more information or have questions about this Request for Proposal, please contact wivoiceshn@dcs.wisc.edu.

March 7, Wisconsin Health News

Wisconsin emergency departments saw suspected opioid overdoses more than double between July 2016 and last September, according to a report released by the Centers for Disease Control and Prevention Tuesday.

The data show that the opioid epidemic hit the Midwest hardest among the country’s regions during that period. The Midwest experienced a 70 percent increase in opioid overdose emergency department visits, according to an analysis that covered 60 percent of emergency department visits in the United States. The average was 30 percent nationwide.

The CDC also separately analyzed data for 16 states, including Wisconsin, which saw a 109 percent increase in suspected opioid overdose emergency department visits during that period. It was the highest increase among the analyzed states.

“This fast-moving epidemic does not distinguish age, sex or state or county lines, and it’s still increasing in every region of the United States,” CDC Acting Director Dr. Anne Schuchat told reporters on a press call.

Other Midwest states saw increases too, with Illinois reporting a 66 percent increase, Indiana a 35 percent increase, Ohio a 28 percent increase and Missouri a 21 percent increase.

The findings show a need for better coordination between public health and public safety agencies to address overdose outbreaks. It also shows a need for more prevention and treatment efforts, according to the CDC.

“Research shows that people who have had at least one overdose are more likely to have another,” Schuchat said. “However, if the person is seen in an emergency department, we are presented with an opportunity to take steps to prevent a repeated overdose.”

NOTE: Wisconsin ACEP President Lisa Maurer, MD was interviewed by NPR and featured in the following article. The article inadvertently shows Dr. Maurer's affiliation with Ohio rather than Wisconsin. 

89.3 WFPL/HEALTH - February 21, 2018
By Lisa Gillespie

Starting July 1, some Medicaid enrollees could be fined for going to a hospital emergency room if they end up not actually having an emergency.  The new policy is part of bigger changes to the Medicaid program led by Governor Matt Bevin.

The penalties apply to adults who gained coverage after Kentucky expanded Medicaid, such as adults without dependents, or some parents who are in families that make between 54 and 138 percent of the poverty line.

“The intent of the policy is to reduce inappropriate emergency department use and educate individuals about the most appropriate setting for their health care needs,” Doug Hogan, a spokesman for the Kentucky Cabinet for Health and Family Services, wrote in an email.

Medicaid, the state-federal health care program for low-income and disabled Americans, is paying for a bigger chunk of ER visits since the health insurance program expanded in 2014. In 2015, for instance, almost 47 percent of the ER visits in Kentucky were paid for by Medicaid, up from about 30 percent in 2012, according to a report by the Foundation for a Healthy Kentucky.

Here’s how it’ll work: Enrollees will be given a “My Rewards” account. If the state deems an ER visit as unnecessary, My Rewards dollars will be deducted from that account, ranging between $20 to $75. That account will also be used to earn “dollars” for dental and vision services, since these Medicaid enrollees are losing automatic coverage of those benefits.

Enrollees could also make a co-payment if they don’t have a My Rewards account.

If an enrollee calls their insurance company nurse hotline before going to the ER, that penalty will be waived, even if the ER visit isn’t for an emergency.

Here’s who could be affected:

• Parents earning between 54 percent and 138 percent of the poverty line;
  
• Adults without dependents.
  
• Pregnant women, former foster care youth and enrollees who obtain a “medically frail” exemption will have access to a My Rewards account, but won’t face these penalties.  
  

Determining A ‘Non-Emergency’

There’s debate about what percentage of emergency room visits are unnecessary. The answer depends on where the information comes from.

Health care researcher Truven Health Analytics analyzed millions of ER claims from 2010 and found 71 percent of visits were avoidable or unnecessary. The American College of Emergency Physicians, meanwhile, says only about 3.3 percent of ER visits are “avoidable.”

There’s also a difference in how the state, an ER doctor and a patient define “non-emergency.”

“There are very few patients who come to the ER who truly know that they didn’t have an emergency right up front,” said Dr. Lisa Maurer, an emergency room doctor in Wisconsin.

Maurer understands that Kentucky’s new policy is supposed to discourage unnecessary ER visits but she worries it will deter patients who truly need to come.

“We want to make sure that our patients feel that if they’re having an emergency, they can come to the emergency department,” Maurer said, who is also on the state legislative-regulatory committee at the American College of Emergency Physicians.

Dr. Ryan Stanton works as a doctor in an emergency room in Lexington. He agrees with Maurer that people can’t always tell when something is an emergency. To regular people, conditions that a health insurer or an ER doctor might not see as an emergency, is to a patient, an emergency. Stanton used the example of patients with high blood pressure who fear they are on the verge of having a stroke. 

“We’re hearing on the radio these ads about blood pressure causing stroke, and you need to go to the ER right away,” said Stanton. “But blood pressure is rarely an emergency. But to the lay public, blood pressure is a stroke waiting to happen.”

A visit because of high blood pressure and fear of a stroke could be classified as a non-emergency if Stanton finds the patient wasn’t actually unstable or about to have a stroke.

An Emergency In ‘Access to Care’

 “How many people do we have that call the family doctor, and the receptionist says, ‘If you can’t wait three days to get an appointment with us, then just go to the ER?’” asked David Wesley Brewer, former president of the Kentucky chapter of the American College of Emergency Physicians.

Brewer said another reason people come to the ER, even if they know know it’s not an emergency, is because Medicaid enrollees have a hard time finding a primary care practice with immediate availability. The Truven Health analysis found that of the 71 percent of what it deemed “unnecessary” ER visits, more than 40 percent of those people could have been safely treated in a primary care setting.

And locally, at the University of Louisville Hospital, two thirds of ER visits occur after hours, when cheaper alternatives like primary care offices or free clinics are closed. And the vast majority of visitors, the hospital said, have either been directed by their primary care office/insurance nurse line to go to the ER, or have a time sensitive medical need.

Lei Lei, MD
WACEP Secretary/Treasurer

I have been out of residency for five years, and it is remarkable that even in my relatively young career, I find myself and my colleagues all over the country burdened with burnout. After having kids and starting my life anew after almost a decade of the “it’ll get better” mentality, I sometimes wonder if I was overly optimistic about the practice of medicine. Though it seems like it is the current “hot topic,” it is becoming increasingly apparent that physician burnout is a persistent and growing issue in our profession which leads to significant downstream effects.  Burnout contributes to poor physician retention, which results in worsening physician shortages, which in turn will self-propagate as the remainder physicians struggle to fill the holes leading to medical errors, bad patient care, and of course more burnout. Physician burnout contributes to depression and one of the highest suicide rates of any profession.  

Our profession is woven into our identities. Work is not just work; it comes home with us; and goes to sleep with us.  Physicians have been trained to project an indomitable image.  In reality the typical emergency physician statically does not sleep well, eat well, and doesn’t seek treatment for mental and physical ailments.  Our irregular schedules working holidays and weekends make it difficult to manage family life; our unwieldy student loans hold us financially captive to the medical field as we are often not in a position to replace our income by alternative means. Third shifters are at particular risk for metabolic syndrome and chronic sleep disturbance correlating with an increase incidence of hypertension, diabetes, and decreased lifespan.1 At the hospital we are charged with caring for our patients, striving to please exacting administrators, and being the stoic leader in the chaos of the ED. Self-care is always a peripheral after-thought. Even at home, we are often primary providers and our family members often view us as an endless resource for medical expertise. We care for others, but our own wellness is not a priority. 

Physicians are leaving medicine or looking for alternative revenue streams for this reason. The Association of American Medical Colleges is projecting a shortage between 40,800-104,900 physicians by 2030. One third of practicing physicians will be of retirement age within the next 10 years. The younger physician cohort are suffering from burnout and cynicism not previously experienced by other generations of physicians.  A Facebook group “Physician Side Gigs” boasts twelve thousand members of practicing docs who looking to decrease clinical work and supplement their income. Our profession is facing some serious issues, but physicians can only affect part of a solution. Hospital administrations, medical educators, and federal and state regulators will have to prioritize physician wellness by addressing physician burnout. Many residency programs are enacting curriculum changes that build new physician resiliency and minimize burnout, but we should also ask ourselves: what can practicing docs do to improve their own resilience and what can hospitals and governments do to promote physician wellness. 

My goal is to convince our collective profession that prioritizing our health and wellness needs to come off of the back burner. It is time to stop viewing self-sacrifice as a necessity in the culture of medicine. Hospital administrators will not do this for us. Hospital staff will not do this for us. Only we can advocate for ourselves.  This can mean telling your colleagues to take a break during a shift that allows for eating, pumping, or just a simple escape from the chaos of the department.  This can mean offering positive reinforcement for our colleagues who are making healthy choices. This can mean standing up for our colleagues who are being singled out. We need normalize these behaviors as the standard and not the exception. Let us be more honest with ourselves and in our daily interactions. The grumbling we hear during shift change and on our day-to-day exchanges with worn-out colleagues is a symptom of a larger problem.  We need to start and sustain these conversations. The more we passively absorb the stresses of this dysfunctional healthcare system, the more devalued we will be as doctors.  

We must also focus on enacting changes across the system that favors sustaining physician wellness and changing the long standing cultural practices within medical communities that reinforce self-sacrifice as a necessity in medical practice. Healthy practices should be reinforced by our community and government. The biggest hurdle is simply making this a conscious priority in our minds as well as those of hospital administrators. This could mean framing the issue in terms of loss in productivity, physician retention, poor patient care, and mistakes in health care. As a member of professional organizations like WACEP and the Wisconsin Medical Society, you are supporting initiatives that benefit physicians and helping these issues to gain visibility and attention in legislation and policy. 

With that I would like to announce that in the following months, WACEP will be starting a social media initiative to promote physician wellness. Please follow us on Twitter @WisconsinACEP or Facebook @WIACEP for updates.

1. Wang, F., Zhang, L., Zhang, Y., Zhang, B., He, Y., Xie, S., Li, M., Miao, X., Chan, E. Y. Y., Tang, J. L., Wong, M. C. S., Li, Z., Yu, I. T. S. and Tse, L. A. (2014), Meta-analysis on night shift work and risk of metabolic syndrome. Obes Rev, 15: 709–720. doi:10.1111/obr.12194

WACEP 2018 SPRING SYMPOSIUM - HOTEL RESERVATION DEADLINE IS FEBRUARY 19th!

Planning to attend the Wisconsin ACEP 2018 Spring Symposium next month?  Make your hotel reservations NOW! The deadline to receive overnight accommodations at the WACEP group rate of $149 is on MONDAY.

Book your stay by calling The Edgewater directly at 1-800-922-5512 and request the Wisconsin Chapter, American College of Emergency Physicians room block. You may also book online using this direct link for WACEP's room block: http://theedgewater.link/WACEP2018. The cut-off date to book at the group rate is February 19, 2018. 

February 12, Wisconsin Health News

The Joint Finance Committee signed off on two bills last week targeting the state’s opioid epidemic, teeing up the proposals for votes in the Assembly and Senate. 

One of the bills would provide funding to combat drug trafficking, support substance abuse prevention efforts, establish treatment courts and provide medication-assisted treatment to inmates leaving jail. The other would make a series of changes to boost treatment and prevention efforts.

The committee approved an amendment to the second bill, which aimed to address some concerns raised about the bill streamlining the process for people to become substance abuse counselors.

“Wisconsin already has a pretty high threshold for requirements, both from an educational standpoint and from a clinical standpoint,” said bill author and JFC Co-Chair Rep. John Nygren, R-Marinette. "Even with these changes, we are still on the high end of all our neighboring states.”

The amendment also changed a part of the bill mandating that the Department of Health Services remove prior authorization requirements for prescribing buprenorphine combination products, a treatment for opioid addiction. Instead, DHS would have to report back to the Legislature every six months until the requirements change.  

The amendment didn't include a request by the medical community to remove parts of the bill requiring some healthcare providers take continuing medical education credits on prescribing opioids.

The Wisconsin Medical Society, which supported the bills, said in testimony that the proposal is unnecessary for the Medical Examining Board, which has issued rules requiring such education through 2019. Nygren praised the Medical Examining Board’s work.

“This is not a move to be punitive,” he said. “The Medical Examining Board has actually taken steps. Others haven’t.”