Bobby Redwood, MD, MPH, FACEP
President, Wisconsin Chapter, ACEP

A Roller Coaster of a Year for Wisconsin Emergency Medicine

December is a natural time for reflection and there is certainly plenty to contemplate in the Wisconsin Emergency Medicine landscape of 2017. Let’s take a moment to revisit the major events of 2017 that affected our specialty at the state and national level and also look towards the future at what 2018 holds in store for WACEP and Wisconsin Emergency Medicine. Fair warning, this newsletter is a little longer than our usual format—its worth it though—2017 has been a wild ride.

A Political Neophyte in the White House and an Assault on Health Care Access

As I write this, Donald Trump’s national approval rating sits at 32%*, the lowest fourth-quarter approval rating of any president since polling began. The president blew his trust with many of us early by lying about historic attendance at his inauguration and stacking his cabinet with less than credible individuals (Flynn, Bannon, Scaramucci, etc, etc, etc) and then went on to shock and isolate large numbers of emergency physicians with his self-proclaimed Muslim travel ban** and apparent inability to condemn white supremacy after a violent KKK rally in Charlottesville. ACEP responded to the intolerance by redoubling its commitment to diversity in our specialty and initiating the viral twitter hashtag #ilooklikeanerdoc.

By July, the mismanagement had shifted towards health care as congress tried to force through the Better Care Reconciliation Act, a half-baked attempt at repealing the Affordable Care Act that would have eliminated insurance coverage for more than 20 million people over the next decade, including 394,100 Wisconsinites. WACEP launched a successful action alert against the BCRA as well as the subsequent “Skinny Repeal,” and the Affordable Care Act (ACA) remains the law of the land. Unfortunately, the president and congress remain determined to limit access to care and have taken some reckless actions that include withholding the ACA cost-sharing subsidies, failing to fund the Children's Health Insurance Program, approving the sale of “junk” insurance plans, and shortening the annual ACA enrollment period to an abysmally short six weeks. We at WACEP considered asking Trump’s health and human services secretary, Tom Price, to help ensure that access to care is preserved in Wisconsin, but he resigned in September after racking up $400,000 in travel bills for chartered flights on a taxpayer-funded Gulfstream 4.

Great Strides for Wisconsin ACEP

If you find the national political scene a bit depressing, rest assured that WACEP has been working overtime to provide a rewarding practice experience for emergency physicians in our state.

This year we hosted our first ever Wisconsin Emergency Medicine Spring Symposium that included over 75 attendees, 14 exhibitors, 13 faculty presenters, 2 hands-on workshops, and one physician-led jazz band! We felt especially flattered that national ACEP immediate past president Becky Parker and president-elect John Rogers made the trip to Wisconsin to attend our Spring Symposium. The event started with education and moved forward into advocacy as our specialty recorded its highest ever attendance (really) for the subsequent Wisconsin Doctor Day at the capitol. At that event, the house of medicine honored our specialty by highlighting Emergency Medicine medicaid reimbursement as one of the four priority issues to be presented to our legislators in 2017.

If you missed the Spring Symposium and Doctor Day, we hope you had a chance to attend another one of WACEP’s events in 2017. The list is long and includes gems like our posh Wisconsin EM reception at Del Campo in Washington DC; our listening tour stops in Janesville, Eau Claire, Merrill, and Appleton; or one of our four open board meetings, held quarterly in either Madison or Milwaukee. Still looking for a chance to connect with the WACEP board? The pizza party is on us…starting in 2018, just drop us an email and we’ll schedule a listening tour at your convenience, in your ED or hospital!

Three-Pronged Mission 2017/2018

While the events above highlight progress for WACEP as an organization, our central focus continues to be our three-pronged mission to serve our profession, our physician workforce, and our patients. In April of 2017, we renewed this three-pronged commitment by voting on our organization’s priorities for the 2017/2018 year. We voted to support our profession by advocating for increased Medicaid reimbursement in Wisconsin, to support our physician workforce by expanding the size and scope of the Spring Symposium, and to support our patients by working with the Wisconsin Medical Society to decrease the length of stay for psychiatric patients in the emergency department.

As a demonstration of their commitment to WACEP’s three-pronged mission, I am extremely proud to report that 100% of the WACEP board of directors donated to the WI Emergency Medicine PAC. Likewise, general WACEP members came out in force, raising over $8000 for the PAC in 2017, thus surpassing all previous years’ contributions and facilitating first-rate access to our state legislators and their staff.

David and Goliath

One major development for Wisconsin Emergency Medicine in 2017 is the arrival of a national contract management group to our physician staffing landscape. In June of this year, Envision bought Infinity HealthCare, a democratically run (via a board of directors) multi-specialty physician group practice based out of Milwaukee that includes more than 340 providers in Wisconsin and Illinois and staffs 25 emergency departments. 

Envision is a publicly traded physician staffing corporation (NYSE: EVHC) and the parent company of EmCare. Nationwide, Envision manages physician staffing/contracts for more than 1,600 clinical departments in 45 states and the District of Columbia. A large proportion of their physician employees are emergency physicians. Envision has a larger market share than Team Health and the physician services "unit" of Envision makes about $6 billion of Envision's total annual revenue.

Wherever you stand on the issue, a titan of physician staffing has arrived in Wisconsin. What will the job landscape look like for our 2020 Wisconsin EM graduates? Madison Emergency Physicians brought to you by Team Health. Emergency Medicine Specialists brought to you by USACS? Perhaps Wisconsin will buck the nationwide trend and physician operated practices will persevere in the Badger State? Or better yet, perhaps we’ll find that perfect mix?

Ghosts of Christmas Past

If that last section got you riled up, settle down and pour yourself a mug of mulled wine, because this one’s a doozy. The advocacy nerds and policy wonks among us know that certain issues, like Scrooge’s three ghosts, tend to come back and haunt emergency physicians and in 2017, the chains are really rattling.

First, the prudent layperson standard of 1997, which requires that insurance coverage is based on a patient's symptoms, not their final diagnosis, has come under attack in multiple states. We have to make sure Wisconsin does not become the next Missouri, where Anthem BCBS has created a list of over 2,000 diagnoses that it considers to be “non-urgent”.

Second, the specter of out-of-network billing has finally arrived in Wisconsin. What does out-of-network billing look like in practice? To put it simply, a patient’s emergency physician does the work and the insurance company does not pay. The insurer is able to do this by offering in-network rates that are far below fair market value, thus forcing physicians “out-of-network” and sticking the patient with the bill for physician services. We have to ensure that Wisconsin emergency medicine protects its climate of fair coverage and resists the scourge of out-of-network billing.

Third, medical malpractice caps in Wisconsin could soon be non-existent. Wisconsin lawmakers have put a $750,000 per-occurrence cap on non-economic damages in medical malpractice cases, but that limit was deemed “unconstitutional on its face” by a Wisconsin appeals court in July 2017. The matter is on its way to the state supreme court as of November 1^st and WACEP has organized a multi-specialty coalition to help protect the cap. Malpractice caps are proven to prevent lawsuits, if they are lifted, let the malpractice free-for-all begin.

On top of all that, the ghost of Christmas present is currently at work in the U.S. Congress, as our legislators are trying to eliminate the individual mandate as part of their year-end tax bill. The move would increase the number of uninsured patients in Wisconsin and increase the proportion of uncompensated emergency care. Enough with the chain rattling Jacob Marley…give us a break!

Hope for the Future and a Milestone for Emergency Medicine

Looking forward to 2018, the WACEP team is working hard to make sure that your new year is as bright and shiny as a healthy glottis beneath the warm light of a Mac-3. For starters, Wisconsin Doctor Day is just around the corner on January 30^th. We are committed to getting out-of-network-billing on the agenda, thus cementing the leadership of emergency medicine on this key issue. Just two months later, emergency physicians from around the state will descend upon the gorgeous Edgewater Hotel in Madison for the second annual WACEP Spring Symposium! In response to all the divisiveness at the national level, our theme this year is “Building Connections.” The two-day event will be held on March 14^th-15^th and will—for the first time ever—be combined with the UW/MCW Emergency Medicine Research Forum. The festival of emergency medicine will continue in the summer with a joint Illinois-Wisconsin career fair at Northwestern University and culminate in San Diego as WACEP celebrates 50 years of Emergency Medicine at our annual Wisconsin event at the ACEP Scientific Assembly.

On a personal note, I will be greeting the New Year with a wistful tear in my eye, as I pass the baton to the incoming WACEP president. It has been a privilege and an honor to serve each and every one of you. You are the tireless emergency physicians who work 24/7/365 to help keep the great state of Wisconsin safe. You are the professionals entrusted with the stewardship of our loved ones’ health when they are most vulnerable. 2017 may have been a bit of a rollercoaster, but with emergency physicians like you sustaining our professional society, I knew this ride would never fly off the rails.

*Pew Research Center
**http://time.com/4703614/travel-ban-judges-donald-trump-words/

Doctor Day 2018 is fast approaching and it’s important that physicians like YOU participate in our annual advocacy event in Madison on Tuesday, Jan. 30. 

It’s a full day of speakers, issue briefings and a visit to the Capitol to advocate on behalf of your profession. The day will conclude with a reception at DLUX.  The tentative schedule and online registration can be found at widoctorday.org. The event is free to all physicians and medical students thanks to very generous support from sponsorship organizations. 

Each year, Doctor Day attendees hear from some of the leading voices in Wisconsin politics and health care policy. We’re awaiting final confirmation from speakers, but physicians attending Doctor Day 2018 will enjoy the same high-level experience. Also, our speakers will update physicians on health care issues still under debate in the State Capitol. The January 30 meeting date coincides nicely with the final days of the state legislature’s activity, and therefore puts physicians in policymakers’ offices at the best time to maximize impact on the issues physicians care about. 

Physicians also will hear the latest regarding Wisconsin's cap on noneconomic damages in medical liability cases—currently being heard by the Wisconsin Supreme Court. One of the state’s top medical liability attorneys, Guy J. DuBeau, will explain how a lone case—tried in Milwaukee County—left Wisconsin with no limit on noneconomic damages and what physician organizations are doing to fix that problem. 

Staff and committee members will take care of every detail—from breakfast, briefings, speakers, lunch and scheduling your visits with legislators to the reception at the end of the day! 

Please consider joining us for a great day of advocacy on behalf of your profession and your patients!  Register now on the Doctor Day website.

December 6, Wisconsin Health News

The Department of Health Services has accepted the resignation of Medicaid Director Michael Heifetz, who is leaving for the private sector, according to a statement.

Heifetz, who also serves as administrator of the Division of Medicaid Services, will leave the department Dec. 13. Deputy Administrator Casey Himebauch will serve as the division's interim leader.

“Michael has been invaluable in his role as Medicaid director, representing Wisconsin’s vision for the future in the national spotlight,” DHS Secretary Linda Seemeyer said in a statement. “We will greatly miss his leadership and insight, as well as his candor and energy.”

A DHS spokeswoman said that Heifetz is "pursuing career opportunities" in the private sector. She did not respond to a question asking for more specifics.

Heifetz joined the department as Medicaid director in September of last year. He previously served as state budget director. Before that, he was vice president of governmental affairs at Dean Clinic and SSM Health of Wisconsin.

Heifetz has also left his position on the Group Insurance Board and was replaced by State Budget Director Waylon Hurlburt in October.

WACEP President to be featured on Wisconsin’s 57 Television

As the 2017/2018 Flu Season Ramps Up, Wisconsin Emergency Providers Take Charge on Vaccine and Antibiotic Education. Wisconsin ACEP President Bobby Redwood, MD, MPH, FACEP and Brian Kayon, PA-C will be featured on Wisconsin Doctors, episode #183, to promote the flu shot and clarify basic antibiotic stewardship principles. You are encouraged to watch this 30-minute program and to spread the word to others to become informed.

Where to watch:

• Charter: 6
  
• Charter HDTV: 613
  
• AT&T Uverse: 57
  
• AT&T HDTV: 1057
  
• Direct TV: 57
  
• Dish: 58
  

When to watch:

• 12/11: 11:30a, 9:00p
  
• 12/12: 6:30a
  
• 12/13: 5:00p
  
• 12/14: 5:30a
  
• 12/17: 9:30p
  
• 12/18: 11:30a, 9:00p
  
• 12/19: 6:30a
  
• 12/20: 5:00p
  
• 12/21: 5:30a
  
• 12/24: 9:30p
  

The show will be posted to the Wisconsin Doctors YouTube page as it becomes available. 

The legislature is considering legislation based on proposals from the Workers Compensation Advisory Council.  The proposals were developed Labor and Management representatives on the Council.  But not all of the proposals share the support of the Council’s health care representatives, including a recommended fee schedule.  Health care organizations will need to be even more active this session than last to again defeat the fee schedule proposal.

It is important to note that works compensation premiums have dropped – without a government mandated fee schedule.  This year alone, employers received an 8.46 percent reduction in their worker’s compensation insurance premiums, saving employers an estimated $170 million.  At the same time, Wisconsin’s health care system continues to lead the nation in outcomes with injured employees returning to work a full three weeks earlier than the national average.  And health care costs per worker’s comp claim lower than the national average.

Your calls are needed to both the State Assembly and State Senate to explain why the proposed health care fee schedule could harm Wisconsin’s model worker’s compensation system. Entering your address under "Who Are My Legislators" on the State Legislature’s website to locate their contact information.

Let your State Representative and State Senator know you are a physician in their district, serving patients who are also constituents and that you are opposed to an artificial fee schedule for a worker’s compensation system that provides the nation’s best care at a below-average worker’s compensation cost.  Thank you for your time and action on this important issue.

Deputy Insurance Commissioner J.P. Wieske will outline what a Wisconsin version of the Affordable Care Act could look like at the Dec. 13 Wisconsin Health News Newsmaker Event.

Wieske announced this fall the state is considering applying for a 1332 waiver from the law, which allows states to develop unique solutions for providing affordable healthcare coverage. Wieske will discuss the state’s next steps, as well as provide an update on open enrollment and the current insurance market.

Wieske has served as the state's deputy insurance commissioner since 2016. Before that he was the department's legislative liaison and public information officer for five years. He previously served as the executive director of the Council of Affordable Health Insurance.

 Register here.

November 3, WMS Medigram

The Wisconsin Medical Society Board of Directors has named Clyde “Bud” Chumbley, MD, MBA, chief executive officer of the Wisconsin Medical Society.

“I’m excited to have the opportunity to serve as the next CEO of the Wisconsin Medical Society; I consider it a tremendous honor,” said Dr. Chumbley, who will begin on November 27. “Having been a Society member for 37 years, I’m a firm believer in its mission to advance the health of the people of Wisconsin by ensuring access to high-quality, cost-efficient care. And I look forward to drawing on my experience to further strengthen the Society so we can continue to make a difference for our patients and our profession.”

In addition to caring for patients as a board-certified obstetrician/gynecologist throughout his 36-year medical career, Dr. Chumbley has held numerous leadership and management positions, including serving nearly 20 years as president and CEO of a large, independent multi-specialty medical group practice. He currently serves as chief medical adviser for Wisconsin Medical Society Holdings and as chief medical officer for the Wisconsin Medical Society Holdings Association Health Plan.

Past leadership roles in Wisconsin include serving as chief medical officer/chief clinical integration officer for Aspirus Health and president of Aspirus Clinics, and as president and CEO of ProHealth Care Medical Associates. He also has served on the board of directors and as past chair and treasurer for the Wisconsin Collaborative for Healthcare Quality. In Texas, he served as chief medical officer for Scott & White Healthcare in the Austin region.  

Doctor Chumbley is a graduate of the University of Missouri School of Medicine and the Kellogg School of Management at Northwestern University and holds medical licenses in Wisconsin and Texas.

“We were fortunate to have a number of highly qualified candidates interested in this position,” said Jerry Halverson, MD, chair of the Society’s Board of Directors and co-chair of the search committee. “Doctor Chumbley is an excellent advocate for physicians and the patients we serve, and with his extensive administrative experience and medical expertise, we believe he is an outstanding choice to lead the Society. We look forward to all we can accomplish under his leadership.”

Doctor Chumbley is the eighth Society CEO in its 176-year history. Susan L. Turney, MD, MS, FACMPE, FACP, was the first physician to hold the position from 2004 to 2011.

U.S. Antibiotic Awareness Week - November 13-19, 2017
By Bobby Redwood, MD, MPH, FACEP

Greeting Wisconsin Emergency Physicians! As we boldly stride forth into cold and flu season (or perhaps we’re getting dragged, kicking and screaming), I would like to take a moment to celebrate one of the lesser-known Fall holidays: U.S. Antibiotic Awareness Week is November 13-19, 2017!

To celebrate the occasion, academic and community emergency physicians from across the state have compiled two top 10 lists to help guide emergency physicians’ clinical practice.  These evidence-based recommendations have been compiled by the Department of Health Services Antimicrobial Stewardship Emergency Medicine Sub-Committee and will be available in print form next month.

Here’s an online preview; feel free to print out the PDFs (which include references) and post in your ED!

Top Ten Ways for Emergency Physicians to Avoid Prescribing Unnecessary Antibiotics (download)

1. Beware UTI myths. 40% of antibiotics given in hospital settings are avoidable. Odor, bacteriuria, nitrates, leukocyte esterase, and pyuria cannot diagnose UTI without clinical signs/symptoms.
2. Use the modified Centor Score for pharyngitis. One point is assigned for each of the following criteria: fever, absence of cough, tonsillar exudates, and swollen/tender anterior cervical nodes. Current guidelines recommend no rapid testing and withholding antibiotics in patients with scores of zero and one, and treating only positive rapid test results for scores of two or greater.
3. Treat sinusitis as viral unless strict criteria are met. Sinusitis symptoms must be present for ≥10 days without any evidence of clinical improvement OR patient has severe symptoms or signs of high fever (≥39°C [102°F]) and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days OR worsening symptoms or signs characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection. If criteria are met, first-line therapy should be a 10-day course of amoxicillin.
   
4. Avoid screening for asymptomatic bacteriuria. Asymptomatic bacteriuria is common, It is present in up to 5% healthy premenopausal women, 22% community dwelling elder women, 50% and 35% of institutionalized women and men respectively. Urinalysis for infection should only be sent in patients with urinary symptoms.
   
5. Think twice about “UTIs” in patients with altered mental status. Implement wait and see approach to non-specific symptoms of weakness, falls, fatigue, and/or delirium in elders, long term care residents, and patients with cognitive impairment before starting antibiotic for UTI
   
6. Consider not prescribing antibiotics for uncomplicated abscesses. Several studies conducted in the ED provide data to support withholding antibiotics after incision and drainage of uncomplicated abscesses, even in cases of suspected methicillin-resistant Staphylococcus aureus. One large RCT supports TMP/SMX use in abscesses.
   
7. Avoid double coverage for community-acquired cellulitis. TMP/SMX retains nearly 100% effectiveness vs. CA-MRSA. Wisconsin clindamycin resistance rates approaching 30%. No need to double cover uncomplicated cellulitis, single agent cephalexin is sufficient.
   
8. Consider watch and wait prescriptions with acute otitis media. Most otitis media is viral. Delaying treatment is usually associated with resolution of clinical signs and symptoms. Only 40% of watch and wait prescriptions are filled.
   
9. Use procalcitonin to help guide decision to antibiose in COPD. The FDA approved procalcitonin in 2017 to guide antibiotic initiation in LRTI.
   
10. Avoid antibiotics for routine dentalgia. Reversible pulpitis, periodontitis, and mechanical endodontic conditions present as tooth pain, but do not require antibiotics. NSAIDs and nerve blocks are recommended therapy. Antibiotics are appropriate if there is an adjacent space infection, trismus or odynophagia.
    

November 8, Wisconsin Health News 

The Assembly’s mental health reform committee has unanimously approved a bill that would prohibit law enforcement from transporting an individual to emergency detention from an emergency room unless a hospital or medical staff member gives the OK. 

The bill, a result of about three years of negotiation with the Wisconsin Counties Association and the Wisconsin Hospital Association, also extends immunity under the emergency detention statute to healthcare providers. 

Rep. Melissa Sargent, D-Madison, called the bill an “important piece of legislation” but asked for clarification from Legislative Council in response to a memo from Mental Health America of Wisconsin. 

In the memo, Mental Health America of Wisconsin agreed on the need for medical clearance but asked for clearer language to ensure that it does not override the authority of counties to make final disposition determinations. 

“Part of my concern is not creating a circular firing squad, so to speak, where it’s not like everyone is pointing their finger at somebody else and saying, ‘We’re giving this to you, it’s not ours,'” Sargent said. 

Brian Larson, senior staff attorney for the committee, said his reading of the bill is that it doesn’t override the county’s authority. 

Under law though, individuals can only be detained for 72 hours without a court order. So a county’s decision could be “kind of considered a conditional approval” if someone ends up needing an emergency room for 72 hours, Larson said. 

“This statutory change makes it so that when the county is giving its approval, it’s basically saying, ‘We approve the emergency detention once the person is suitable to be detained,’” he said.

By Lisa Maurer, MD
WACEP Board of Directors 

For two days before the Scientific Assembly, councilors from each state meet to discuss proposed ACEP policy.  Some new topics of ACEP policy just approved include:

1. Work to prevent abrupt changes in ED contract groups 
   
2. Supporting paid parental leave and work on producing best practice guidelines for how to actually implement this fairly in various EM practice environments
   
3. Increase resources (read: money) to promote EM physician wellness and workforce diversity 
   
4. As oxy abuse transitions to heroin abuse, support development and study of supervised injection facilities that although controversial in some ways, have been successful in other countries.
   

Then during Scientific Assembly, I was able to do lots of work on policy issues pertinent to our Wisconsin's efforts.  Ongoing projects include:

1. Medicaid reforms, including reimbursement.  As states get more flexibility, ACEP is considering drafting model Medicaid reform legislation, and then selecting a state that could utilize national ACEP resources to push through legislation. I know what state I'll be volunteering for the pilot!
2. Fighting unfair legislation on out-of-network balanced billing.  In many states, groups are getting squeezed out of contracts by unfair compensation, then state legislatures are banning balanced billing.  This is creeping into WI, and WACEP is working with PFC to be proactive. Check them out: http://thepfc.org/the-issue/
3. Lots of insurance companies are starting to implement policies that try to limit "non emergent" visits, often by refusing to pay claims for visits they retrospectively consider non emergent based on the final dx.  This is a clear violation of the prudent layperson standard, which is law for most public and private insurance companies, and it IS starting to happen in WI.  (What is the PLP standard? http://newsroom.acep.org/2017-05-16-Emergency-Physicians-Anthem-Blue-Cross-Blue-Shield-Policy-Violates-Federal-Law). Our patients will be put in a dangerous position, with increased delayed care due to fear of insurmountable out of pocket costs.  I'm working with ACEP to decide how to use their resources to fight this.  Keep me updated if you see/hear about this with patients.

Lastly, CMS director Seema Verma has declared a "Patients Over Paperwork" initiative, which looks like it may actually be more than just a headline.  Director Verma met with ACEP last week, and discussed specifics, including the decreasing EHR burdens and getting rid of MIPS.  With ACEP's new president, Paul Kivela, being a doc from an independent one-hospital group, there is a new push to focus on improving practice for docs working in the trenches.