By Bradley Burmeister, MD
WACEP Board of Directors

On November 1^st, seven Wisconsin physicians stood up for our profession at White Coat Day on Capitol Hill during the ACEP Scientific Assembly. Members met with both Wisconsin senators as well as several representatives from throughout the state. During their visit to Capitol Hill, Wisconsin ACEP members advocated for two key issues: 1) Liability tort coverage for federally mandated EMTALA-related services and 2) Information regarding the prudent layperson standard and potential violations of existing law.

The first issue is regarding HR 548 and SB 527, the Health Care Safety Net Enhancement Act. This resolution provides federal legal protections for physicians and on-call consultants providing EMTALA-related care much like physicians in the VA, Indian Health Service, and FQHC’s have. Having protections such as these would likely decrease the cost of liability coverage, encourage emergency physicians to relocate to locations where the liability environment is less than ideal, and also incentivize more robust coverage by on-call specialists.

The second issue relates to the prudent layperson standard, which is law in federal institutions as well as in 47 states (including Wisconsin). Recently, insurance companies have started to once again use antiquated scare tactics to inhibit patients form pursuing care in the emergency department. The decision to cover the cost of care is being based on the discharge diagnosis. For example, a patient in Georgia reportedly was in a motor vehicle crash and had an emergency department evaluation which fortunately was able to exclude a significant injury.  The patient was discharged with a diagnosis of “cervicalgia.” Astonishingly, this was not covered as the insurance company deemed the diagnosis non-emergent, even though a more emergent diagnosis could have been made had it not been ruled-out by the treating provider. Emergency care only encompasses about 2-3% of health care dollars and these tactics have not been proven to be effective. Already, roughly 40% of patients defer obtaining emergency care due to fear of expense. These tactics could lead to a delay in obtaining care when an emergent condition does present. This delay could cause harm.

In terms of updates from our legislators, representatives let the Wisconsin ACEP team know that, within health policy, there are relatively few issues being actively debated, primarily due to the focus is on tax reform. It’s anticipated; however, that the energy will renew next year so keep checking the Wisconsin ACEP website for updates and action alerts. Also, be sure to attend Wisconsin's Doctor Day 2018 on Tuesday, January 30 in Madison for your own opportunity to advocate for emergency medicine!

October 25, Wisconsin Health News 

Hospitals say a bill would clarify the role and liability of providers in emergency departments when people who are having a mental health crisis are detained by law enforcement. 

The proposal got a public hearing in an Assembly committee Tuesday. 

Currently, law enforcement officers can take someone they believe to be mentally ill, drug dependent or developmentally disabled into custody for emergency detention. The person has to pose a danger to themselves or others and can’t be detained for more than 72 hours. 

A county department has to approve the need for detention and can't do so unless a mental health professional has performed a crisis assessment. 

Under the bill, law enforcement couldn’t transport an individual for detention from an emergency room until a hospital employee or medical staff member who is treating the individual approves the transfer. 

The Wisconsin Hospital Association spent almost three years negotiating with the Wisconsin Counties Association on the proposal, which they say remedies a regulatory conflict between state and federal law.

“This legislation does not change the process to initiate an emergency detention, but necessarily and correctly leans on the medical judgment of healthcare professionals in hospital emergency departments to ensure a patient transfer is medically appropriate,” Matthew Stanford, WHA general counsel, wrote in testimony.

Sarah Diedrick-Kasdorf, deputy director of government affairs for the Wisconsin Counties Association, wrote in testimony that "there was significant back and forth" between providers and counties as they developed the bill.

The counties association is comfortable with the proposal's language, she said. She acknowledged that changes to the law are difficult given the number of players involved and "an already complicated section of the statutes."

In its testimony, WHA said the bill would also address a recent attorney general opinion that found immunity for those who act in accordance with Wisconsin emergency detention statute doesn’t extend to healthcare providers. Some providers are concerned that they may be liable to a patient or third party if the county or law enforcement decides to let a patient go against medical advice, according to WHA.

“This bill provides better clarity in statute so that a healthcare provider’s liability to an individual or third party more is more clearly limited to the healthcare provider’s authority to seek, but not impose, an emergency detention on the individual,” Stanford wrote. “The bill further clarifies that a healthcare provider may fulfill a duty to warn by contacting law enforcement or the county crisis agency.”

Kit Kerschensteiner, Disability Rights Wisconsin managing attorney, has concerns about the bill since the processes around emergency detention can get complicated.

“It gets messy,” she said. “There should be more people at the table to discuss how this would work and come up with a viable solution.”  

Kerschensteiner also raised concerns about liability under the bill.

Jonathan Safran, a Milwaukee personal injury attorney, said he had concerns about part of the bill that would insert those who determine that transfer of an individual is medically appropriate into current law that governs the liability of others involved in the emergency detention process. 

“I’m not a fan at all with putting in legislation an indication of to how someone should be relieved of any potential liability,” he said. “I’m not a fan when there’s a presumption that someone acts in good faith and then I’m not a fan when it provides what one needs to prove that someone didn’t act in good faith.”

The State Public Defender’s Office provides representation for commitments under the same chapter of law that includes emergency detentions. They’re currently reviewing the bill.

“State and federal statutes and case law govern this process,” spokesman Randy Kraft said in a statement. “The SPD is cognizant of the challenge in balancing the liberty interests against the necessity to conduct needed medical procedures.”

Both the Badger State Sheriffs' Association and the Wisconsin Sheriffs and Deputy Sheriffs Association are neutral on the proposal. 

By Julie Doniere, MD
WACEP Board of Directors

There is a dark, smelly staircase leading from the parking garage into my Emergency Department.   Five years ago when I climbed those stairs at the beginning of my shifts, I distinctly recall feeling like I was walking down to the gallows.  In retrospect, I was completely burnt out and I now recognize that one of the things sucking the life out of my soul was the constant head-butting with my patients over opiate prescriptions.  

Admittedly, I still don't ascend those steps on the wings of doves; however, after becoming more involved and educated about the opiate epidemic my work-related stress has substantially subsided. 

It is important for us to realize that emergency physicians did not cause the opiate crisis!  New research led by the Mayo Clinic shows opioid prescriptions from the ED are written for a shorter duration and smaller dosage than those written elsewhere.  Similarly, a study recently published in the Annals of Emergency Medicine, also demonstrates that patients who receive an opioid prescription in the ED are less likely to progress to long-term use. We may not be the cause of the problem, but we sure have to deal with its outcome every shift at work. We are fortunate to be practicing in Wisconsin at this time, as our state has been particularly proactive in this arena.

Changes that Wisconsin has implemented over the past few years have been impressive.  State Representative John Nygren put together a forward thinking and very effective initiative on opioid prescriptions, the EPDMP has been a useful tool for all ED physicians, and the number of prescriptions for opiates has fallen across the State. WACEP has, of course, been an active presence throughout this journey. Milestones include publishing statewide best practices and information handouts for opiate prescribing in the ED, providing original EM-specific CME to comply with the mandatory opiate education requirements, and having emergency physician and WACEP member Tim Westlake honored by the Wisconsin Medical Society as a physician citizen of the year for his dedicated efforts in combatting the opioid epidemic.

Most recently, I attended the October meeting of the Wisconsin Coalition for Opiate Prescription Reduction on WACEP’s behalf. At the meeting, key stakeholders highlighted steps that our state has taken in the opiate crisis and outlined a vision for the future.  As mentioned earlier, it has been shown that the ED has not been the prevalent source of narcotic prescriptions.  OB, Neurology, and Primary Care were well represented at this meeting.  They, too, have curtailed their prescriptions greatly.  That is encouraging news of course; however, as it has become more difficult and costly to attain prescription narcotics, there has been a dramatic rise in heroin abuse.  It is heartening that the Wisconsin state legislature is directing its focus towards the treatment of that abuse and that funding for treatment centers is increasing.  WACEP will continue to negotiate to ensure equal access to those in need across our state.

So, continue to fight the good fight.  Please know that WACEP will continue to work with the legislature to increase funding and access to treatment of opiate abuse. 

Oct. 12, 2017 WMS Medigram

In partnership with the Wisconsin Department of Justice (DOJ) and the Drug Enforcement Administration (DEA), local law enforcement agencies will be holding Prescription Drug Take Back Day on Saturday, Oct. 28. Police and sheriffs’ departments will host events throughout Wisconsin as part of the Take Back Day.

In partnership with the Wisconsin Department of Justice (DOJ) and the Drug Enforcement Administration (DEA), local law enforcement agencies will be holding Prescription Drug Take Back Day on Saturday, Oct. 28. Police and sheriffs’ departments will host events throughout Wisconsin as part of the Take Back Day.

The goal of Prescription Drug Take Back Day is to provide a safe, convenient and responsible means of disposal of unused or expired prescription drugs, while also educating the community about the potential abuse and consequences of improper storage and disposal of these medications.

Drug take back days are held each spring and fall across the country, and according to Attorney General Brad Schimel, the April 2017 Drug Take Back events in Wisconsin reached a record-breaking collection of 66,830 pounds of unused medications. Wisconsin had more law enforcement agencies participate in the biannual event than any other state in the country with 267 police and sheriffs’ departments from 69 counties hosting 150 events.

In addition to the semiannual Take Back Day event, there are 328 permanent drug disposal drop boxes throughout Wisconsin, providing citizens a convenient, environmentally friendly and anonymous way to dispose of unused medications all year. Wisconsin has more drug disposal boxes than 46 other states, behind only California, Texas and Pennsylvania.

For more information, including a list of accepted medications, visit the DOJ’s website. Additional information also is available on the “Dose of Reality” website, which features an interactive map people can use to find a drug take-back location near them.

Whether lawmakers should reform the state’s workers’ compensation program is shaping up to be a top legislative issue this fall. Business and labor groups contend that treatments are too expensive and see a fee schedule as a solution. Provider groups tell a different story. They say costs per claim are below the national average, while patient satisfaction rates remain high and workers return to the job faster than other states. 

Learn more about the latest legislative proposal, including new efforts to combat opioid abuse, at a Wisconsin Health News panel, Tuesday Nov. 7 in Madison.  Panelists:

• Joanne Alig, Senior Vice President of Policy and Research, Wisconsin Hospital Association
•  Mark Grapentine, Senior Vice President of Government Relations, Wisconsin Medical Society
• Chris Reader, Director of Health and Human Resources Policy, Wisconsin Manufacturers & Commerce

Learn more and register

The deadline for Wisconsin medical license renewal is approaching—Oct. 31, 2017, for MDs and Feb. 28, 2018, for DOs—and new this cycle is the Medical Examining Board (MEB) requirement for most physicians to complete two CME credits on its Opioid Prescribing Guideline. 

Upon renewal, physicians must attest that they have completed the required opioid prescribing CME or will by Dec. 31, 2017. Only MEB-approved courses satisfy the mandate. All physicians should maintain a record of their participation; however, documentation is required only in the event of an audit.

Register for WACEP's on-demand webinar and obtain your required opioid prescribing education today!

September 19, Wisconsin Health News

Attorney General Brad Schimel has joined the chief legal officers for 36 other states and territories to ask that insurers revise policies to reduce opioid prescribing. 

Schimel and the other attorneys general wrote Marilyn Tavenner, the CEO of America's Health Insurance Plans, requesting that her members review payment and coverage policies to prioritize non-opioid pain management. 

"We have witnessed firsthand the devastation that the opioid epidemic has wrought on our states in terms of lives lost and the costs it has imposed on our healthcare system and the broader economy," Schimel and others wrote. 

They added that they'll soon be working with state insurance commissioners and others "to initiate a dialogue" with insurers to identify practices that can reduce opioid prescription and those that don't.

"The status quo, in which there may be financial incentives to prescribe opioids for pain which they are ill-suited to treat, is unacceptable," the attorneys general wrote. "We ask that you quickly initiate additional efforts so that you can play an important role in stopping further deaths."

Cathryn Donaldson, spokeswoman for America's Health Insurance Plans, said they share the attorneys general's commitment to addressing the opioid epidemic. Health plans cover approaches to pain management that include more cautious opioid prescribing, careful patient monitoring and other treatments, she said.

Many health plans have already instituted programs that are helping to "dramatically reduce how much - and how often - opioids are prescribed," she said.  

"By working together, doctors, hospitals, health plans and policy leaders can provide people with better pathways to healing - without putting their lives in danger because of opioids," she said.

In July a State Court of Appeals decision in the Mayo v. WIPFCF case ruled unconstitutional Wisconsin’s $750,000 cap on non-economic damages for medical malpractice cases (passed by the Legislature in the late 1990’s).  The case has been appealed to the Wisconsin Supreme Court and awaits the Court’s decision (which is anticipated to occur in the next couple of weeks) on whether they will take the case; most court watchers believe they will do so. 

The case has great significance for Wisconsin’s medical liability climate.  Facing many other medico-economic challenges, and building from Doctor Day partnerships, WACEP has taken the lead organizing a coalition of eight specialty medical societies to petition the Court to be named Amici (“friends of the court”) -- non-parties to the original case who may be affected by, or who can offer unique insight into the impact of the Court’s ultimate decision.  

If granted Amici status, the coalition will work together to submit a brief explaining to the Court the potential impact on specialty physicians and their patients.  No doubt many similar briefs will be offered in a case of this significance, and it is anticipated the Court will set a briefing schedule later this fall.

You may recall that for several years, WACEP has attempted to work cooperatively with the WI Department of Health Services (DHS) to educate staff about Wisconsin’s worst-in-the-nation rates for reimbursement of Emergency Physician Services in Wisconsin’s Medicaid programs, and seek "fair" reimbursement at least on par with surrounding states.  Having once again experienced empathy without action from DHS, WACEP undertook a more aggressive legislative solution this year. 

As a part of the State Legislature's Joint Finance Committee’s (JFC) review of the 2017-19 State Budget, Representative John Nygren led an effort to require DHS to create a study group made up of Medicaid program staff and outside Emergency Physicians to examine care provided to Medicaid patients, search for ways to save money, and make recommendations back to JFC.  The goal was to find savings in the system that could then turned back into increasing reimbursements for Emergency Physician Services – ultimately costing the Medicaid program nothing more. 

This study group, if successful, would have served as a model for other private-public efforts.  The JFC ultimately incorporated a requirement for an Emergency Physician Study Group, and it was approved by the full Legislature in September.  

Unfortunately, Governor Walker vetoed the provision (along with 99 other items, many of them similar studies or reports from agencies) this week, stating in his veto message that the study duplicated existing “managed care and care coordination efforts in the DHS.” 

With healthcare reform, the ACA, discussions about future Medicaid program funding and block grants all still in flux in Washington, these discussions are far from completed, and we will plan to regroup and continue these efforts in the coming months. 

Many thanks to Lisa Maurer, MD, WACEP Board member who spearheaded the effort, as well as to all of you who responded to WACEP’s recent Legislative Alerts asking you to contact the Governor’s office.

Enhancing the pediatric readiness of the nation’s emergency departments (EDs) to care for children is of utmost importance to improve the quality of care and outcomes for ill or injured children. Wisconsin Emergency Physicians are encouraged to participate in pediatric ED readiness initiatives.

The US Department of Health and Human Services Health Resources and Services Administration (HRSA) EMS for Children (EMSC) Program and the EMSC Innovation and Improvement Center (EIIC) have partnered with the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association to support a pediatric quality improvement collaborative. The collaborative began in April 2016 and efforts are ongoing with a goal of working with existing emergency care systems to improve and encourage pediatric readiness based on compliance with the 2009 joint policy statement, “Guidelines for Care of Children in the Emergency Department (ED).”

 In 2013 the National Pediatric Readiness Project provided a baseline assessment of the nation’s capacity to care for children in an emergency. This assessment identified that the majority of children are cared for in community and rural emergency departments rather than specialized hospitals such as children’s hospitals. It was also noted that the readiness of these institutions to care for the emergency needs of children varied greatly (www.pedsready.org).

Pediatric readiness programs assist state and territory-specific teams in working closely with stakeholders to identify criteria and characteristics, and to supply resources such as policies, procedures, and equipment, to best meet the needs of children within their own state or territory.

Additional Resources:

• Guidelines for Care of Children in the Emergency Department policy statement (link)
  
• EMSC Innovation and Improvement Center (link)
  

Contacts:

• Ms. Loren Rives, Senior Manager, Academic Affairs, ACEP
  
• Dr. Madeline Joseph or Dr. Kathleen Brown, ACEP Liaisons on the EIIC