CMS Untethers Pain Quality Metrics from Reimbursement

Until now, pain management questions on patient satisfaction surveys have been seen by some physicians as a barrier to moving toward optimal use of opioids in emergency care.  Many thanks to our member, Dr. Timothy Westlake, for working with Senator Ron Johnson (R-Wis) on legislation known as the Promoting Responsible Opioid Prescribing (PROP) Act, which prohibits those pain management questions on satisfaction surveys from being used to calculate Medicare reimbursement. 

Due to the support seen for the PROP Act as well as feedback from the medical community during the comment period, the Department of Health and Human Services finalized a rule implementing provisions of the PROP Act to help curb the opioid epidemic.

“I applaud the administration for implementing my bipartisan, commonsense solution to fight the opioid epidemic,” said Sen. Ron Johnson (R-Wis.), chairman of the Senate Homeland Security and Governmental Affairs Committee.  During the Committee’s field hearing in Pewaukee, Wisconsin, in April, Dr. Westlake, the Vice Chairman of the State of Wisconsin Medical Examining Board, testified that the PROP Act is “the single-most important piece of legislation reform that [policymakers] could do.”  

“Physicians must be free to exercise their best judgment when prescribing the proper level of pain medication – that’s what patients and taxpayers expect,” said Johnson.

Wisconsin, ACEP has developed Opioid Prescribing Guidelines specific to emergency medicine. Members are encouraged to download and post these guidelines, and also to attend the WACEP 2017 Spring Symposium on March 28 in Madison when up-to-date education and information on opioid prescribing will be presented. 

Asymptomatic Bacteriuria: Are Emergency Physicians Part of the Problem or Part of the Solution?
Bobby Redwood, MD, MPH

A 72 year-old female presents from your local nursing home with altered mental status. She's comfortable and conversive with normal vital signs and no pain on exam, but thinks its 1956 and calls you and all your staff, "Ralphie". You're handed seven pages of medication administration records without any past medical history or history of present illness. You call for additional information, but they just had a shift change and no one at the facility is able to tell you what happened. After a head CT, chest Xray, EKG and rainbow labs, the only abnormal finding is a urinalysis with bacteria, pyuria, nitrites, and leukocyte esterase. Your nurse reports the urine was dark and foul smelling.

Alright Ralphie, this is where the rubber hits the road...what do you do?

If you are like me, you are probably tempted to do a quick fist pump because you found something to treat, order a gram of ceftriaxone, admit the patient to the medicine floor and get on with your shift. Depending on where you work, this method of management may earn you a talking to from the nursing home director or your infectious disease department. You may find yourself being shamed for practicing sloppy medicine and contributing to antibiotic resistance. Deep down, you have doubts that the bacteriuria caused the altered level of consciousness, but you were practicing in the real world, with little clinical background on the patient, and needed to make a game day decision...what's an emergency physician to do?

Asymptomatic bacteriuria (also known as an asymptomatic urinary infection) is defined as an isolation of bacteria in an appropriately collected urine sample without signs or symptoms to a urinary infection (sorry folks, altered mental status is not a sign of a UTI). The prevalence of asymptomatic bacteriuria is between 5-7% in healthy adult women, but skyrockets to 10-50% in the nursing home population and nearly 100% in patients with chronic indwelling catheters. 

There was a time when all asymptomatic bacteriuria was treated as though it were a clinical UTI. The practice started because pregnant women with asymptomatic bacteriuria frequently went on to develop pyelonephritis. When the asymptomatic bacteriuria was treated, no pyelonephritis ensued. Clinicians of that era hypothesized that asymptomatic bacteriuria was consistently harmful in all populations and thus warranted antimicrobial treatment. This turns out not to be true; outside of pregnancy and patients undergoing urologic procedures, treating asymptomatic bacteriuria gives your patient all the risks of antimicrobial therapy with none of the benefit. Adding insult to injury, the practice of treating asymptomatic bacteriuria contributes significantly to the public health threat of antimicrobial resistance (especially in nursing home populations). Ready for a shock? A 2014 report from the CDC estimates that 39% of antibiotics prescribed for "UTI" were not necessary. The data is there, but so is the dogma...so I ask you again...what's an emergency physician to do? 

By arming ourselves with information, we can develop an approach to asymptomatic bacteriuria that is reasonable, defensible, and protects the public health without jeopardizing the health of the individual patient. Here are some common myths about UTIs and asymptomatic bacteriuria:

• Smelly pee = UTI. Foul smelling urine or change in urine appearance does not correlate with infection. It is usually related to hydration status.
• WBCs = UTI. Pyuria is inflammation within the genitourinary tract and is measured as WBCs in the urine. It is a common accompaniment of asymptomatic bacteriuria and should not influence decisions about antimicrobial therapy.
• Leukocyte esterase and/or nitrites = UTI. Not so fast, leukocyte esterase suggests pyuria and nitrites suggest bacteria--either of these could be present in asymptomatic bacteriuria, so clinical context (i.e. symptoms) really matters.
• Positive culture always means UTI. A good specimen has fewer than five epithelial cells per low-power field on urinalysis. A "positive" culture is meaningless if the sample was contaminated.
• UTI is a common cause of altered mental status in the elderly. Actually it is an uncommon cause and this type of anchoring bias can work against us in terms of uncovering the true cause of our patient's altered mental status. Before you think UTI, think of more common (and also more subtle) etiologies like medication reactions, sundowning, dehydration or sensory impairment.

Let's get back to our patient; she's altered, her urinalysis sure looks "positive", and she lives in a nursing home that is likely covered from floor to ceiling in a thin film of gram positive rods, so I ask you yet again...what's an emergency physician to do? 

• First, check prior records to see if her urinalysis always appears "positive", you may discover a trend of asymptomatic bacteriuria. 
• Second, recall that UTI is an actually an uncommon cause of delirium and the chances that your patient has occult bacteremia from a urinary source are low. 
• Third, do not administer antibiotics and let your admitting physician know that you are consciously resisting the urge to treat the "UTI" in favor of uncovering the more likely alternate cause of her altered mental status.
• Lastly, check your inbox to read emails of praise from your infectious disease and long term care colleagues--you, my friend, are a cautious physician and a noble steward of antibiotics!

In summary, inappropriate treatment of asymptomatic bacteriuria is a big problem. Some of us are part of the problem, others are part of the solution. If 39% of the antibiotics prescribed for UTIs are unneccesary, we have some work to do in terms of educating our workforce and our patients about asymptomatic bacteriuria. If this is a topic that is relevant in your ED, think about sitting down with your inpatient team and hammering out a protocol to ensure a uniform approach towards asymptomatic bacteriuria. 

Want to learn more? Check out this 2016 article on the topic by Wisconsin emergency physician Jeff Pothof!

Bottom line: "Elderly patients with acute mental status changes accompanied by bacteriuria and pyuria, without clinical instability or other signs or symptoms of UTI, can reasonably be observed for resolution of confusion for 24–48 h without antibiotics, while searching for other causes of confusion" [J Emerg Med. 2016;51(1):25-30].

Wisconsin Health News 

The Medical Examining Board approved a revised version of a rule defining telemedicine Wednesday. It now heads to Gov. Scott Walker's office and then the state Legislature for approval.  

The board has spent the last year drafting the rule, scrapping its original proposal after healthcare providers raised concerns. The final rule clarifies that a physician-patient relationship can be established through telemedicine and provides guidelines on equipment and technology as well as internet diagnosis and treatment. 

"The two different versions of the telemedicine rule are pretty stark," said Mark Grapentine, senior vice president of government relations at the Wisconsin Medical Society. "One was super-detailed and lengthy, the other one is much more flexible and probably usable by the board itself." 

The Alliance of Health Insurers also backed the rule. "Telehealth is a means to improve upon the high-quality healthcare system we already enjoy, particularly by improving patient access, regardless of distance and mobility," Executive Director R.J. Pirlot wrote in testimony. 

Claudia Tucker, vice president of government affairs for Texas-based TelaDoc, said they're pleased that the board accepted their recommendations to address HIPAA concerns and said they also support the latest version of the rules. 

But some testimony questioned whether the rule could be construed to prohibit other healthcare professionals from providing care through telehealth. Linda Roethle, vice president of regional business development at Bellin Health, said that more than just physicians and physician assistants should be covered under the rule, including nurse practitioners, clinical psychologists and clinical social workers. "Please do not create any additional barriers for patients," she wrote in her testimony.  

Tine Hansen-Turton, executive director of the Convenient Care Association, recommended language stipulating that nurse practioners can practice telehealth. The association represents clinics located inside retail locations like grocery stores and pharmacies. "Wisconsin's retail clinics are primarily staffed by nurse practitioners," Hansen-Turton wrote. There are 35 retail clinics in the state, according to her testimony.

Dr. Kenneth Simons, board chair, said the board can't create rules for professions it doesn't oversee. 

WACEP to offer opioid-specific education at 2017 Spring Symposium

Now in effect, a Wisconsin Medical Examining Board emergency rule requires continuing medical education (CME) on opioid prescribing guideline. The CME requirement is one component of a comprehensive statewide strategy to address prescription drug abuse in the best interest of public health and safety.

To address the requirement, WACEP is incorporating an opioid educational component into the Spring Symposium schedule. Mark your calendars and plan to attend the symposium, scheduled to take place on Tuesday, March 28, 2017 at The Madison Concourse Hotel, Madison, WI. Plan also to stay in Madison the following day for Doctor Day 2017. 

The conference planning committee has been working with members of the MEB. While details are still being finalized, preliminary indication is that the Spring Symposium curriculum will be approved to meet the state's educational requirement.

Also on the opioid front, WACEP has been invited by Tim Westlake, MD, Vice Chairman of the Medical Examining Board and Chairman of the Licensing and Controlled Substances Committees, to participate on the Wisconsin Coalition for Prescription Drug Abuse Reduction. WACEP will be represented on the Coalition by Board Member Julie Doniere, MD, and will have an opportunity to showcase WACEPs' efforts in combating the opioid epidemic. 

WACEP Spring Symposium event registration will soon be available. Visit the WACEP Conference web page for schedule information, and check back to register. In the meantime, See below and book your lodging through the WACEP room block today!

Wisconsin Health News

Heathcare organizations called on Gov. Scott Walker's administration and lawmakers to consider the impact that self-funding the health plan for state and local employees could have on Wisconsin's healthcare market. 

Fourteen groups, including the Wisconsin Chapter, ACEP, Wisconsin Counties Association, Wisconsin Hospital Association and the Wisconsin Medical Society, sent a memo to lawmakers Monday cautioning that the "potential repercussions" of self-insuring "could be far-reaching" and "significant" for the state's taxpayers and economy. 

The Department of Employee Trust Funds has issued a request for proposals to self-insure the health plan for state and local employees. In such an arrangement, the state would take on the risk for the roughly 250,000 state and local employees, as well as their families, currently covered under the program. 

The proposal could reduce the number of HMOs serving the program. It could also save the state up to $42 million, according to one report. A different report said the move could save $20 million or cost the state up to $100 million. Walker has said any savings would go to education. 

The 14 organizations called on the state's Group Insurance Board, members of the Joint Finance Committee and Walker to "fairly compare" the results of the RFP to the current system, evaluate "possible significant risks to state taxpayers" and assess whether self-funding protects the competitive strength of the state's health insurance market. 

"The State Group Health Program has been remarkably successful in using choice and competition to control costs, improve quality and maintain financial stability and value for taxpayers," they wrote. "Any alternative the state considers should be held to this high standard." 

Walker spokesman Tom Evenson wrote in an email that the governor appreciated the input and will take it in consideration. 

"In the end, we will move forward with a plan that is best for Wisconsin," he said. 

Join Wisconsin Health News on December 6th in Madison for a panel presentation on scope of practice, team-based care and the future healthcare workforce. 

The federal health reform law has ushered in a new wave of patients. Meanwhile, the state could face a shortfall of more than 4,000 doctors by 2035, and a 35 percent gap between the demand for nurses and the actual supply by 2040.

So, who is going to take care of all these new patients? How will primary care be delivered in the future? In what areas does it make sense to expand the scope of practice? Where does it not?

A panel of experts will tackle these questions and more during a Wisconsin Health News Panel Dec. 6 at the Madison Club. Panel participants will include: 

• Dr. Dave Clemens, President-Elect, Wisconsin Dental Association
  
• Gina Dennik-Champion, Executive Director, Wisconsin Nurses Association
  
• Eric Elliot, President-Elect, Wisconsin Academy of Physician Assistants
  
• Linda Jorgenson, Former President, Wisconsin Dental Hygienists Association
  
• George Quinn, Executive Director, Wisconsin Council on Medical Education and Workforce
  
• Steve Rush, Vice President, Workforce and Clinical Practice, Wisconsin Hospital Association 
  
• Dr. Ken Schellhase, President-Elect, Wisconsin Academy of Family Physicians

Register now.

Doctors who prescribe controlled substances will have to complete training relating to the Medical Examining Board's opioid guidelines under a rule that went into effect earlier this month. 

The Department of Safety and Professional Services signed off on the emergency rule last week. It requires doctors renewing their licenses to complete two hours of training on the guidelines out of their 30 hours of bienniel mandatory continuing medical education.

Read the rule.

November 3, Wisconsin Health News - A federal grant will help Ministry Health Care expand its telemedicine program to clinics across seven northcentral Wisconsin counties. 

The United States Department of Agriculture announced the $432,258 grant last week. It'll expand a project allowing advanced practice nurse practitioners to consult with physicians and provide care in facilities serving Clark, Forest, Lincoln, Marathon, Portage, Vilas and Waupaca counties. 

"These investments will help provide better healthcare and educational opportunities for rural residents," USDA Secretary Tom Vilsack said in a statement. 

Ministry, which is part of Ascension, plans to add therapeutic services to the program, including dietary and diabetic counseling, tele-psychiatry and post-hospitalization, post-surgical follow-up, according to the USDA.

The project will connect 13 rural clinics and two hospitals to Ministry Saint Claire's Hospital in Weston, according to Ministry spokesman Tom Weaver.  

It will allow Ministry to care for more complex patients within their home communities and has the potential to provide more than 100,000 telemedicine visits during the next three years, Weaver said.  

Ministry's project was one of only seven healthcare projects and the only Wisconsin project funded in the grant cycle. Eighteen projects in 16 states received $4.7 million.

November 2, Wisconsin Health News - The state collected 58,729 pounds of unwanted medications and prescription painkillers during a national prescription drug take back day on Oct. 22, the Department of Justice said Tuesday.

The state's also increased the number of registered permanent medication return boxes in the state to 295. That's nearly double the 152 in September 2015. 

"The fight against this epidemic isn't over, but with continued effort from citizens, we will save lives," Attorney General Brad Schimel wrote in a blog post. 

In late April, the state collected 62,618 pounds of prescription drug. The amount of collected drugs at that point was third in the nation, behind California and Texas.

November 1, WISHIN - WISHIN Connections is the monthly e-Newsletter from the Wisconsin Statewide Health Information Network (WISHIN).  We will keep you up to date with WISHIN activities, news on health information exchange (HIE) and new product developments.

In the October 2015 edition of WISHIN Connections, we outlined the benefits of regional and statewide health information exchanges (HIEs) like WISHIN in enabling collaboration among groups striving for healthcare interoperability. A year has passed and the content of that article is still relevant. But as HIE evolves, questions remain about how all of the options compare and contrast with each other.