June 5, Wisconsin Health News

The Joint Finance Committee approved a Republican plan Tuesday night that would provide around $200 million more in state money for Medicaid beyond its cost-to-continue over the next biennium.

Overall, the Republican proposal boosts state spending for health services by $588 million, which includes $356 million for the cost-to-continue for the Medicaid. 

The proposal, which passed 11-4 along party lines, would provide $60 million more in state money for disproportionate share hospital payments, which head to providers that serve a high volume of Medicaid patients. It would also provide $4 million more in state money for payments that go to rural hospitals.

Other changes include $92 million more in state money for long-term care. That breaks down to $30 million for nursing homes, $36.9 million for personal care workers and $27 million for direct caregivers in Family Care. The motion also includes $24.7 million in additional state and federal money to expand reimbursement for physicians and behavioral health services. 

Democrats criticized the plan because it didn’t take federal dollars to expand Medicaid. The money used for the motion comes at the cost of other parts of the state budget, said Rep. Evan Goyke, D-Milwaukee. 

“This motion advances, by and large, the status quo with additional investment here, and additional investment there, pick a winner here, pick a loser there,” he said. “But it isn’t a plan to bring forward the entire state’s healthcare system.”

JFC Co-Chair Rep. John Nygren, R-Marinette, pushed back against claims that expansion would cover an additional 82,000 people as those covered through expansion can find subsidized health plans through the Affordable Care Act’s exchange.

He noted that around half of those who would be covered by expansion already have insurance.

“That’s the lie of the year that has been presented before us – the lie of the year,” he said. “This motion addresses the needs of the most vulnerable in our state.”

The GOP-backed motion makes greater investments than Evers’ budget in some areas, keeps in place other parts of his plan, pared back some of his proposals and axes other provisions.

It also includes several new items, including a $2.5 million Medicaid rate increase for physical health services providers and $1 million in grants for free and charitable clinics over the biennium.

New to the proposal are $500,000 in state money for a child psychiatry consultation program and $1 million over the biennium for programs that provide clinical supervised practice to those training to become social workers, counselors, psychologists or family and marriage therapists.

Lawmakers also opted to add $100,000 for a suicide prevention grant, $100,000 for an outreach campaign on vaccinations and $250,000 for respite care.

At a press conference before the committee took up the measure, Nygren said Republican lawmakers were tripling the investment Evers put toward nursing homes, as well as making greater investments in personal care and Family Care.

Other provisions stayed in place from Evers’ budget, including providing funding for a hub-and-spoke model of care that would provide a medical home health benefit for people with substance abuse disorders. Lawmakers modified the provision so the Department of Health Services would have to ask the committee to release state funding for the proposal.

Also adopted from the governor’s budget were plans to expand funding for intake, application and screening costs for the children’s long-term care services program, $6.9 million in state and federal funding for telehealth in Medicaid and a $250,000 a year increase for grants under the minority health program. 

GOP lawmakers backed additional money for the Wisconsin Well Woman Program, which provides preventive health screenings. They set aside funds for money that would help public safety answering points comply with training requirements that dispatchers provide assistance on administering CPR. And they backed Evers’ call for DHS to reallocate five full-time positions to staff an infant mortality prevention program.

They also adopted Evers’ recommendation to eliminate the sunset date on Medicaid reimbursement for clinical consultations. And they backed $66,700 in state money to develop a plan for a mental health consultation program.

The motion opts to have the state cover a greater share of county crisis intervention share through a $13.4 million increase in state and federal money as Evers proposed. But the committee deleted a provision in his budget that would have provided $2.5 million in state money for regional crisis stability facilities. 

GOP lawmakers also scaled back Evers’ proposed investments in dental care. They opted to provide $2.5 million in state and federal funding for dental services provided to patients with special needs, half of what was included in the governor’s budget. 

They backed additional funding for dental health initiatives, including Seal-A-Smile, which provides preventative services in schools, but axed a plan to provide more money to support oral health program positions at DHS.

Gone from the proposal is Evers’ plan for $38.8 million for new dental access payments. The lawmakers left in place a program that increased Medicaid rates for pediatric and adult emergency dental services rates in Brown, Marathon, Polk and Racine Counties that Evers’ budget would have ended.

Also pared back were Evers’ plans to hire more dementia care specialists and his lead poisoning prevention initiative.

Provisions cut from Evers’ plan include his proposed funding for doula services, an extension of how long post-partum women can remain on Medicaid after giving birth and a proposed community health benefit to offer non-medical services to Medicaid members.

And lawmakers didn't include proposals for additional funding for tobacco control efforts and $500,000 over the biennium for healthy aging grants.

The adopted motion ends a proposed expansion of Birth to 3, a program offering early intervention services to children who are at risk of developmental delays. It instead directs the department to transfer, on a one-time basis, $2.3 million for the 2019-2020 fiscal year and keeps the budget level flat the following year. 

Nygren ruled a Democratic motion that would have accepted federal funding to expand Medicaid “out of order” as the committee already voted to remove the provision from the budget. 

Lisa Maurer, MD
Immediate Past President

WACEP board members, Drs. Lisa Maurer, Bill Falco and Brad Burmeister [pictured here with U.S. Representative Bryan Steil (R-WI-01)] traveled to Washington DC for the annual Leadership and Advocacy Conference and the ACEP-coordinated visits with Wisconsin’s legislators. 

The conference began with outstanding speakers and breakout sessions on leadership and how leadership might intersect with violence prevention, diversity in medicine, civic duties of physicians as community leaders, and practical tips on how to be an effective advocate for your patients and colleagues.  Wisconsin emergency medicine will certainly benefit from lessons learned. 

As the focus narrowed a bit at the conference to legislative advocacy, Drs Falco, Burmeister and Maurer met personally with staff and legislators from five different offices, including both Senate offices, and informed staff for many other offices from around Wisconsin.  Although there are many issues related to emergency medicine that are important to our legislators, our conversations turned to current and pressing issues for them right now: surprise medical bills and improving care for our patients in psychiatric crises. 

Related to increasing access to care for our patients with psychiatric disease, we spoke in support for recent bills both on the House and Senate that would supply states with grant funds to use as they see most helpful at the local level to bolster psychiatric care.  Discussions around surprise bills were more complicated and detailed, making sure that lawmakers understand that it is important to emergency physicians that our patients are not faced with narrow networks and insurmountable bills as they access crucial emergency care.  We were able to explain that for most cases of “surprise bills,” this is actually a description of high out of pocket costs from unrealistically high deductibles. 

To that end, our legislators were very interested to hear about our suggested mechanisms for ensuring fair payments for emergency care without escalating costs of care, all the while leaving the patient out of the process.  They now understand that while it’s paramount for protecting our patients’ access to care, it’s also very important for protecting emergency physicians as we continue to face challenges in negotiating contracts with insurance companies. 

Overall, our team was comforted to see how well informed our legislators and staff are regarding issues that are important to us.  The lawmakers actively asked for our follow up with them to make sure they keep our issues in the forefront of their minds.  To this end, our board will be asking for help from our members who live and work in the various districts around our state, to make sure these legislators know about how these issues affect you and your patients specifically. 

WACEP President's Message, May 2019
Jeffrey Pothof, MD, FACEP

We as emergency physicians have chosen a demanding career.  Not only do we work days, nights, weekends and holidays, we also play witness to some of the best, and often the worst experiences people and families go through.  Being the ever-present patient advocate can also be an exhausting activity, almost daily having to think outside the box to get patients what they need in a system and society that at times just seems broken.  At the same time the ratio of value-added to non-value-added work seems to be going in the wrong direction.  It’s no surprise that in a recent Medscape survey 48 percent of us reported burnout.

Lately there has been more attention to this issue.  Many have been exploring the “why” and others have been offering suggestions on “what” to do about it.  I’m no expert in wellness and I can’t really tell you how much you should exercise or how you’ll find the time to sleep a little more.  Everyone is a bit different when it comes to connecting with other people and many of us have different ideas of how what we do is part of something bigger than any one of us.  I sometimes struggle to use my electronic health record, so I don’t think I’d be the right one to show you how to use yours.

As I reflect on all the headlines, reports, and studies on wellness among physicians and especially emergency physicians, my first reaction is one of appreciation.  Despite all the reasons you see, hear, and experience you still don your scrubs, throw on the white coat, and head in to the department.  I just want to say THANK YOU to all of you for being such dedicated professionals and standup individuals.  Hats off to you emergency physicians.  Although it sometimes doesn’t feel like it amidst all the distractions, all of you are making a difference in the lives of others however big or small.

For those of you who may not be finding the meaning you need in a demanding career such as emergency medicine, I encourage you to take action.  You are far to valuable to your patients but also to your family and friends.  We need you.  All of us at WACEP are here to support you and there are many resources available to find what works best for you.  ACEP has a dedicated site and section that I encourage you to check out at https://www.acep.org/life-as-a-physician/wellness/. 

WACEP members are invited to collaborate on an AACT grant-funded project initiated by Colorado ACEP to examine providers attitudes toward treating opioid use disorder and initiating buprenorphine/naloxone treatment in the ED. Survey respondents will be entered in a drawing for a chance to win a $100 Amazon gift card. 

On many shifts we see patients whose lives have been negatively impacted by the opioid crisis. Some have overdosed, some have abscesses, and others are requesting opioid pain medications in the ED yet again. We do a great job of treating their acute issue, knowing their addiction will make a repeat visit inevitable. These are the names we recognize as soon as we pick up the chart; the PDMP’s we’ve checked multiple times before. We’re hoping you can help us develop some options.

We are surveying ED providers to determine their experience with and attitudes toward initiating suboxone in the ED. Please head to https://is.gd/EDbupe to participate in our quick survey. 

It’s completely voluntary and any ED provider can take this anonymous survey to see how they feel about ED buprenorphine (commonly called Suboxone) and what tools they need to improve care for patients with opioid use disorder. 

COMIRB# 19-0088 PI: Matthew Zuckerman
Study Title: Attitudes to Emergency Department Medication Assisted Therapy
matthew.zuckerman@ucdenver.edu 

Bradley Burmeister, MD

On May 1^st, over 20 Emergency physicians were among the more than 300 physicians from across Wisconsin to participate in Doctor Day in Madison.

The two main policy issues for this year focused on Medicaid reimbursement and the personal conviction waiver for immunizations.  

As you know, Wisconsin continues to be at or near the bottom for Medicaid reimbursement. In fact, for most Emergency Department levels of service, Wisconsin is dead last for reimbursement often at rates far below overhead costs. Adequate and fair Medicaid reimbursement is important in order for patient to have access to both primary and specialty physicians.

In general, legislators provided feedback that they understand the Medicaid issue is regarding access. Many had a very strong understanding, and realize the issue is not just about the bottom line for physicians.

This year’s particular “ask” regarding Medicaid was focused on institutional versus non-institutional payments. The Governor’s budget includes Medicaid expansion and with expansion, over $300 million dollars would become available. The budget, however, allocates all of these funds as institutional payments to hospitals and health systems, and not toward physicians or other non-physician providers.

The second issue was around support of proposed legislation to end the personal conviction waiver for school-mandated vaccines. Wisconsin is one of only 18 states that continue to permit a personal conviction to waive the requirement to have vaccines for school-aged children. In many states, parents can seek a medical waiver or a religious waiver. But only a few states, including Wisconsin, allow parents to essentially check a box exempting their children from the vaccine requirement. Since 1997, Wisconsin has seen a significant increase in parents obtaining a vaccination waiver. While medical and religious waivers, which represent less than 1% of all waivers, have not increased over time, the personal conviction has seen a steady and dramatic increase and represents the vast majority of total waivers. 

Legislation has been introduced that seeks to end the personal conviction exemption but continues to permit medical and religious waivers. As you know, the science is clear on immunizations, and we must maximize our “herd immunity” for the betterment of the whole community.

To summarize, Doctor Day 2019 was a tremendous success. To continue our advocacy efforts, several of us from WACEP leadership are now in Washington DC to participate in ACEP’s Leadership and Advocacy Conference. There, we will meet with legislators and staff from Wisconsin, and will engage in advocacy at the national level. Stay tuned for additional updates, and in the meantime, save the date for Doctor Day 2020, scheduled for January 29, 2020 in Madison. We hope to see you there!

Prescribed pain medication after surgery and traumatic injury is among the most common first exposures to opioids. SPOTS offers an opportunity for collaborative learning with experts about best practices in opioid prescribing, and with other providers around the state about the current challenges and opportunities in treating our injured patients’ pain.

Between March and September, the program offers a monthly session hosted from the teleconference facilities at the University of Wisconsin. Each are hour-long session will start with a 15-20 minute didactic presentation from an expert in the field, followed by an open conversation between our expert presenters and the participants. 

The May 23, 2019 session will begin at 4:00 pm and will feature Drs. Mike Repplinger and Benjamin Schnapp, who will present "Opioid prescribing for surgery and trauma in the Emergency Department." Register here.

Participants will receive Opioid CME credit, and may either attend live or view recorded sessions online. Note that if you prescribe controlled substances, Wisconsin’s Medical Examining Board requires that you earn two CME credits on responsible opioid prescribing between 1/1/2018-1/1/2020. Each session in the SPOTS series counts toward one hour.

SPOTS is a collaborative learning series presented by the South Central Wisconsin Healthcare Emergency Readiness Coalition (SCWIHERC), South Central Regional Trauma Advisory Council (SCRTAC), and the Surgical Collaborative of Wisconsin (SCW), through a generous grant from the Wisconsin Department of Health Services.

Meet your Wisconsin Colleagues for a Reception during SAEM!

WACEP Members are invited to join the University of Wisconsin Department of Emergency Medicine for a sponsored event at SAEM's 2019 Annual Meeting in Las Vegas. 

Wednesday, May 15 at 6:00 pm
The Loft at Cabo Wabo
3663 Las Vegas Blvd. South
Las Vegas, NV 89109

Please RSVP by Friday, May 10th .

Jeff Pothof, MD, FACEP
WACEP President

You know we all practice in a special place when you can run in shorts and a t-shirt and two days later be shoveling a few inches of snow.  With the warmer weather comes an important annual event in the state. 

Known as “Doctor Day” we all have an opportunity to don a white coat and engage in face to face conversation with those individuals whose decisions affect not only our practice, but the lives and wellness of our patients.  This year is particularly impactful for us as emergency physicians as we have many issues important to our specialty that need legislative support.

For those of you who have participated in the past, thank you.  If you’ve never attended a Doctor Day and can find some time to get away on May 1^st I’m certain it would be worth your effort.  WACEP will be hosting a private policy primer update beforehand to prepare all of you on the key issues. The Doctor Day agenda itself promises to be high yield.  We have Wisconsin’s governor Tony Evers slated to speak and the topics that will be front and center for the day include Medicaid access and the historically low reimbursement rates in Wisconsin, as well as the extremely hot topic of childhood vaccination and personal conviction exemptions.  I’m nearly certain all of you have an opinion on that topic.  The day wraps up with time for you and other providers to talk with legislatures, and finishes with a reception close by at Madison’s on King.

For more details and the link to register please visit https://www.widoctorday.org.

Lisa Maurer, MD
Immediate Past President, WACEP

As a part of replacing the Sustainable Growth Rate (SGR), CMS has deemed that we must start reviewing "appropriate use criteria" (AUC) before ordering any CT, MRI, PET, or nuclear medicine studies (does not apply to Xray, U/S).  The American College of Radiology (ACR) has been approved as an eligible group to participate in defining what is and isn’t “appropriate.” 

Starting in 2021, if an ordering physician does not demonstrate through an EHR Clinical Decision Support tool (CDS) that they have consulted the AUC for the study your ordering, CMS will not reimburse the professional or technical charges for the study. 

To clarify, you have to review the AUC, but not necessarily adhere to them.  Emergency physicians will find it to be important because CMS also gives radiologists the green light to refuse to do the studies for which appropriateness criteria were not reviewed.  This system is already in place in the ambulatory care setting.  It will be implemented in the emergency department in less than a year, on Jan 1 2020, but the first year is for "education and operations" and no claims will be denied.  As patterns amongst insurers normally happen,  we can certainly expect commercial insurers to follow suit soon thereafter.  This follows a trend happening for having higher standards for "indications" for studies we order, as already evidenced by our dropdown boxes, etc when you order any image. How this will work in practice for testing from the ED is unclear.

1. These criteria do not apply for patients that have an Emergent Medical Condition as defined by EMTALA.  However, this is a rather high bar that arguably some of our patients do not meet, and we all know the reputations of payors for determining if care was "emergent" based on final diagnosis rather than presenting symptoms.  
2. The regulations released from CMS specifically name EDs as being a place of service where these AUC apply. 

Given the above somewhat conflicting information, our hospitals will likely roll this out for all CTs, V/Qs, and MRIs that are ordered from the ED, not excluding patient care that we determine in the moment to be for someone having a true Emergent Medical Condition. 

What will this actually look like in real practice?  It would be reasonable to expect a more extensive clicking process as you enter the order rather than just choosing the indication in a drop down.  In order to minimize impact on workflow, ideally it would just be a modified drop down to choose the most applicable (predetermined to be appropriate) criteria, with an additional option to demonstrate that you have reviewed the criteria and feel it appropriate to deviate from them.  Hospitals will have to invest in CDS as an adjunct to the EHR, or the existing EHR will have to be updated to meet this need.

Reviewing a couple specific examples of “appropriateness” scores helps to clarify what a future rollout in our workflow may look like.  Take a look at the table from ACR grading various studies looking for aortic dissection.  Graded on evidence for utility and radiation exposure.  Doing a PET scan, for example, would be considered "usually not appropriate" but MRA/CT/echo would all be considered "usually appropriate." 

For a more common example, consider head CT imaging for head injury.  ACR describes that a noncontrast head CT is “usually not appropriate” for patients with GCS of at least 13 that do not meet criteria for imaging based on New Orleans Criteria, Canadian CT Head Rules, or NEXUS II guidelines.  However, if GCS is less than 13 or if imaging is indicated based on the above listed guidelines, then the head CT is “usually appropriate.” 

What should you do now?  Contact your hospital administrators to see how they are planning to meet this requirement:

1. Prevent this from creeping to other imaging study orders such as X-rays, ultrasounds, etc. 
2. Make sure that whatever EHR adaptations are done are sensical and workable.  ACEP recommends the CDS created by the ACR, called "ACR Select."  We should not be expected to access an external web portal for our CDS, which also exist.  
3. If the workflow is clunky, we need to have a process in place to bypass choosing criteria for studies that must be done immediately for critically ill patients. 

References:
ACEP summary article from March 2017 (link)
ACR site for CDS (link) 
Complete list of ACR appropriateness criteria organized by clinical topic (link)

Bradley Burmeister, MD, Emergency Medicine Delegate to WMS 

The Wisconsin Medical Society House of Delegates met on Sunday, April 7, 2019.  Several Emergency physicians participated in the annual policy-making function of the society. Three resolutions introduced and sponsored by WACEP were discussed and accepted as policy. 

The first resolution, Assessing Medical Stability of Patients with Acute Mental Health Needs in the Emergency Department, seeks to form consensus principles on the utility of the Emergency department to provide medical clearance and hopefully expedite the process to make it more patient-centered. 

The second resolution, Addressing Mental Health Treatment Barriers Created by the Medicaid IMD Exclusion, asks the Society to provide information on the exclusion to interested membership and support a Medicaid waiver demonstration application that seeks to receive federal financial participation for Institutions for Mental Diseases services provided to Medicaid beneficiaries. The IMD exclusion is a decades-old law that was intended to pass the cost of mental health treatment to the states. It prevents federal Medicaid dollars from be utilized for certain inpatient psychiatric care. This exclusion has contributed to the challenges of financing, and therefore placement of inpatient psychiatric care for the Medicaid population. 

The final resolution seeks to revise the Wisconsin Psychiatric Bed Locator. This portal is meant to provide up-to-date information on psychiatric bed availability; however the information available is not always up-to-date or accurate, and the system has not been utilized by most emergency departments. This resolution brings together psychiatrist and emergency physicians to help improve effectiveness of the application. 

Lastly, the WMS Board presented an informational report outlining a proposed revision of the organization’s Constitution and Bylaws, whereby the policy-making body of the Society would transfer from the House of Delegates model to the Board of Directors. It was reported that several other states have successfully transitioned to this governance model. The new process would seek input from members throughout the year, rather than once per year as is done under the current model, and would provide a significant cost-savings to the organization. The proposal will be discussed and potentially voted on at the 2020 House of Delegate meeting next April.

If you have any interest in collaborating on behalf of emergency physicians at the Wisconsin Medical Society or beyond, or if you’d like further information on the items of business discussed at this year’s House of Delegates, please feel free to contact me.