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 1st 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 30th. 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 14th-15th 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