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March 2018 President's Message - Substance Use Disorder Treatment in the ED 0 A. Moulin Substance Use Disorder Treatment in the ED By Aimee Moulin, MD, FACEP When I was a resident at LA County Hospital, one of our frequently flyers - I’ll call her Janet - was an intermittently homeless women in her mid 40’s with bright blue eyes and wavy, gray brown hair. Janet would complement my earrings or shoes in a way that you could tell she had once cared a lot about her looks. She’d lived for many years with addiction to alcohol, benzos, and opiates. Perhaps Janet sold the Norco we gave her; she was once caught trying to buy another patient’s shoes in exchange for her Norco. Janet could be manipulative, belligerent, and occasionally combative; but we took care of her so often in the emergency department (ED) we’d come to adopt her. Sometimes on my way to work I’d give her $5 as I passed her panhandling in front of the hospital. She was a permanent fixture of my residency, until the day she was found dead alone in a hotel room. In the hundreds of times I had taken care of Janet not once did I talk to her about addiction, or offer treatment for her substance use disorder.   According to the 2014 National Survey of Drug Use and Health, 20.2 million Americans have a substance use disorder.1 It will not surprise anyone who has worked in an ED that substance use disorders are highly prevalent in ED populations.2 The Drug Abuse Warning Network (DAWN) estimated there were 5.1 million drug related ED visits in 2011.3 The actual number of ED patients with substance use disorders is likely much higher.4-6 In one multi-center study, as many as 64% of adult ED patients met criteria for problematic substance use.6 Yet, few are in treatment.4,7 Patients with untreated substance use disorders are 81% more likely to require hospitalization during their ED visit and 46% more likely to have had an ED visit in the prior year, with the estimated additional hospital charges numbering $777.2 million.7 Patients with substance use disorders are over represented in our high-utilizer populations.8,9 We often have multiple opportunities to intervene and address the underlying reasons for the ED visit. There is a growing body of evidence to support ED interventions for substance use. Recent studies have shown cost-savings, decreased substance use, and increased engagement in treatment programs after Screening, Brief Intervention, and Referral to Treatment (SBIRT).10-13 Specifically for patients with opiate use disorders, medication-assisted treatment (MAT) has shown decreased mortality.14 For patients with opiate use disorders, EDs are often the primary access points. EDs already have an important role in opiate overdose reversal and treatment for complications related to opiate use.15 An ED intervention and initiation of treatment with Buprenorphine increases engagement in treatment.16 As much as the focus of opiate use disorders has been on physician prescribing practices, the causes of addiction are multi-factorial. However, EDs are perhaps uniquely positioned to participate in the solution. EDs have an important role in identifying patients with substance use disorders and linking patients to treatment. We are acutely aware of the consequences of substance use disorders and it is time that we intervene to prevent the inevitable consequences. There are challenges. As a specialty we are facile with acute intoxication and withdrawal syndromes, but not screening and treatment. Finding the time in a busy ED shift to have a meaningful conversation on addiction and identifying appropriate outpatient follow-up can feel like an overwhelming barrier. Often, we are tempted to turn a blind eye rather than confront what we know to be true. We can’t do this alone; resources such as substance use counselors and tele-health are vital to filling these gaps. Our Chapter has taken on this challenge to bring tools and resources to our EDs to make this possible. As a first step we’ve put together information on buprenorphine with the California Healthcare Foundation, which you can find on the next page. The Chapter is sponsoring a budget allocation to create a statewide pilot program that places certified drug and alcohol counselors in each of the roughly 325 EDs throughout California. At an estimated $50,000 per counselor, the cost of the pilot program would be $20 million. My ED has a certified drug and alcohol counselor, paid for by the University of California, and we have seen a remarkable impact. The patient testimonials motivate me to fight to expand access to substance use counselors across the state. There is a lot of work to be done and I look forward to hearing from you about your experience. My patient from residency might not have been amenable to treatment, certainly not on her first visit, but she did give me multiple opportunities to intervene. It is time we start the conversation.   REFERENCES   Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health Substance Abuse and Mental Health Services Administration; September 2015 2014. Wu LT, Swartz MS, Wu Z, Mannelli P, Yang C, Blazer DG. Alcohol and drug use disorders among adults in emergency department settings in the United States. Annals of emergency medicine. 2012;60(2):172-180.e175. Crane EH. Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. The CBHSQ Report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013:1-9. Rockett IR, Putnam SL, Jia H, Smith GS. Assessing substance abuse treatment need: a statewide hospital emergency department study. Annals of emergency medicine. 2003;41(6):802-813. Rockett IR, Putnam SL, Jia H, Smith GS. Declared and undeclared substance use among emergency department patients: a population based study. Addiction (Abingdon, England). 2006;101(5):706-712. Macias Konstantopoulos WL, Dreifuss JA, McDermott KA, et al. Identifying patients with problematic drug use in the emergency department: results of a multisite study. Annals of emergency medicine. 2014;64(5):516-525. Rockett IR, Putnam SL, Jia H, Chang CF, Smith GS. Unmet substance abuse treatment need, health services utilization, and cost: a population based emergency department study. Annals of emergency medicine. 2005;45(2):118-127. Capp R, Rosenthal MS, Desai MM, et al. Characteristics of Medicaid enrollees with frequent ED use. The American journal of emergency medicine. 2013;31(9):1333-1337. Urbanoski K, Cheng J, Rehm J, Kurdyak P. Frequent use of emergency departments for mental and substance use disorders. Emergency medicine journal : EMJ. 2018. Pringle JL, Kelley DK, Kearney SM, et al. Screening, Brief Intervention, and Referral to Treatment in the Emergency Department: An Examination of Health Care Utilization and Costs. Medical care. 2018;56(2):146-152. Barata IA, Shandro JR, Montgomery M, et al. Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review. The western journal of emergency medicine. 2017;18(6):1143-1152. Bruguera P, Barrio P, Oliveras C, et al. Effectiveness of a specialized brief intervention for at-risk drinkers in an Emergency Department. Short term results of a randomized controlled trial. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2018. D'Onofrio G, Fiellin DA, Pantalon MV, et al. A brief intervention reduces hazardous and harmful drinking in emergency department patients. Annals of emergency medicine. 2012;60(2):181-192. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ (Clinical research ed). 2017;357:j1550. Weiss AJ, Bailey MK, O'Malley L, Barrett ML, Elixhauser A, Steiner CA. Patient Characteristics of Opioid-Related Inpatient Stays and Emergency Department Visits Nationally and by State, 2014: Statistical Brief #224. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. Jama. 2015;313(16):1636-1644.
by A. Moulin
Thursday, April 19, 2018
February 2018 President's Message 0 A. Moulin EMPAC Endorses Antonio Villaraigosa for Governor By Aimee Moulin, MD, FACEP On every shift, in every emergency department (ED) up and down the state, we treat patients who are being failed by our current healthcare system. A woman with kidney stones who can't get in to see a specialist and keeps coming back to the ED in excruciating pain even though she has Medi-Cal. A child with a severely broken arm who, after an initial visit to the ED, can't get in to see an orthopedist despite being on Medi-Cal, and whose parents have no choice but to bring her back to the ED for follow-up care. A man struggling with mental illness who cycles in and out of crisis because he has difficulty accessing regular psychiatric care.   This is not an aberration or rare occurrence. Sadly, this is the face of a Medi-Cal system that is failing its enrollees. One in three Californians is now insured through Medi-Cal. These patients were promised healthcare. They got insurance, but they didn't get real access to care. Our members treated nearly 15 million patients last year - a number that has grown annually. A number which got bigger after the passage of the Affordable Care Act (ACA) because the newly insured had no other access to treatment for very serious medical problems other than the ED. Some of these serious medical conditions could have been prevented if patients had real options for regular medical care. Through our legislative advocacy, we have continually argued that more must be done to ensure that Californians have universal access to healthcare. While there are many avenues to reach universal healthcare, we do not support the single payer legislation before the State Assembly, SB 562. There are no details in SB 562 and we see every day what happens when you provide insurance to people without any details about how they will actually be provided care and by whom. Single payer just means the government pays the healthcare bill. It doesn't say anything about what kind of healthcare people will receive. Californians need healthcare, not health insurance. The State of California is the single payer for Medi-Cal today and, given what we see every shift in the ED, the system we have today isn’t working. We must start by fixing what we have. That will be no small feat for the next Governor of California. In the December issue of Lifeline, staff outlined the 2018 gubernatorial election and the process of California ACEP’s PAC, the Emergency Medical Political Action Committee (EMPAC). Chapter leaders met with numerous candidates for governor and shared stories of the challenges facing our patients and ways we’d like to see the system reformed. Based on these interviews, EMPAC is pleased to endorse Antonio Villaraigosa because we need a Governor who is committed to delivering the promise of the ACA: universal access to care. Antonio Villaraigosa is committed to ensuring that being insured by Medi-Cal means having access to specialists and primary care doctors during the hours you need them. If California can deliver a first-world healthcare system to its Medi-Cal enrollees, then it has the credibility to takeover providing healthcare of all Californians. Until then, it only promises to make things worse. Antonio Villaraigosa is someone who embraces the challenge of delivering on Medi-Cal’s promise to millions of Californians. We know it won't be easy, if it was, it would already be done. It will take significant vision, tenacity, and a commitment to invest the State's resources into this important human infrastructure need. EMPAC and the Chapter’s leadership believe that Antonio Villaraigosa is the right person to address California’s healthcare challenges.
by A. Moulin
Thursday, April 19, 2018
January 2018 President's Message - Anthem's Attacks on the Prudent Layperso 0 A. Moulin Anthem's Attacks on the Prudent Layperson Standard By Aimee Moulin, MD, FACEP It has been 31 years since Congress passed the Emergency Medicine Treatment and Active Labor Act (EMTALA), which forever changed our specialty and our healthcare system. EMTALA codified the right to access emergency care and stabilizing treatment long before the Affordable Care Act (ACA). Prior to the 1986 law, patients could be turned away or unceremoniously dumped on public hospitals because of their inability to pay or insufficient insurance. The law applies when an individual has a medical emergency and they arrive at a hospital who has a contract with Medicare. At the same time the law created an unfunded mandate to provide emergency care.   Who pays for the unfunded mandate created by EMTALA has been an ongoing challenge. According to a 2003 report from the Center for Health Policy Research, the average emergency physician provides more than ten times the average of all other specialties in uncompensated, EMTALA-mandated care.1 In addition to subsidizing the care of indigent patients, emergency physicians also provide uncompensated care to insured patients due to the varied practices of private insurance companies to deny payment for or to underpay for emergency care. The principle of the “prudent layperson” standard for defining insurance coverage for emergencies is one of the most important principles in supporting our emergency care system. It is the statutory protection against one of those insurance company methods for payment denial. It defines an emergency medical condition as "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in — (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part."2 For example, an insurance company can’t refuse to cover an emergency department (ED) visit for a patient whose chest pain turns out to be indigestion. The prudent layperson standard means insurance companies cannot deny coverage to patients on the basis of their final diagnosis. This protection was included in the ACA and has been California law long before the ACA. Identifying patients who don’t need emergency treatment is complex, and can take multiple diagnostic tests and the expertise of an emergency physician. It is not possible to accurately correlate a patient's chief complaint with his or her discharge diagnosis and any attempt to do so results in undertriage that could result in hospital admission and/or surgical procedures in the future.3 However, this past year Anthem released a list of ED discharge diagnoses they deemed unnecessary. In a handful of states Anthem plans to or already is in the process of denying their customers coverage and leaving insured patients without any coverage for emergency care. It undermines the value and expertise of ED care from triage nurses, pharmacists, emergency physicians, and social workers. All the while, Anthem has had a banner year with share prices up 50% over last year. California is not one of the states where Anthem has announced this policy. In 1994 California ACEP sponsored legislation ensuring a patient’s right to emergency care by establishing the prudent layperson standard in our state. However, Anthem is threatening to undermine this patient-centered guarantee by announcing a plan to reimburse paramedics to not transport patients to the ED. This represents a new paradigm for emergency medical services (EMS) in California. This is functionally different than the practice of a patient-initiated non-transport where a patient declines transport and signs a refusal of transport (a field AMA). Instead, Anthem’s decision would incentivize EMS-initiated refusal of transport. Without proper protections, incentivizing paramedics to not transport patients to EDs is potentially dangerous to patients and the EMS system. Approximately 90% of EMS related litigation involves non-transport. EMS-initiated refusal involves considerable risk for the patient and EMS providers. Data on triage agreement between paramedic and emergency department staff is generally poor. Current medical literature does not support the safety of paramedic determination of medical necessity.4-8 Determining medical necessity is a complex decision that is difficult to make in the field environment.9 Paramedics are not trained to make diagnoses in the field and patients with serious conditions may present with seemingly minor complaints or with symptoms that are difficult to elicit and identify. The inherent challenges of a pre-hospital environment does not allow for the privacy needed for a medical screening history and examination. EMS-initiated refusal of transport for 911 patients is unlikely to reduce ED crowding. Hospitals are full due to boarding and limited inpatient capacity. Anthem’s new policy to reimburse for EMS-initiated refusal of transport for 911 patients creates a new reimbursable service that patients may be required to pay for. Ultimately it threatens the public trust that exists: that upon accessing the 911 system, they will be evaluated and treated in the pre-hospital setting and transported to the appropriate hospital. EMTALA protections for patients apply to hospitals. The general public believes they have accessed the hospital emergency system, and those protections, when calling 911 for a medical emergency. This is a surreptitious attack on the prudent layperson standard and decades of patient protections over the right to emergency care. Our healthcare system is undergoing transformational forces; EDs are neither the source of all problems, nor the answer to all challenges in the healthcare system. We will need to embrace change and innovation. But, this must not come at the expense of the basic right to life saving emergency care.   REFERENCES   Kane C. Physician Marketplace Report: The Impact of EMTALA on Physician Practices. . American Medical Association;2003. Li J, Galvin HK, Johnson SC. The "prudent layperson" definition of an emergency medical condition. The American journal of emergency medicine. 2002;20(1):10-13. Raven MC, Lowe RA, Maselli J, Hsia RY. Comparison of presenting complaint vs discharge diagnosis for identifying " nonemergency" emergency department visits. Jama. 2013;309(11):1145-1153. Brown LH, Hubble MW, Cone DC, et al. Paramedic determinations of medical necessity: a meta-analysis. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2009;13(4):516-527. Fraess-Phillips AJ. Can Paramedics Safely Refuse Transport of Non-Urgent Patients? Prehospital and disaster medicine. 2016;31(6):667-674. Neeki MM, Dong F, Avera L, et al. Alternative Destination Transport? The Role of Paramedics in Optimal Use of the Emergency Department. The western journal of emergency medicine. 2016;17(6):690-697. Pointer JE, Levitt MA, Young JC, Promes SB, Messana BJ, Ader ME. Can paramedics using guidelines accurately triage patients? Annals of emergency medicine. 2001;38(3):268-277. Silvestri S, Rothrock SG, Kennedy D, Ladde J, Bryant M, Pagane J. Can paramedics accurately identify patients who do not require emergency department care? Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2002;6(4):387-390. Millin MG, Brown LH, Schwartz B. EMS provider determinations of necessity for transport and reimbursement for EMS response, medical care, and transport: combined resource document for the National Association of EMS Physicians position statements. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2011;15(4):562-569.
by A. Moulin
Thursday, April 19, 2018
March 2018 Advocacy Update - California ACEP's 29th Annual Legislative Lead 0 K. McQuaid-Craig California ACEP's 29th Annual Legislative Leadership Conference By Elena Lopez-Gusman and Kelsey McQuaid-Craig, MPA Now in its 29th year, the Legislative Leadership Conference (LLC) is an important and influential event for emergency physicians and residents of all stripes to attend. Held in Sacramento, just steps from the State Capitol, over 100 emergency physicians, both seasoned veterans and those just embarking on a career in emergency medicine, will join California ACEP on April 17th for a day full of advocacy training, interesting policy discussions, and meetings with California’s policy makers on behalf of emergency physicians and patients.   The advocating that California ACEP members do each year at LLC on behalf of emergency medicine is truly impactful. This year’s LLC is more important than ever. As you read in the President’s Message, California ACEP is embarking on a budget allocation to place a certified drug and alcohol counselor in every emergency department (ED) in the state. We’re also pursuing 2 other budget allocations: Prop 56 GME funding for emergency medicine residencies and a one-time $20 million allocation to the Maddy Fund. But that’s not the only thing we’re working on this year! The Chapter is also sponsoring 3 mental health bills. AB 451 (Arambula) ensures that EMTALA applies to acute psychiatric hospitals by prohibiting financial screening of mental health patients in need of transfer to a higher level of care. Similarly, AB 2983 (Arambula) prohibits hospitals from requiring a patient who is voluntarily seeking mental health care to be placed on a 5150 hold as a condition of accepting transfer of that patient from an ED. Finally, AB 2099 (Gloria) clarifies that a copy of a 5150 form and the use of an electronic signature on a 5150 form are valid. This is your chance to advocate for improved care for your most vulnerable patients. Don't miss the opportunity to shape the future of healthcare in California! The program will start at 9:30 am and will continue through the morning with an array of speakers and advocacy trainings to develop the skills necessary to partake in the afternoon meetings with legislators and legislative staff. Attendees will break for a free lunch, provided by California ACEP, to meet with peers prior to participating in legislative meetings at the Capitol. California ACEP will arrange legislative meetings on your behalf and will provide you with information on important legislation to prepare you. Don’t worry if you’ve never attended LLC before. There will be an experienced member with you at every meeting. Following an afternoon of meetings at the Capitol, attendees are invited to attend a free reception, hosted by California ACEP, conveniently located near the Capitol. This unique and fun conference is FREE and residents are encouraged to attend. We hope you will join us in our 29th year advocating on behalf of emergency medicine at the State Capitol! Visit californiaacep.org/mpage/LLC2018 to register. For more information, contact Lauren Brown at (916) 325-5455 or lbrown@californiaacep.org.
by K. McQuaid-Craig
Thursday, April 19, 2018
February 2018 Advocacy Update 0 K. McQuaid-Craig California ACEP Continues to Fight for Better Access to Mental Health Care By Elena Lopez-Gusman and Kelsey McQuaid-Craig, MPA California emergency departments (EDs) struggle on a daily basis to provide effective, appropriate, and timely care to mental health patients. Inadequate community mental health resources, lack of access to psychiatrists and other mental health professionals, unclear laws and regulations, and poor coordination of care lead to suboptimal care for the mentally ill. The disproportionate ED resources devoted to patients with acute psychiatric emergencies leads to disruptions in care, crowding, and delays impacting all patients and staff in the ED.   Patients brought in on a 5150 hold, and therefore requiring a mental health evaluation prior to ED discharge, must often wait hours to days for a mobile psychiatric emergency team to arrive and/or must be transferred to a designated psychiatric facility. Arranging transfers can be extremely difficult. Beds are limited and some psychiatric hospitals refuse transfers of uninsured or Medi-Cal patients. Geriatric and pediatric beds are even more limited, leading to even longer boarding times in EDs for these vulnerable populations. Improving psychiatric care has been a priority for the Chapter, and a 2013 survey of Chapter members about the status of emergency psychiatric care in California reaffirmed just how badly reform was needed. Approximately 60% of survey respondents reported an average boarding time of over 12 hours for mental health patients. We also observed varying degrees of access to psychiatric resources and inconsistent application of the Lanterman Petris Short (LPS) Act across counties. It was in this context that the Chapter joined with the California Hospital Association (CHA) and the California Psychiatric Association (CPA) in 2015 to co-sponsor AB 1300 (Ridley-Thomas) to alleviate some of the obstacles in providing emergency psychiatric care. AB 1300 was defeated in 2016, but out of its defeat came a productive series of stakeholder discussions that allowed us to find common ground with other organizations interested in improving mental health care. Those meetings led to the introduction of two of our 2017 sponsored bills: AB 451 by Assembly Member Joaquin Arambula, MD and AB 1119 by Assembly Member Monique Limόn. Chapter members report that when they are treating patients with mental illness, they often have limited access to health records for their patients. AB 1119 (Limόn) clarifies that providers do not need to obtain patient consent to share mental health information for treatment purposes in an emergency. This bill was signed into law by Governor Brown and will make it easier for emergency physicians to restart dedication and communicate with a patient's existing mental health provider. AB 451 (Arambula) seeks to remove barriers for patients who need additional psychiatric services and require transfer to a psychiatric hospital to receive a higher level of mental health care. Our 2013 member survey revealed that, almost universally, hospitals require voluntary patients to be on a 5150 hold prior to accepting transfer of that patient from the ED. There is no such mandate in law; in fact, the law clearly favors voluntary treatment. This requirement by hospitals places an unnecessary barrier to care for patients who seek treatment voluntarily. AB 451 clarifies that hospitals may not require a patient to be on a 5150 hold as a condition of accepting transfer of that patient from an ED. Chapter members also reported psychiatric hospitals routinely ask the insurance status of a patient before determining if they will accept the transfer. Similar to EMTALA, California law prohibits patient dumping and ensures that everyone who comes to an ED is treated for their emergency medical condition, regardless of their ability to pay. Because not all hospitals have the capability – due to lack of available specialists or capacity - to treat every condition, this law also requires hospitals to accept transfers of patients with emergency medical conditions from another hospital. Hospitals are expected to accept an appropriate transfer of an unstable patient and cannot ask about payment until the patient is both medically and psychiatrically stabilized. AB 451 ensures that this law also applies to acute psychiatric hospitals. After concerns were raised by the Service Employees International Union (SEIU) about the portion of AB 451 pertaining to 5150 holds, we agreed to amend the bill to remove that section. Before we were able to amend the bill, AB 451 was held on the Senate Appropriations Suspense File and did not move forward in 2017. The bill will be eligible to be heard during the 2018 Legislative Session and we are committed to moving forward with the agreed upon amended language. As we learned in 2015 with AB 1300, sometimes dividing the bill into smaller parts leads to a more successful outcome. In this vein, California ACEP will be sponsoring separate legislation to prohibit hospitals from requiring a patient who is voluntarily seeking mental health care to be placed on a 5150 hold as a condition of accepting transfer of that patient from an ED. We are determined to change current practice by hospitals, which places undue civil liberties restrictions on patients seeking this care voluntarily. Additionally, California ACEP will be sponsoring legislation in 2018 to clarify that a copy of a 5150 form and the use of an electronic signature on a 5150 form are valid. In some counties, patients have been denied care because their accompanying 5150 form was not an original. The law is silent on whether this is required and, unfortunately, has led to inconsistent interpretations among counties. This is a dated practice in an age where electronic signatures are widely accepted as binding and secure for various legal and medical documents, including most prescriptions. Original signature requirements add additional time and bureaucratic obstacles to helping patients receive urgently needed mental health care. While these sponsored bills will not solve all of the problems with delivery and access to mental health care, they will have an impact on the patients seen every day in your EDs. These legislative actions do not happen in a vacuum. At the same time, our Mental Health Work Group is assembling a toolkit for medication initiation in the ED and de-escalation techniques. We continue to engage in stakeholder meetings with the Steinberg Institute, NAMI California, Disability Rights California, the California Psychiatric Association, and others to find ways to improve access to mental health treatment. The Chapter is committed to improving mental health care in California’s EDs. We remain focused on the goal to decrease the excessive boarding time and delays mental health patients endure. No matter the outcome of our sponsored legislation, we will continue to fight for better care for our patients.
by K. McQuaid-Craig
Thursday, April 19, 2018
January 2018 Advocacy Update - Defending Patients Against Anthem's Attacks 0 K. McQuaid-Craig Defending Patients Against Anthem's Attacks on Access to Care By Elena Lopez-Gusman and Kelsey McQuaid-Craig, MPA   As you read in the President’s message this month, Anthem Blue Cross/Blue Shield has rolled out a new policy in upwards of 14 states, including Georgia, Ohio, and Kentucky, among others. Anthem’s policy forces patients to pay for any emergency department (ED) visit with a final diagnosis that Anthem deems to be non-urgent; a clear violation of the prudent layperson standard codified in federal law.     This policy forces patients, not emergency physicians, to decide whether they are experiencing an emergency. A 2013 study in JAMA found a nearly 90 percent overlap in symptoms between emergencies and non-emergencies.1 There are even examples of claim denials for patients brought in by EMS. At least one patient in Missouri was transported by ambulance to the ED after a car accident and treated for minor injuries; Anthem denied her claim.   Thankfully, California ACEP sponsored legislation in the past to establish a robust prudent layperson standard in California that prevents Anthem from implementing this policy.   As Dr. Moulin outlined, in mid-December we learned of a new payment practice Anthem is planning to implement on January 1, 2018. Anthem plans on reimbursing ambulance transport providers for not transporting patients to the hospital. Because payment for non-transport financially incentivizes ambulance providers to avoid taking patients to the ED, without important consumer protections, this practice could lead to bad patient outcomes and predatory billing practices.   The consequences of this ambulance transport reimbursement policy are potentially serious for patient safety. As a result, we sent requests to the Department of Insurance and the Department of Managed Healthcare asking that they delay this change in reimbursement practice until there can be greater regulatory and public scrutiny.   We have a number of concerns with Anthem’s proposed California policy.   First, this creates a financial incentive to not provide healthcare to individuals who have called 911. There is a significant difference in paramedic and physician assessment of patients into emergent, urgent, or non-emergent/non-urgent categories.2 That same study found that paramedics under triaged almost one in five patients. Under current practice, that under triage does not pose great patient risk because patients are transported to an ED where an emergency physician will examine them. Given the time for transport involved in most ambulance runs, as well as the burdens of wall time, this new reimbursement policy creates a strong incentive for non-transport, resulting in patient harm.   Second, patients with Medicare, Medicaid, the uninsured, the elderly, and the critically ill disproportionately rely on an ambulance transport to the ED.3 As a result, this policy will place these vulnerable populations at even greater risk.   Third, this has the potential to increase the patient’s out of pocket costs if they are required to pay their contractual share of cost for this “service” even if they refuse ambulance transport.   Finally, it is unclear if the ambulance transport providers would be held liable for any harm that resulted from their decision not to send a patient to an ED. If a patient is harmed, the law should be clear about who is liable.   We will pursue all available avenues to stop Anthem's attempts to deny patients access to emergency care. We will also be investigating potential changes to state law in order to protect patients from this dangerous policy.   We will pursue all available avenues to stop Anthem’s attempts to deny patients access to emergency care. California ACEP has always stood with patients against insurance company denials of care and will stand with them again.   REFERENCES     Raven MC, Lowe RA, Maselli J, Hsia RY. Comparison of presenting complaint vs discharge diagnosis for identifying " nonemergency" emergency department visits. Jama. 2013;309(11):1145-1153. Neeki MM, Dong F, Avera L, et al. Alternative Destination Transport? The Role of Paramedics in Optimal Use of the Emergency Department. The western journal of emergency medicine. 2016;17(6):690-697. Squire B T, Tamayo A, Tamayo-Sarver, JH. At-Risk Populations and the Critically Ill Rely Disproportionately on Ambulance Transport to Emergency Departments. Annals of Emergency Medicine. 2010;56(4):341-347.
by K. McQuaid-Craig
Thursday, April 19, 2018
December 2017 Advocacy Update: The 2018 Gubernatorial Election 0 K. McQuaid-Craig The 2018 Gubernatorial Election By Elena Lopez-Gusman and Kelsey McQuaid-Craig, MPA In November 2018 Californians will have an important decision to make: who will be the next Governor of the State of California.   Having a Governor who is passionate about health care has never been more important in California. While repealing the ACA has not yet been possible in Congress, the repeal of the individual mandate seems politically possible, at the time of this writing, and there will undoubtedly be other federal changes to the healthcare landscape. One in three Californians are on Medi-Cal, and cuts, block grants, or other scale-backs to Medicaid would dramatically impact Californians and the emergency care system. How California leads and responds will most certainly affect your practice.   This election also gives California ACEP the first opportunity in decades to work with a Governor who knows and values our organization and understands the role our members have in health care delivery. As you know, Governor Brown has continued to ignore pleas to increase Medi-Cal provider reimbursement rates and under his administration the Department of Managed Health Care has failed to enforce network adequacy or go after systemic underpayment by health plans. 2018 will provide a unique opportunity for emergency physicians to work with a new Governor to improve California’s health care safety net.   California ACEP is reviewing the candidates to determine who would be the best ally of emergency medicine. As a part of the process of determining which candidates our Emergency Medicine Political Action Committee (EMPAC) should support, your advocacy staff and Board of Directors is interviewing gubernatorial candidates.   According to a USC Dornsife/Los Angeles Times poll conducted between October 27th and November 6th, one year from the 2018 election, this is where the candidates stand: Lieutenant Governor Gavin Newsom (D) – 31% Former Los Angeles Mayor Antonio Villaraigosa (D) – 21% Assembly Member Travis Allen (R) – 15% State Treasurer John Chiang (D) – 12% Businessman John Cox (R) – 11% Former State Superintendent of Public Instruction Delaine Eastin (D) – 4%  While California has elected many Republican Governors in its history, the state is increasingly electing Democrats to statewide offices, and unless a Republican candidate with gravitas decides to enter the race, the next Governor of California will be one of the leading Democratic candidates from the field you see listed above. The most recent campaign finance reports, filed on June 30, 2017, show Newsom leading the candidates with $13.1 million cash on hand, followed by Chiang with $5.7 million and Villaraigosa at $4.4 million.   In November the California ACEP Board of Directors met with Mayor Villaraigosa. He spent over an hour speaking with the Board and answering their questions. Medi-Cal provider rates and access to care were clear priorities for him.   On January 9th, the Board of Directors will be meeting with Lieutenant Governor Newsom and we are finalizing a meeting with Treasurer Chiang. This will allow the Board to hear from the candidates and ask them questions about their views on healthcare and the role of emergency medicine. The mere fact that these meetings are taking place signals the importance of emergency medicine to the next Governor of California, and stands in stark contrast to the attention paid to California ACEP by the last several Governors.   After the Board has met with the candidates, EMPAC will endorse a candidate and contribute to support their campaign efforts. We will share the endorsement with California ACEP members, and the public.   Thanks to generous contributions to EMPAC by California ACEP members like you, emergency physicians have become a force to be reckoned with in California politics. Without member involvement and contributions from all of our donors, we will not be able to continue to develop and elect emergency medicine champions.   For more information on how to make a contribution to EMPAC, please contact us at info@californiaacep.org or by calling the Chapter office at (916) 325-5455.
by K. McQuaid-Craig
Thursday, January 4, 2018
November President's Message - Impossible Situations 0 A. Moulin Impossible Situations By Aimee Moulin, MD, FACEP The struggle to find an inpatient bed at a designated psychiatric facility is something we all share. Decades of cuts to inpatient and outpatient services have taken their toll on our mental healthcare system. California has lost 25% of inpatient psychiatric beds since 1995. As of 2016, California had 1 bed for every 5,886 people.1 Nationally there has been a steady increase in emergency department (ED) visits by patients with mental health diagnosis; 10% of all ED visits are for psychiatric illness and almost 2% of all visits result in a transfer to an inpatient psychiatric hospital. 2, 3 The mismatch of the need for mental healthcare services and available resources places us, and our patients, in an impossible situation every day, every shift. Our Chapter has worked to improve systems of care for patients with psychiatric illness. California ACEP has advocated for your ability to make clinical decisions about patients with psychiatric illness so that you can do what’s right for your patients. The Chapter has worked to update the outdated LPS Act. We’re pushing to break down the barriers to transferring mental health patients: supporting the creation of an online psychiatric bed registry to help match patients to resources and working to open up psychiatric facilities to patients will all types of insurance. So it was with much trepidation that we have followed the AnMed Health case that fined a South Carolina hospital under the Emergency Medical Treatment and Active Labor Act, otherwise known as EMTALA. EMTALA requires hospitals that accept Medicare to provide appropriate medical screening and treatment to stabilize the patient’s condition. The mere whisper of an EMTALA violation strikes fear in every emergency physician and administrator. On top of that, add the frustration and legal mine–field of our antiquated laws governing involuntary treatment and this particular case has been especially fraught. The South Carolina based AnMed health system settled with the Office of Inspector General for $1.295 million for failing to appropriately screen and stabilize psychiatric patients presenting to their ED. The case involves 36 patients with serious mental illness, including suicide and homicidal ideations. These 36 patients, in the opinion of the treating emergency physician, needed inpatient psychiatric treatment at a facility equipped to treat patients on an in-voluntary basis. However, the state-run inpatient psychiatric facility designated to accept patients on an involuntary basis did not have enough beds to meet the demands of the community. Patients meeting criteria for involuntary hospitalization waited in the AnMed Health ED for an open bed. Sound familiar…?  A survey of California ED directors found patients were waiting in ED’s over 24 hours.4 Length of stay for psychiatric patients are significantly longer than for non-psychiatric patients with similar dispositions.5 Not surprisingly, closures of inpatient psychiatric beds have a measurable impact on nearby ED’s.6 It leads to an impossible situation that regularly plays out in EDs.  What is less familiar is that the AnMed Health System did have inpatient psychiatric services and an on-call psychiatrist. Yet the hospital didn’t make these resources available to help take care of their ED patients, even though patients in this case waited between six to thirty-eight days to be transferred. The EMTALA violation was for failing to use available hospital resources (i.e. psychiatry consultation) in the stabilization of psychiatric patients. AnMed Health did not admit liability under the settlement deal.  This case has raised a lot of questions. By citing the hospital for not obtaining psychiatric consults, some have argued this calls into question an emergency physician’s ability to medically screen and stabilize psychiatric patients. However, this case seems more to do with what obligations a hospital has to making its consultants available to emergency physicians who request them, rather than to suggest that an emergency physician is not qualified to medically screen and stabilized psychiatric patients. It also raises the question of what obligations a hospital has to provide consultation when they have telepsychiatry available. Our broken mental healthcare system has placed emergency physicians in impossible situations. Clearly the status quo is not acceptable. We need solutions and resources to provide care for our patients will mental illness. What do you think about the AnMed Health case? What solutions have you found to do your best to provide mental health care in the midst of a system that we all know if failing our patients and us? Post your thoughts in the comments below.    REFERENCES Lowe S. California's Acute Psychiatric Bed Loss. California Hosptial Association. 2017. Capp R, Hardy R, Lindrooth R, Wiler J. National Trends in Emergency Department Visits by Adults With Mental Health Disorders. The Journal of emergency medicine. 2016;51(2):131- 135.e131. National Hospital Ambulatory Medical Care Survey: 2014 Emergency Department Summary Tables, tables1,4,15,25,26. In: National Center for Heatlh Statistics DoHaHS, ed. Atlanta GA: Centers for Disease Control and Prvention; 2017. Stone A, Rogers D, Kruckenberg S, Lieser A. Impact of the mental healthcare delivery system on california emergency departments. The western journal of emergency medicine. 2012;13(1):51-56. Zhu JM, Singhal A, Hsia RY. Emergency Department Length-Of-Stay For Psychiatric Visits Was Significantly Longer Than For Nonpsychiatric Visits, 2002-11. Health affairs (Project Hope). 2016;35(9):1698-1706. Nesper AC, Morris BA, Scher LM, Holmes JF. Effect of Decreasing County Mental Health Services on the Emergency Department. Annals of emergency medicine. 2016;67(4):525-530.
by A. Moulin
Wednesday, November 22, 2017
October 2017 Advocacy Update - The Future of the Maddy Fund 0 K. McQuaid-Craig The Future of the Maddy Fund By Elena Lopez-Gusman & Kelsey McQuaid-Craig, MPA   BACKGROUND As we discussed in the September Issue of Lifeline, the Chapter has been hard at work to expand implementation of the Maddy Emergency Medical Services (Maddy) Fund in those counties that have not fully implemented it. The Maddy Fund was established to reimburse providers, hospitals, and emergency medical services for uncompensated care. Funding of the Maddy Fund was initially provided through the passage of SB 12 (Maddy). The law permits counties to levy an additional penalty upon every fine, penalty, or forfeiture imposed and collected by the courts in violation of the Vehicle Code. Each county may elect to assess up to $2 per $10 in fines, penalties, or forfeitures for purposes of supporting emergency medical services. The passage of SB 1773 (Alarcón) in 2006 enacted Government Code §76000.5 to allow county boards of supervisors to levy an additional penalty of $2 for every $10 upon every fine, penalty, or forfeiture imposed and collected by the courts involving a violation of the Vehicle Code. In total, counties can collect up to $4 per $10 in fines to fund emergency medical services. The Maddy Fund is just one of many programs that relies on penalty assessments for funding; a point of much debate in the Legislature.   Not only is Governor Jerry Brown opposed to penalty assessments in general, but the Legislature has been exploring ways to eliminate penalty assessments over the past two years. Governor Brown has made clear his dislike for penalty assessments to pay for programs that he feels should be paid for by taxpayers generally, not just those who pay traffic fines, though he has also expressed support for the goals of the programs themselves – including emergency care funding. In 2011, Governor Brown took the unusual step of allowing AB 412, which was sponsored by California ACEP and renewed the Santa Barbara County Maddy Fund, to become law without his signature. The Governor even went so far as to send a message to the Legislature to accompany his “action”, which is normally reserved for vetoes, in which he stated his support for the Santa Barbara Maddy County Fund program but not the funding mechanism. Again in 2013 and 2016, Governor Brown signed our sponsored legislation to extend the SB 1773 portion of the Maddy Fund, but expressed his dislike of the funding mechanism. MOVEMENT TO REFORM THE FINE AND FEE SYSTEM In 2016, the Legislative Analyst’s Office (LAO) released a report entitled Improving California’s Criminal Fine and Fee System. According to their research, over $1.9 Billion in fine and fee revenue was deposited into state and local funds in 2013-14. Approximately 42% of that revenue went to funds administered by local governments, including the Maddy Fund. Similarly, the State received over half of the revenue, $1 Billion in 2013-14. Since 2010-11, the amount of fine and fee revenue distributed to state and local governments has declined by approximately $200 Million. An additional $11.2 Billion in fines and fees went unpaid in 2013-14, many because the cost of collection would outweigh the original amount to be collected. The LAO report paints a startling picture of the fine and fee system in California. Outside organizations, like the Lawyers’ Committee for Civil Rights of the San Francisco Bay Area (Lawyers’ Committee), have evaluated the impact of California’s fine and fee system. In a report entitled Paying More for Being Poor: Bias and Disparity in California’s Traffic Court System, the Lawyers’ Committee analyzed the impact of numerous programs to reduce fines and fees based on ability to pay. They found that a well-designed system based on ability to pay brought in more money than the traditional flat fee system. The California Traffic Tickets/ Infractions Amnesty Program, which is no longer in operation, collected nearly three times more delinquent debt per case than court-ordered collections. California counties reported the proportional sanctions and reasonable installment plans resulted in greater collection. The Lawyer’s Committee also looked at pilot programs in Maricopa County, Arizona and Staten Island, New York. The Maricopa County pilot was randomized and showed that more people in the pilot paid on time; within one year of the fine being issued, 52.7% of defendants in the pilot had paid in full compared to just 10% of defendants in the traditional system. On average, pilot program participants paid approximately $355 more toward their fine than did those in the traditional system. While other programs have shown success, it is unclear how many Californians would take advantage of a fee reduction program, if the results in other states can be replicated, and what impact it would have on the Maddy Fund.   LEGISLATIVE EFFORTS The Legislature’s dislike for penalty assessments became evident during the 2015 Legislative Session. Senator Jim Beall authored SB 326 to renew penalty assessments under the Emergency Medical Air Transportation Act, which augments emergency medical air transportation reimbursement payments made through the Medi-Cal program. The Assembly Committee on Appropriations forced the following amendments into the bill:   The Legislature finds and declares all of the following: (a) Penalty assessments have been used to fund an increasing number of programs that should properly be funded by broad-based financing mechanisms. (b) The ever-increasing reliance on penalty assessments to fund core state programs is a regressive financing mechanism, and is particularly harmful to individuals who can least afford these assessments. High fines and assessments can perpetuate a cycle of poverty and inequality, given that individuals with lower incomes are more likely to miss payments and suffer the consequences. (c) It is in the state’s interest to ensure funding for emergency medical air transportation is sufficient to maintain access to these critical services for Medi- Cal beneficiaries and all individuals in California. (d) Therefore, it is the intent of the Legislature to identify alternative funding sources for emergency medical air transportation and cease reliance on penalty assessment revenue to fund these services. (e) Accordingly, it is the intent of the Legislature to cease the collection of penalty assessments on January 1, 2018, pursuant to the Emergency Medical Air Transportation Act. The amendments by the Assembly Committee on Appropriations make clear the hostile environment in the Legislature concerning penalty assessments. During the 2017 Legislative Session, Senator Bob Hertzberg introduced sweeping reforms in SB 185, which was an attempt to address the high cost of tickets for moving violations, specifically the large number of fees and fines that are added on to the original cost of the ticket. The bill allowed people to petition the court to have their fine reduced and the bill mandated that the fine be reduced if the person met certain income levels. In all, there are 23 county administered funds and 57 state administered funds that rely on penalty assessments. Ultimately, SB 185 was held on the Assembly Appropriations Suspense File and is now a two year bill. This means it can be brought back up during the 2018 Legislative Session. We must analyze the impact the bill will have on penalty assessments and what it will mean for the Maddy Fund.   IMPACT ON THE MADDY FUND According to the LAO, deposits in the Maddy Fund dropped from $93.3 million in 2009-10 to $86.1 Million in 2013-14. We do not have more recent numbers from the State. As you well know, despite the implementation of the Affordable Care Act (ACA), visits to the ED are up, and millions of Californians remain uninsured. Millions more remain under-insured by Medi-Cal, making it difficult to adequately finance the emergency care system. The Maddy Fund is critical to maintaining access to quality emergency care for all Californians and it is imperative that we maintain a steady funding stream. While we would like to know the impact SB 185 (Hertzberg) will have on penalty assessments and what it will mean for the Maddy Fund, the nature of similar efforts illustrates how difficult it is to determine the precise consequences. What is clear is that the Chapter must maintain a dialogue with the Legislature about possible consequences for the Maddy Fund.   If you have any questions, please contact us at info@californiaacep.org or by calling the Chapter office at (916) 325- 5455.
by K. McQuaid-Craig
Wednesday, November 22, 2017
September 2017 Advocacy Update - The Maddy Fund: Chapter Advocacy at the Lo 0 K. McQuaid-Craig The Maddy Fund: Chapter Advocacy at the Local Level By Elena Lopez-Gusman & Kelsey McQuaid-Craig, MPA   Typically when we write about the Chapter’s advocacy efforts, we talk about actions taken in the legislative arena, but we also advocate at the local level. Over the years, California ACEP has dedicated advocacy resources to establishing and renewing the Maddy Emergency Medical Services Fund (Maddy Fund). These efforts continue outside of the Legislature and into your communities.   BACKGROUND The Maddy Fund was established to reimburse providers, hospitals, and emergency medical services for uncompensated care. Funding of the Maddy Fund was initially provided through the passage of SB 12 (Maddy). The law permits counties to levy an additional penalty upon every fine, penalty, or forfeiture imposed and collected by the courts in violation of the Vehicle Code. Each county may elect to assess up to $2 per $10 in fines, penalties, or forfeitures for purposes of supporting emergency medical services. This portion of the fund has no sunset date, however counties who did not elect to create a Maddy Fund under this authorizing statute prior to 1991 are no longer eligible to do so. Approximately $50 million is generated throughout the state annually by the 49 counties who have implemented this portion of the Maddy Fund.   The passage of SB 1773 (Alarcón) in 2006 enacted Government Code §76000.5 to allow county boards of supervisors to levy an additional penalty of $2 for every $10 upon every fine, penalty, or forfeiture imposed and collected by the courts involving a violation of the Vehicle Code. SB 1773 (Alarcón) also allocated 15% of the funds collected for pediatric trauma care – known as “Richie’s Fund”. Richie’s Fund is the only source of funding for pediatric trauma. The SB 1773 portion of the Maddy Fund was reauthorized in 2016 and will sunset on January 1, 2027, unless continued by the Legislature by passage of future legislation. Approximately $50 million is generated annually by this portion of the Maddy Fund. Over 30 counties have implemented this portion of the Maddy Fund – some of which have implemented both portions of the fund, others who have only implemented this provision. As you well know, despite the implementation of the Affordable Care Act (ACA), visits to the ED are up, and millions of Californians remain uninsured. Millions more remain underinsured by Medi-Cal, making it difficult to adequately finance the emergency care system. The Maddy Fund is critical to maintaining access to quality emergency care for all Californians. MADDY FUND ALLOCATION SB 612 enacted Health and Safety Code Section 1797.98a which specifies a maximum 10% of these revenues can be used for administration of the funds by the counties.    The remaining 90% is allocated as follows: 58% to physicians who provide emergency services and care to patients who have no insurance coverage or who are unable to pay for their emergency care including the undocumented; 25% to hospitals providing disproportionate trauma and emergency medical services; 17% to counties for EMS purposes as determined by the county. SB 1773 also specifies that by law a maximum 10% of these revenues can be used for administration of funds. An additional 15% is dedicated to pediatric trauma care. The remaining 75% is then distributed as above (58% to physicians, 25% to hospitals, 17% to local EMS). COUNTY ADVOCACY California ACEP was recently successful in convincing the Sacramento County Board of Supervisors to implement the SB 1773 portion of the Maddy Fund. We’ve engaged in discussions with Sacramento County for over 10 years, but were recently successful due to a change in county leadership, clarification by the State Controller about how fines and penalties are distributed, and the continued persistence of local emergency physicians, like Dr. Doug Brosnan. In July 2017, the Sacramento County Board of Supervisors voted to implement the second half of the Maddy Fund. The Courts have asked to delay implementation until January 2018 to better align with a software update they are currently undergoing. Based on historical data, we are hopeful that the Board’s action will result in additional Maddy Fund revenues in excess of $2 million. This will be a major investment in Sacramento’s emergency care safety net! In late August, a Chapter member approached us for help implementing the Maddy Fund in Imperial County. Imperial County has one of the highest uninsured rates in the state and, unlike neighboring counties, has not implemented the Maddy Fund. We’ve just started participating in discussions with stakeholders and are committed to our advocacy efforts…for however long it takes. Additionally, we’ve noticed a vast variation in how much money counties collect and how much is disbursed to physicians, hospitals, and emergency medical services. We are comparing historical data to get a better understanding of counties’ behavior and policies and, if we discover that these variations are as a result of something improper, we will be engaging in more local advocacy to ensure that these dollars go to their intended recipients and strengthen the emergency care system. Ultimately, the key to strengthening the Maddy Fund is our partnership with you. If you notice changes to your reimbursement, or think that the county isn’t  paying out its full share, please let the Chapter office know. We’ll work with you to ensure that Maddy Funds are being spent on their intended purpose. Similarly, if you’re in a county that has not fully implemented both portions of the Maddy Fund, let us know. We’re here to help you establish these funds. Despite the implementation of the ACA, California still has millions of uninsured residents and that will only get worse if Congress repeals or alters Medicaid expansion under the ACA. With leadership and help from Drs. Perlroth, Fenton, Pao, Jones, Richard, Ludlow, and Sugarman, California ACEP is currently working on a tool kit to help our members hold their county accountable and fully establish the Maddy Fund. We will be announcing more details about the release of the toolkit in the months to come.  If you have any questions, please contact us at info@californiaacep.org or by calling the Chapter office at (916) 325- 5455.
by K. McQuaid-Craig
Wednesday, November 22, 2017
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