Articles

Roneet Lev, MD, FACEP
Executive Director, IEPC

ACE scores, Adverse Childhood Experiences, are commonly used to identify risks associated with adult health and social outcomes. For example, a high ACE score may be associated with an increased risk for addiction. I reframed ACE scores as Adverse Career Experience as a risk factor for burnout. Brooke Briggance, expert in trauma informed care, agrees with the new ACE application.

Photo credit: thebravelabs.com

You can listen to a conversation about burn out with Brooke Briggance on the podcase High Truths on Drugs and Addiction episode #193.

You can read an article about a new ACE burnout score in an article by Dr. Lev published in Emergency Medicine News.

Roneet Lev, MD, FACEP
Executive Director, IEPC

California needs Prop 36, the Homelessness, Drug Addiction, and Theft Reduction Act. emergency physician witness daily California’s crisis of homelessness, addiction, and medical consequences of crimes. This proposition offers a solution.

Prop 36 seeks to reform parts of Proposition 47, passed in 2014. Changing the old Prop 47, a state passed referendum cannot occur with regular legislation, it requires a new state proposition, hence the new and improved Prop 36.

The problematic old Prop 47 reduced theft and hard drug possession penalties. Unfortunately, it led to the unintended consequences.

Theft of anything less than $950 was reduced from a felony to a misdemeanor. Today there are regular smash and grab thefts just under the $950 but occurring multiple times. Criminals have learned they can repeatedly steal under $950 with little consequence. A misdemeanor conviction punishment can be a fine or supervision by a probation officer. There is lack of incentive not to steal, resulting in individuals stealing over 25 times from a single store. This level of theft has adversely affected retailers and consumers. Yes on Prop 36 allows the first two thefts under $950 to remain a misdemeanor, but a person’s third theft conviction would be a felony regardless of amount.

Drug possession for personal use is now charged as a misdemeanor. Yes on Prop 36 will add fentanyl to a list of hard drugs like heroin and methamphetamine that are considered a felony depending on the amount that is sold or they are armed with a firearm while trafficking drugs. The measure authorizes greater consequences when fentanyl is intentionally sold to someone who dies. Parents whose children died after they took what they thought was a Xanax or Oxy have not been able to get justice for their loved one. They support this measure.

Because of the old Prop 47, California lost its incentive for repeat legal offenders to obtain drug treatment. Prop 36 allows a judge to recommend mandatory drug treatment instead of incarceration. If a person successfully completes treatment, their charges would be dismissed. Family and friends of loved ones say they wish their loved one went to jail or treatment rather than overdose on fentanyl because of their addiction. This is how Prop 36 can save lives.

Prop 36 is a balanced approach supported by Democrats, Independents, Republicans, social justice organizers, crime victims, and drug survivor advocates.

Read more on Yes on 36. Notice the long lost of bipartisan and non-partisan supporters.

California ACEP:
Proposition 35 –
Good for Patients,
Good for You

The following is obtained for the California ACEP website.

Over the past several years, there have been massive expansions in eligibility and benefits for Medi-Cal, but actual access to care for these patients has remained abysmal. The California Health Care Foundation reports that adults enrolled in Medi-Cal were more than twice as likely to report difficulty finding a provider that accepted their insurance when compared to employer-based insurance or Medicare. Proposition 35 will increase access to healthcare for the most vulnerable Californians by securing dedicated funding for physicians treating Medi-Cal patients and expanding access to health care.

Prop 35 Protects the Medi-Cal Rate Increase that CalACEP Fought for and Secured

Proposition 35 will increase Medi-Cal rates across specialties and protect the increases that have already gone into effect as part of Managed Care Organization Tax, including the first Medi-Cal rate increase for emergency physicians in over 20 years. While CalACEP was able to secure increased emergency physician reimbursement this year, many other specialties, hospitals, ambulance providers, and other key pieces of our health care infrastructure did not get funded this year as originally planned. Prop 35 ensures that those other providers are funded and ensures the state cannot redirect the emergency physician rate increase funds for non-health care purposes.

We Need your Help to Pass Prop 35

California’s health care system is in crisis. Your emergency departments are overcrowded, and the strain will only increase if hospitals and clinics continue to close. Patients wait months to see a doctor or specialist or come to the ED after delaying care to the point of crisis. Care for 15 million children, seniors, disabled, and low-income families on Medi-Cal is significantly underfunded. The state has repeatedly redirected more than $20 billion in health care funding to non-health care purposes. California ACEP supports Proposition 35 because it will protect the resources necessary for ensuring access to care for the most vulnerable Californians.

If you would like more detailed information about the initiative, visit the Prop 35 website at www.voteyes35.com.

Leon Adelman, MD, MBA, FACEP
Co-Founder & CEP Ivy Clinicians
Author, Emergency Medicine
Workforce Newsletter
Clinical Emergency Physician, Wyoming

Only about one-quarter of attending emergency physicians are practice-owners. For many employed emergency physicians, working condition improvement is desperately needed. Emergency medicine has become the specialty with the highest burnout rate and lowest levels of job satisfaction.

Improving working conditions is generally more difficult for employees than for practice owners. Some would say, just kick out the non-physician-owned groups and bring in a better EM practice. The problem with that solution is that emergency physicians don’t determine who staffs a hospital’s emergency department. The hospital CEO makes that decision.

Employed emergency physicians who are dissatisfied with their working conditions and do not want to change jobs have the legal right to bargain collectively with their employer. In other words, EPs have the right to unionize.

Source: Author’s analysis of AMA 2020 Physician Practice Bench

For community EDs, what are the most likely outcomes from emergency physicians bargaining
collectively with their employer and the hospital?

1. The hospital CEO would get mad. Unionized employees have legal protections to publicize poor working conditions. No hospital CEO wants their emergency physicians to talk with the press about boarding, staffing, or quality concerns.
2. The hospital would terminate the staffing company’s contract. Emergency physicians unionizing against a subcontractor would mean the end of that contract.
3. The hospital would choose a physician-owned group to staff the ED. Legitimate practice owners cannot unionize. If the physicians remain employees rather than becoming owners, the union can also remain.

Bottom line: collective bargaining through unionization is the most effective method for employed community emergency physicians to change their contract-holder from a CMG to a physician-owned group.

For recent examples, check out Ascension St. John and the Greater Detroit Association of Emergency Physicians:

• https://www.michiganpublic.org/podcast/stateside/2024-06-20/statesidepodcast-
  doctor-says-private-equity-threatens-patient-care
• https://www.acepnow.com/article/the-er-docs-strike-back

NSA and Payment Leaks

Robert Chavez, MD, President, IEPC
Providence Little Company of Mary Medical Center Torrance

Here are my pearls for this month:

NSA – No Surprise Act
NSA IDR Criteria to be disseminated to your RCM company or the CFO of your group. When submitting IDR claims, always keep in mind the 6 criteria being considered by the IDRE. These are the following:

1. QPA in the same geographic region, increased for inflation. (From 2019).
2. Level of training, provider experience, and quality and outcomes of the provider
   (Think MIPS).
3. Market share of the provider or facility.
4. The patient acuity or complexity of the case.
5. The teaching status, case mix, and scope of services.
6. Demonstration of good faith efforts or lack thereof made by the provider or plan
   to be in network, previous network rates for the last 4 years.

Payer Leaks
All private groups should make it a point to review EOBs (Explanation of Benefits) at least once or twice a year to avoid any payment leaks. It can be surprising how often incorrect payments are made even with in-network payers. Take a moment to make sure your RCM partner calculates this as a percentage of Medicare for all payers, in-network and out-of-network. With this, it will allow you to do a much faster apples to apples comparison. If you find a leak, namely, you are being paid less than your contract calls for or an out-of-network payer is paying you less for your services, then have your RCM company reach out to the payor directly and do a deep dive to see how far back the leak goes chronologically. this can sometimes lead to a nice “catch up” check from your in-network insurance carriers. Finally, you can potentially use this information during the IDR process to demonstrate potential decreases in pay by the insurance carrier affecting your Qualified Payment Amount (QPA).

Roneet Lev, MD, FACEP
Executive Director, IEPC

Dr. Roneet Lev and newborn Ariella with Governor Gray Davis

Ariella Lee joined IEPC when she was in high school at 14 years old. There was reluctance to hire a young kid as an assistant to a large organization of doctors, but the IEPC board decided to take a chance. Ariella put on a suit and pumps and impressed the doctors with her ability to organize meetings and lunches. She went on to analyze the annual IEPC survey and create a list of California hospitals and ED directors. Ariella was a natural for the role of Administrative Director when IEPC’s original director stepped down. Ariella grew with IEPC through high school and college. Her IEPC experience was included in her medical school application.

Keren Lee, MD LT MC USN, Ariella Lee, MD LT MC USN

In May 2024, Ariella graduated from the Uniformed Services University Medical School and matched into the Anesthesia residency program at Balboa Naval Medical Center in San Diego.

In the picture, she is in her Navy whites uniform with her sister Keren Lee, who also attended USU Medical School and hooded Ariella during her medical school graduation.

I, Ariella’s mother, am of course proud of my daughter, and am sharing this news with our IEPC physicians, who are also proud of her and thankful for her service to our country and IEPC.