Articles

Practice Essentials of Emergency Medicine is designed to augment your knowledge of several critical business topics. The modules are free to ACEP and EMRA members. Topics include Reimbursement, Contracts, Negotiations, Operations, Billing and Coding, Risk Management, Quality and Patient Safety, Leadership and Innovation, Legal and Regulatory issues, EM Informatics, and Personal Finance. https://www.acep.org/education/practice-essentials.

Clay Whiting, MD
IEPC Member at Scripps Mercy
in San Diego

Dr. Clay Whiting, IEPC member at Scripps Mercy in San Diego, discussed violence in the emergency department with KPBS. See Link to the story by Heidi de Marco, New California law target ER violence but some say it’s not enough. ACEP found that more than 90% of ER doctors were threatened or attacked in the previous year. Even when incidents are reported, Whiting said accountability is rare. AB 977 went into effect in January. The new law increases jail time for people who assault ER workings from 6 months to one year, and raises penalties up to $2,000.

Roneet Lev, MD, FACEP
Executive Director, IEPC

In the ABCs of resuscitation, “A” is for airway. You would not think emergency physicians need such a lesson, but in a recent chaotic rescue, I noticed that sometimes the basics are forgotten.

Try this. Next time you are laying down on a hard surface, hyperextend your head and try to breathe. Now lift your head to your neutral position and take a breath. You don’t have to be in a code blue to feel the difference in a patient airway.

When I was volunteering in Israel over the past year, we trained the medics, emphasizing the basics. Dr. Debra Weiss, director of the emergency department at Asuta Hospital, devised an interactive training session that emphasized proper head positioning and jaw thrust. All participants felt for themselves how it is harder to breath when the head is misaligned. They also learned a trick of placing the patient’s head on the knees to proper position the head and then apply the jaw thrust.

The Israeli airway lesson was fresh on my mind when I attended a special event with thousands of people. People crowded at the stage for hours. It was hot, the crowd was older, perhaps alcohol was involved, and some people started to drop. In the area where I was standing, four people experienced syncope. It was quite dramatic. Security had me stay near the speakers in a spot where I can watch the crowd. I missed most of the show, and may have damaged my hearing, but I enjoyed being a doctor in a different setting. After 30-plus years as an emergency physician, I still jump to action when there is a medical emergency.

The crowd, who got to know me as the rescue doctor, directed me to the middle of the thick crowd, where an elderly man lay unconscious. His head was hyperextended, and I initially could not feel a breath. If I held his head up, I could feel good breathing. When his head dropped in extension, his breath diminished. An unconscious head can be very heavy. I had a good Samaritan assist in holding up the head.

There was no way to get a gurney into this crowd. The unresponsive man was lifted on the shoulders of several men and carried out of the dance floor to an open area where we met the official medical responders. This team had doctors, residents, and paramedics. I introduced myself as an emergency physician, gave my report, and moved aside to support the man’s son. By the way, speaking to family is important. This man’s son was angry and agitated until I explained what was happening.

I observed the code and watched my patient’s head go back to his hyperextended position. The medical team got an oral airway, a nasal airway, and an ambu bag. It is not easy to intervene in another team’s code, but I gently explained that if they just position his airway, he will breathe.

And hence, I write this article as a reminder that the “A” in airway is important, and to share the trick of laying the victim’s head on your knees to get that perfect neutral and sniffing position. It works, even when you are wearing a sparkly evening gown.

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

Hello friends and colleagues,

It is that time of year when your RCM company of CFO should be sending out letters to your OON payers to adjust the qualified payment amount (QPA). The QPA is supposed to be equivalent to the Median-In Network Rate for a given insurance payer. It is subject to be an annual inflationary adjustment starting in 2019. When adjusting for inflation, this should be +24.7% for 2025. This is important because it is one of the criteria utilized in the IDR process and sets your patients cost sharing amounts for a given year. You can also make use of this increase during during your IDR open negotiation as well as your IDR submission.

Also, keep a close eye on your 2025 EOBs to look for a mandatory Medi-Cal rate increase for all Medi-Cal products. The rate increase should be equivalent to 90% of Medicare for E&M codes and 80% of Medicare for all procedures. It will obviously take some time for these rates to go into effect and I suspect we will not see the EOBs reflect the increase until after the first quarter. It would not hurt to send out a letter reminding your Medi-Cal entities of this rate increase, though they should all be aware. Once the increases go into effect, there should be retroactive “catch-up” checks to reimburse back to January 1, 2025 at the new increased rates.

Finally, keep an eye out for any updates affecting the 2.83% Medicare cuts that went into effect January 1, 2025. If Congress passes another continuing resolution, it may have a “Medicare Fix,” which would decrease the cut for the year. If this occurs, have your RCM company reach out to your payers and make sure they adjust their EOBs and check to see if any retroactive payments from Medicare are to be included. (Wishful thinking I know).

Click here to view a PDF of the October 2024 Newsletter.

In this issue:

• President Pearls – Payment Leaks
• Should Emergency Physicians Unionize?
• Yes on Prop 35
• Yes on Prop 36
• What’s Your EM Burnout Score
• A Game-Changer in Methamphetamine Treatment
• IEPC Speaker Series

Roneet Lev, MD, FACEP
Executive Director, IEPC

CS-1103 is entering Phase 2 trial. The new drug is a sequestrant that bind methamphetamine within minutes. California is ground zero for meth and we see methamphetamine toxicity daily in the form of agitation, mental health crisis, and cardiac effects. You can read more about CS1103 in an article on Kevin MD.

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.