Lifeline

lifeline DECEMBER 2017

THE TUBBS

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TABLE OF CONTENTS |

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2TH0E 1 8

GUBERNATORIAL ELECTION

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4 PRESIDENT'S MESSAGE 6 ADVOCACY UPDATE 8 GUEST ARTICLE 12 GUEST ARTICLE 16 ANNOUNCEMENTS 17 UPCOMING MEETINGS & DEADLINES 18 CAREER OPPORTUNITIES

California ACEP

Board of Directors & Lifeline Editors Roster

2017-18 Board of Directors Aimee Moulin, MD, FACEP, President Chi Perlroth, MD, FACEP, President-Elect Vivian Reyes, MD, FACEP, Vice President Vikant Gulati, MD, FACEP, Treasurer Sujal Mandavia, MD, FACEP, Secretary Lawrence Stock, MD, FACEP, Immediate Past President Reb Close, MD, FACEP (At-Large) John Coburn, MD Casey Dart, MD, CAL/EMRA President Carrieann Drenten, MD Doug Gibson, MD, FACEP Kevin Jones, DO John Ludlow, MD, MBA, FACEP Karen Murrell, MD, MBA, FACEP Luke Palmisano, MD, MBA, FACEP Mitesh Patel, MD, MBA, FACHE, CPE Maria Raven, MD, MPH, FACEP Nicolas Sawyer, MD Lori Winston, MD, FACEP

Advocacy Fellowship Aimee Moulin, MD, FACEP, Director

Lifeline Medical Editor Richard Obler, MD, FACEP, Medical Editor

Lifeline Staff Editors Elena Lopez-Gusman, Executive Director Kelsey McQuaid-Craig, MPA, Director of Policy and Programs Lucia Romo, Membership and Education Coordinator Lauren Brown, Government Affairs Associate Meri Thresher, Administrative Assistant

DECEMBER 2017

Index of Advertisers

Berkeley Emergency Medical Group California ACEP ? Member Renewal California ACEP - Legislative Leadership Conference California Hospitalists/ Emergency Physicians Medical Group, Inc Emergency Groups' Office Emergency Medical Management Associates Emergency Medical Specialists of Orange County Emergency Physicians Management Envision Physician Services Independent Emergency Physicians Consortium Ohio ACEP Emergency Medicine Board Review Courses Ventura Emergency Physicians

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Page 18 Page 14 Page 15 Page 18 Page 10 Page 10 Page 18 Page 18 Page 7 Page 7 Page 11 Page 18

WELCOME new members!

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DECEMBER 2017 | 3

PRESIDENT'S MESSAGE |

By Aimee Moulin, MD, FACEP

PUNCHING

ABOVE YOUR WEIGHT

Boxing is highly regulated by weight class, with rigid standards that hinge on a high-pressure weigh-in 24 hours prior to any fight. Some boxers will go to extraordinary measures to drop the last few pounds to make it into a lower weight class. Fighters will restrict water and food intake, engage in vigorous exercise, or take diuretics like Lasix to make sure they can qualify for the lower weight class. An extreme fighter will be dehydrated and weak at weigh-in only to rehydrate and increase calories and turn it around in the following 24 hours. Why? ... Because conventional wisdom states that someone from a lighter weight doesn't have much of a chance against a heavier fighter. Punching above your weight describes someone who competes outside his or her class. This is true of our specialty and of California ACEP.

O ur emergency departments (ED) are a key piece of the healthcare system. Emergency Medicine represents 2% of the healthcare workforce, and 4% of the healthcare dollar. Yet, our

EDs provide half of the acute care visits by patients covered by Medicaid and CHIP, and two-thirds of acute care visits by uninsured patients. 1 EDs are responsible for over 50% of hospital admissions and send 1.8 million

patients to the ICU each year. We are the decision makers for the most expensive piece of healthcare spending. At 141.4 million ED visits nationally, there are 45.1 ED visits for every 100 Americans.2 These ED visits are not

4 | LIFELINE a forum for emergency physicians in california

a lack of access to primary care; almost 25% of the patients seen in the ED are sent by their primary care providers.3

Despite the hand ringing about rising ED visits in the United States driving our healthcare costs, the US compares well to other industrial nations. England has 42 ED visits per 100 people and Canada has 44.4 per 100. 4 In California, we are beating the national average with 38 ED visits for every 100 people. California compares well to the top 5 most populous states Florida 44, Illinois 41, New York 37, and Texas 49.5 Compared to other industrial nations California is again under the average.

In addition to acute stabilization and management, EDs are diagnostic centers coordinating studies and specialty consults efficiently. We can pull together a care plan in the space of a single visit rather than a complex orchestra of visits to an outpatient lab, radiology center, and specialty clinic that spans the course of several days of missed work. Is it any wonder that, despite decades of trying to undermine the value of our work, patients continue to value our services and our volumes continue to increase?

While Emergency Medicine is not responsible for much of the healthcare costs, we do have an outsized role in managing healthcare costs. An Annals of Emergency Medicine paper from 2013 outlined our role in managing healthcare costs by reducing expensive hospital admissions and avoiding ICU care through topnotch emergency care and management of complex transitions of care.6 Some strategies increase the complexity and length of an ED visit, but reap major benefits for patients and payers alike.

California's EDs are accomplishing all of this with one of the lowest Medicaid reimbursement in the nation. California ranks 49th in Medicaid provider reimbursement, just in front of Rhode Island and Tennessee, which is last due to lack of data. California EDs provide an over-represented portion of care to patients with Medi-Cal. Data from California's Office of State Health Planning and Development shows 41% of California's

Emergency Department Encounters

1,500,000 1,400,000 1,300,000 1,200,000 1,100,000 1,000,000

900,000 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000

0

EMERGENCY DEPARTMENT ENCOUNTERS by EXPECTED PAYER (2012 to 2016)

Medi-Cal 1,399,136

Private Coverage 820,467

Medicare 554,083

Uninsured 232,492 Other 96,351

2012 Q1 2012 Q2 2012 Q3 2012 Q4 2013 Q1 2013 Q2 2013 Q3 2013 Q4 2014 Q1 2014 Q2 2014 Q3 2014 Q4 2015 Q1 2015 Q2 2015 Q3 2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4

Source: Emergency Room Data, 2012 to 2016 Office of Statewide Health Planning and Development

Note: Excludes Emergency room patients that were admitted to the hospital

ED patient population are covered by the Medi-Cal program and 8% continue to be un-insured.

Despite low reimbursement rates and a small share of the physician workforce, emergency physicians pack a big punch; we shape the healthcare delivery system by managing admissions through high quality care.

California ACEP, emblematic of our specialty, regularly punches above our weight in the State Capitol. Recently, the Sacramento Bee published a list of the top 500 lobbyist employer spenders for the third quarter of 2017. The California Hospital Association is ranked 6th among spenders, the California Nurses Association is 12th, and the California Medical Association 19th. Service Employees International Union (SEIU) is ranked third,

behind big oil. California ACEP ranks 215th, yet continues to rack up a remarkable number of achievements.7

Recently California ACEP avoided costly, inefficient legislation mandating querying of the CURES database and HIV testing on every blood draw. California ACEP has consistently supported the practice of emergency medicine, injury prevention, access to care, and other evidence-based policies in the Legislature. California ACEP may be ranked 215th in lobbyist employer spending, but our impact was felt throughout the halls of the State Capitol and in every ED in the state. People underestimate the impact of emergency physicians and California ACEP, but make no mistake, we can go toe to toe with the heavy hitters and make a substantial impact. n

1. Gonzalez Morganti K, Sebastian Bauhoff, Janice C. Blanchard, Mahshid Abir, Neema Iyer, Alexandria Smith, Joseph Vesely, Edward Okeke and Arthur L. Kellermann. The Evolving Role of Emergency Departments in the United States. Santa Monica: RAND Corporation;2013.

2. Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2014 Emergency Department Summary Tables. In: Statistics NCfH, ed: Center for Disease Control.

3. Raven MC, Steiner F. A National Study of Outpatient Health Care Providers' Effect on Emergency Department Visit Acuity and Likelihood of Hospitalization. Annals of emergency medicine. 2017.

4. Fields WW. The acute care continuum in California. Rev Med Clin Condes. 2017;28(2):178-185.

5. Esther Hing PR. Emergency Department Use in the Country's Five Most Populous States and the Total United States. June 2016.

6. Smulowitz PB, Honigman L, Landon BE. A novel approach to identifying targets for cost reduction in the emergency department. Annals of emergency medicine. 2013;61(3):293-300.

7. Smith D. These 500 interestes spent the most influencing California lawmakers this year. Sacramento Bee. November 7, 2017, 2017;Capitol Alert.

DECEMBER 2017 | 5

ADVOCACY UPDATE |

2TH0E 1 8

GUBERNATORIAL ELECTION

Author: 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.

aving 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:

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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@ or by calling the Chapter office at (916) 325-5455. n

RUNNING ON EMPTY?

80% of physicians today are professionally overextended or at capacity, leaving them with no time to see additional patients

Physician burnout rates top 50% in latest Mayo study and work life balance continues to worsen

The average time a doctor spends per week on administrative work brought about by healthcare reform efforts and EHRs, with certain specialties closing in on 50% of their day

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DECEMBER 2017 | 7

GUEST ARTICLE |

2017 ACEP COUNCIL MEETING RECAP Author: Susanne J. Spano, MD, FACEP and Vivian Reyes, MD, FACEP

ACEP held another successful Council Meeting this year, and the California delegation included 29 Councillors, 3 Alternate Councillors, and 2 Past Leaders. ACEP's 2017 Annual Council Meeting was held on October 27th and October 28th at the Marriott Marquis Hotel in Washington, DC. Over 400 Councillors were present this year and 46 vetted resolutions and one late resolution were debated in the Council Reference Committees and voted upon on the Council Floor. Elections for the ACEP President-elect, Council Speaker, Council Vice Speaker, and Board of Directors were also held. Below is a recap of the resolutions and election results.

Reference Committee A:

There were many notable memorial resolutions for longstanding, contributing members to the College. All Bylaws resolutions, with the exception of the diversity resolution (#11) proposed by EMRA, were adopted. Significant debate on the diversity resolution took place with many members in support of the tenets of inclusion of residents as councillors, yet felt that the Bylaws of the College were not the appropriate place for such a suggestion to reside. Creating an electronic Council forum and reforming campaign finance rules were referred to the Council Steering Committee. A resolution addressing Maintenance of Certification (MOC) or "Maintenance of Competence" for practicing emergency physicians was referred to the ACEP Board of Directors. The Texas Chapter withdrew three resolutions on ABEM governance. Lastly, a resolution aiming to better define what qualifies as a "Scholarly Project" was not adopted.

Reference Committee B:

Resolutions addressing public policy relating to prehospital care, coverage for medications for patients in observation status, studying injection facilities, drug shortages, and parental leave were adopted. Resolutions focusing on non-citizen access to emergency care,

hyperbaric center accreditation, prescription drug pricing, and reimbursement for Hepatitis C testing were referred to the ACEP Board of Directors. One resolution about medically supervised injection facilities was withdrawn (#37) given its similarity to another resolution referred to the Board (#31). Finally, a resolution that the California Chapter sponsored, which aims to have the College demonstrate the value of emergency medicine to the public and to policy makers, was adopted.

Reference Committee C:

Resolutions supporting workplace diversity, opioid prescription guidelines, information exchanges with drug monitoring programs, retirement/interruption of practice, harm reduction programs for IVDA, and workplace violence resolutions were all adopted. Resolutions on group contract negotiations, climate change's impact on health (sponsored by the California Chapter), transparency in medical malpractice, non-fatal strangulation, and promoting clinical effectiveness in emergency medicine were referred to the Board. Resolutions that were not adopted included one supporting cannabis to treat opioid dependency and one aiming to have ACEP take a formal stance on cannabis use.

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