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ACEP Leadership Report

March 2019

Want to catch up fast? Here's the latest edition of ACEP's Capital Minute: 

ACEP Applauds House Passage of Bill on Universal Background Checks for Firearm Transfer or Sale
ACEP sent a letter of support for H.R. 8, the “Bipartisan Background Checks Act of 2019,” which, introduced by Reps. Mike Thompson (D-CA) and Peter King (R-NY), would extend the existing system of background checks for firearms transactions to all sales, with certain exceptions for law enforcement, gifts to family members, and transfers for hunting, target shooting, and self-defense purposes. ACEP’s own policy supports universal background checks for firearms, and ACEP has supported similar legislation in the past. The House voted on and passed H.R. 8, though it is unlikely to be taken up in the Senate. Read the press release at newsroom.acep.org.

Emergency Physician Named First Chief Medical Officer of the Office of National Drug Control Policy
The White House Office of National Drug Control Policy (ONDCP) announced that Roneet Lev, MD, FACEP, an emergency physician from San Diego, California and member of the American College of Emergency Physicians (ACEP), will serve as ONDCP’s first ever Chief Medical Officer.

“It is an honor and privilege to serve the administration and the American people,” said Dr. Lev. “I will integrate my 25 years of clinical experience to work on the prevention, treatment, and enforcement aspects of drug addiction. ONDCP Director James Carroll make it very clear that the purpose of our every day job is to save lives – just like what emergency physicians do every shift.”

“We are thrilled that Dr. Lev not only proudly represents emergency physicians in this prestigious role, but also the millions of emergency patients who rely on us every day for essential care,” said Vidor Friedman, MD, FACEP, president of ACEP. “Once again, the importance of emergency medicine is being recognized at the highest levels of government.”

Read the press release.

Recent Advocacy Efforts Focus on Out of Network Billing Issues
ACEP President Vidor Friedman, MD, FACEP, has conducted many meetings on Capitol Hill as part of continued outreach to address out-of-network billing issues and other issues important to emergency medicine. During a busy two-day sprint, Dr. Friedman met with with Senators Lamar Alexander (R-TN), Marsha Blackburn (R-TN), Sen. Patty Murray (D-WA), ranking member of the HELP Committee, as well as HELP Committee Republican staff, staff for Senator Bill Cassidy (R-LA), staff for House Minority Leader Kevin McCarthy (R-CA), Rep. Darren Soto (D-FL), and Rep. Mike Burgess, MD (R-TX), ranking member of the House Committee on Energy and Commerce Health Subcommittee. The following day, Dr. Friedman met with Sen. Maggie Hassan (D-NH), a member of the Senate Bipartisan Price Transparency Workgroup and author of her own surprise billing legislation, and attended a fundraiser with Sen. Johnny Isakson (R-GA).

ACEP’s DC staff continues to supplement Dr. Friedman’s ongoing advocacy efforts with dozens of meetings with key legislators and other stakeholders. ACEP responded to a data request sent to a number of physician associations and groups, hospitals, and insurers by the Senate bipartisan transparency workgroup led by Senator Cassidy that is developing federal legislation to address so-called “surprise bills.”

Sepsis Discussions Continue
ACEP recently met with the Society for Critical Care Medicine to discuss the issues around the Sep-3 definition of sepsis and the difficulties some EM physicians are having with reimbursement and meeting quality measures. Many of the components of the Sep-3 definition require laboratory values or time (response to fluids). Studies have shown that the Sep-3 definition is not accurate in the ED, and CMS does not use Sep-3. ACEP has sent letters to the insurance companies that have used Sep-3 in denials. SCCM provided some language for that letter but declined to sign it with ACEP.

ACEP and SCCM also discussed the 1-hour bundle. ACEP is working on a new guideline for early emergency care for septic patients. ACEP and SCCM agreed to look at joint research projects that would concentrate on early care of sepsis.

Emergency Physician Advocates for SUD Funding on Capitol Hill
Eric Ketcham, MD, FACEP, participated in a congressional briefing sponsored by the Coalition to Stop Opioid Overdose (CSOO) and the Mental Health Liaison Group (MHLG), to share his perspective as an emergency physician who treats individuals with substance use disorders (SUDs) and to encourage Congress to continue its important efforts to address the nation’s opioid epidemic.

Dr. Ketcham’s remarks focused on the unique role of emergency medicine and how emergency departments can better coordinate with resources in the community to ensure patients receive appropriate short- and long-term care. He also reinforced the need for Congress to appropriate necessary funding for the Alternatives to Opioids (ALTO) and Preventing Overdoses While in Emergency Rooms (POWER) Acts that were passed into law by Congress last year as part of H.R. 6, the SUPPORT Act. These two ACEP-developed bills were authorized by Congress last year and now require funding to ensure these critical resources can help expand the reach of emergency medicine to better serve patients with SUDs.

Scoot Safe! Public Health and Safety Campaign Launches
Scooter-related ED visits are on the rise, so ACEP launched a public health and safety campaign to urge millions of electronic scooter riders to scoot safely. The campaign features a public service announcement and downloadable poster that offers commonsense tips for scooter riders.  

ACEP and ASA Discuss Procedural Sedation, Opioids, OON Billing
ACEP leadership met with the American Society of Anesthesiologists Feb. 28 to discuss ACEP’s recent guideline on procedural sedation, the opioid epidemic, and out-of-network billing. Our groups were mutually interested in the topic of physician wellness and agreed physicians should be able to get help for mental illness without jeopardizing their license or hospital privileges. Other issues discussed included firearm violence, drug shortages and independent practice by Pas and NPs.

Committee Selection Process Opens
ACEP President-Elect, William P. Jaquis, MD, FACEP, has opened the selection process for appointing members to serve on national ACEP committees during fiscal year 2019-20. Committee interest forms are due May 17. Find more information about committee roles and selection


February 2019

Want to catch up fast? Here's the latest edition of ACEP's Capital Minute: 


ACEP Board Considers Firearm Safety, Leadership Diversity and More During January Meeting
In late January, the ACEP Board of Directors met and considered several issues related to practice trends and clinical topics. Among their decisions, they voted in favor of:

  • Donating $20,000 to the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM). ACEP has been an inaugural supporter for AFFIRM, a not-for-profit organization founded and led by emergency physicians, and EMF is offering two grants with AFFIRM this year on firearm injury prevention research. 
  • Approving two policy statements, “Reporting of Vaccine-Related Adverse Events” and “Autonomous Self-Driving Vehicles,” which should be available online soon.
  • Approving a joint policy statement “Pediatric Readiness in EMS System,” a collaboration with the American Academy of Pediatrics (AAP), the National Association of EMS Physicians (NAEMSP), the Emergency Nurses Association (ENA), the Pediatric Emergency Medicine Committee, the EMS Committee and other stakeholders. It will available after all groups approve the final draft.
  • Accepting a final report from the Leadership Diversity Task Force that outlines many steps taken to increase diversity in ACEP leadership positions, including:
    • Tracking and reporting diversity data pertaining to ACEP leadership.
    • Recommending that the Council Steering Committee eliminate campaign-related travel, which is seen as an economic and time-related hardship and deterrent for some candidates.
    • Recommending that the Nominating Committee expand the Council Standing Rules to include additional facets of diversity as considerations when reviewing potential candidates.
    • Codifying the Leadership Development Advisory Committee.
    • Naming two College awards after pioneering female emergency physicians: the Judith E. Tintinalli Award for Outstanding Contribution in Education and the Pamela P. Benson Trailblazer Award.

ACEP Presents Framework to Protect Emergency Patients from Out-of-Network Billing
On Jan. 28, ACEP released a framework of proposed solutions to protect emergency patients from surprise billing. The proposed solutions include:

  • Prohibit balance billing
  • Streamline the process to ensure patients only have a single point of contact for emergency medical billing and payment
  • Ensure the patient responsibility for out-of-network emergency care is no higher than it would be in-network
  • Require insurers to more clearly convey beneficiary plan details
  • Require insurers to more clearly explain policyholders’ rights related to emergency care
  • Take the patient out of insurer-provider billing disputes

Seeking Editor-in-Chief for New EM Journal
ACEP is launching a new open access journal in 2020 and is seeking applicants for editor-in-chief. The editor will participate in the full-scale launch work of the journal, including creation of the editorial board and strategic editorial plans. Applications are due March 25.

Response to ONC Draft Strategy on Reducing Administrative Burden Regarding the Use of Health IT
ACEP responded to the Office of the National Coordinator for Health Information Technology’s (ONC’s) draft strategy on ways to reduce burden for providers using health information technology (IT) and electronic health records (EHRs). In general, ACEP supports the main recommendations included in the draft strategy and appreciates the efforts the Administration has already taken to reduce provider burden and to improve the usability and exchange of information. In our comment letter, we described ways CMS can further reduce provider reporting burden under the Merit-based Incentive Payment System (MIPS). Lastly, we expressed our disappointment that the draft strategy does not address the effectiveness of qualified clinical data registries (QCDRs) or what the Administration can do to encourage these as a way of reporting quality measures.

Collecting Comments on Clinical Policy Draft for Acute Headache
The draft “Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the ED With Acute Headache,” is in the review stage of development and is open for comments until April 1.

ACEP Represented at Surprise Billing Event
Board member Tony Cirillo, MD, FACEP, represented ACEP on a panel for a Brookings Institution event, “Emerging Policy Solutions to Surprise Medical Bills,” along with other panelists from organizations representing lawmakers, hospitals, insurers, and consumers. Dr. Cirillo emphasized principles from ACEP’s recently released framework to protect emergency patients when care is out-of-network.


January 2019

ACEP Promotes Heard to Chief Operating Officer
On Jan. 3, ACEP Executive Director Dean Wilkerson, announced the promotion of Bobby Heard to chief operating officer. As ACEP’s budget, staffing and activities have more than doubled in the last 14 years, Wilkerson realized ACEP needed a strong chief operating officer to help manage the organization. “Having Bobby assume this COO role will enable me to do more strategic external facing activities for ACEP’s our mission,” Wilkerson said.

Heard has served as the associate executive director for membership and education for the past 14 years, and he is responsible for many new innovations and significantly growing ACEP’s membership and educational meetings. Heard has an MBA from Baylor University. “I look forward to working hard to serve our members, continuing to add value to the college and helping the organization achieve our mission,” Heard said.

ACEP Submits Comments on Drug Shortages, Managed Care Regulations
ACEP submitted its official response to a November 2018 Food and Drug Administration (FDA) Task Force meeting on drug shortages. This meeting, as well as ACEP’s ongoing conversations with the FDA, was a testament to the effectiveness of advocacy by emergency physicians. During the 2018 Leadership & Advocacy Conference, emergency physicians urged legislators to ask the FDA to look into the root causes of drug shortages and deliver recommendations to Congress on how to fix these significant problems affecting patient care. These letters secured more than 100 bipartisan signatories in the House and more than 30 in the Senate. Only a few weeks later, FDA Commissioner Scott Gottlieb announced the creation of this FDA Drug Shortage Task Force and made this issue one of his top priorities. 

ACEP recently responded to a CMS proposed rule that would revise current Medicaid and CHIP managed care regulations. CMS is proposing to give states more flexibility when establishing network adequacy requirements that Medicaid Managed Care Organizations (MCOs) must follow. In our response, we state that we have long advocated for CMS to enforce strong network adequacy standards in Medicaid managed care and that we strongly believe all Medicaid patients must have access to a full range of health care services. We strongly recommend that CMS require states to include emergency physicians and other safety net providers in the list of provider types for which states are required to establish network adequacy standards.

ACEP Meets With Legislators About Out-of-Network Billing
On Jan. 15, ACEP President Vidor E. Friedman, MD, FACEP, Executive Director Dean Wilkerson, and key ACEP public affairs staff met individually with Sen. Bill Cassidy, MD (R-LA), Rep.Raul Ruiz, MD (D-CA), and Rep. Richard Hudson (R-NC) to discuss a federal approach to resolving out-of-network billing issues. ACEP has weighed in previously with the bipartisan Senate price transparency workgroup spearheaded by Sen. Cassidy on a discussion draft it released late last year of legislation to address out-of-network billing.


December 2018

Want to catch up fast? Here's the latest edition of ACEP's Capital Minute: 


Reimbursement Leadership Development Program Participants Chosen
More than 70 candidates from 22 chapters applied for the ACEP Reimbursement Leadership Development Program, which is designed to identify and train future leaders in EM reimbursement. ACEP will fund chosen applicants to travel to the ACEP Reimbursement and Coding conferences, the Leadership and Advocacy Conference, EDPMA’s Solutions Summit, ACEP headquarters structured sessions and possibly an AMA CPT and AMA RUC meeting. 

The inaugural RLPD class will include:

  • B. Bryan Graham, DO
  • Steven Kailes, MD, MPH, FACEP, FAAEM
  • Lisa Mauer, MD, FACEP
  • Archana Shah, MD, MBA
  • James Shoemaker, Jr., MD, FACEP


ACGME to Reconsider Common Program Requirements After EM Groups Respond
The Accreditation Council for Graduate Medical Education recently released proposed changes to its Common Program Requirements (CPR) that threatened to remove the requirement for residencies to protect a portion of faculty time for core faculty. ACEP sent a letter to ACGME explaining why the proposed changes – a standardized, one-size-fits-all approach for all specialties – would be detrimental to emergency medicine. In response to letters from ACEP and other EM organizations, ACGME has decided to reconsider its proposed changes.


Suter Promoted to Brigadier General
On Dec. 8, 2018, Robert E. Suter, DO, MHA, FACEP, was promoted to brigadier general in the United States Army Reserve. Suter entered the Army in August 1978 on a four-year ROTC scholarship and has served in a variety of positions in the Medical Service Corps. Upon completion of his emergency medicine residency at Brooke Army Medical Center at Fort Sam Houston, he then served as chief of the department of emergency medicine and acute care at the Dwight D. Eisenhower Army Medical Center at Fort Gordon. Suter transitioned into the Army Reserves in 1995. In addition to his military appointments, Suter is a professor of emergency medicine at the University of Texas Southwestern Medical School in Dallas. He was elected and served as president of ACEP from 2004 to 2005 and was president of the International Federation for Emergency Medicine in 2006.


New MOC Center Launches
ACEP recently launched its new MOC Center, a one-stop-shop to help EM physicians keep track of all things MOC. The MOC Center has a variety of helpful features, including LLSA articles and summaries, and reading lists for EM, EMS, Med Tox, Ped EM, CDEM and more.


ACEP Meets with SAMSHA About Suicide Hotline
Sandy Schneider, MD, FACEP, associate executive director for practice, policy and academic lines of service, met with the Substance Abuse and Mental Health Services Administration (SAMHSA) to discuss an enhanced national suicide hotline and a national phone number, such as 611.

ACEP responded to a request for comments from the Federal Communications Commission (FCC) related to the National Suicide Hotline Improvement Act of 2018. This act requires the FCC to conduct a study that examines the feasibility of designating a simple, easy-to-remember, 3-digit dialing code (such as an N11 code) that would be used for a national suicide prevention and mental health crisis hotline system. ACEP supports the creation of a new 3-digit dialing code for mental health emergencies, as it would improve access to appropriate care and could reduce the prevalence of psychiatric boarding. However, we believe that in addition to the new number, there must be adequate resources and services in the community that can provide feasible and safe alternatives to patients seeking care in the ED.


ACEP Meets with CMS
ACEP staff and members of the ACEP CEDR Committee, including ACEP Board members Jim Augustine, MD, FACEP, Aisha Liferidge, MD, FACEP, J.T. Finnell, MD, FACEP, FACMI, and Jon Mark Hirshon, MD, PhD, MPH, FACEP, met with key CMS staff Dec. 14 to discuss a number of issues important to emergency medicine, including the preservation of important quality measures by CMS for use by emergency physicians.


ACEP Participates in MIPS Meeting
ACEP Executive Director Dean Wilkerson, MBA, JD, CAE, and Associate Executive Director for Public Affairs Laura Wooster, MPH, participated in a day-long meeting hosted by the American Medical Association to discuss shared areas of concern and potential advocacy on the MIPS portion of the CMS Quality Payment Program for Medicare (i.e. MACRA). ACEP discussed areas of particular concern to emergency medicine and barriers emergency physicians often face in trying to fully participate and excel in the program.


ACEP Meets with MedPAC About ED Coding and Documentation
On Dec. 13, ACEP met with key staff of the Medicare Payment Advisory Commission, or MedPAC, an independent body created by Congress to advise legislators on payment and access issues in the Medicare program. The goal was to educate staff on trends in emergency department usage and documentation and coding of ED visits.


ACEP Opposes Proposed Rule Regarding Immigrants, Medicare and Medicaid
ACEP responded to a proposed rule issued by the Department of Homeland Security (DHS) that would implement new restrictions for some legal immigrants to obtain green cards if they have previously used public benefits such as food stamps, public housing, Medicare Part D low-income subsidies (LIS), or non-emergency Medicaid. In line with the public statement ACEP released immediately following the release of the rule, ACEP asked DHS to rescind the rule. ACEP believes that if finalized, the rule would cause fear and confusion, causing millions of Americans to disenroll from essential programs and stop receiving benefits for which they are eligible. The loss of Medicaid coverage especially would result in poorer health and health outcomes for affected individuals. It also could drive up ED use, uncompensated care costs, maternal and infant health risks, and transmission of infectious diseases.


ACEP Submits Comments on Naxolone Availability
ACEP submitted comments for the record for a public meeting of the Food and Drug Administration (FDA) on appropriate strategies to increase the availability of naloxone products intended for use in the community. ACEP strongly supports the wide utilization of naloxone, and in our comments, we emphasize our positions on a number of important issues: 1) guidelines for prescribing naloxone; 2) education and training; and 3) cost.

Board Reviews Strategic Plan
The ACEP Board of Directors held its annual strategic planning retreat Dec. 4 – 7 in Savannah, Georgia. In addition to reviewing and revising ACEP's three-year strategic plan, the Board had in-depth discussions regarding a potential alternative ethics complaint process, ways to improve ACEP's governance and the role of the Board, and accreditation programs. ACEP's Board also met with leaders of the Georgia ACEP Chapter to discuss issues in that state.



November 2018

Want to catch up fast? Here’s a new edition of ACEP’s Capital Minute: 

EP Appointed to Deputy Role with Department of Veterans Affairs
Gerard R. Cox, MD, MHA, FACEP has been appointed Deputy Under Secretary for health in the U.S. Department of Veterans Affairs. In that capacity, Gerry is responsible for leading the VA's national policies and programs for health care quality improvement, patient safety, credentialing and privileging, risk management, medicolegal affairs, regulatory compliance, ethics, audit, and investigation, and related areas. Cox joined the Veterans Health Administration's leadership team in January 2014 after serving more than 30 years on active duty in the U.S. Navy as a physician and health care executive.

CMS Releases Final Rule on Changes to the Medicare Physician Fee Schedule, and MACRA/Quality Payment Program
CMS has released its final rule laying out changes to Medicare for 2019 that will impact emergency physicians in a number of ways. Read ACEP's summary of the changes and see how ACEP weighed in on the original proposed rule on behalf of emergency physicians in our comment letter.

Violence in Emergency Departments is Increasing
ACEP hosted a press conference during ACEP18 to discuss new research that shows violence in emergency departments is on the rise. Nearly half (47 percent) of emergency physicians report having been physically assaulted while at work, with 60 percent saying those assaults occurred in the past year. Nearly 8 in 10 also say patient care is being affected, with 51 percent of those saying that patients also have been physically harmed. Read more about the research results and their ramifications.

Board Member Recognized as Health Care Influencer
Mark S. Rosenberg, DO, MBA, FACEP has been recognized as a New Jersey health care influencer, primarily for his work in battling the opioid crisis in emergency departments. Rosenberg, along with Dr. Alexis LaPietra, created the ALTO program, which saw an 82 percent reduction in opioid prescribing over two years.

ACEP Responds to Senate Bipartisan Price Transparency Workgroup Legislation
ACEP submitted a detailed response to the Senate Bipartisan Price Transparency Workgroup regarding their draft legislation on how to address out-of-network billing issues. Read the response letter.

ACEP Responds to Harvard Pilgrim Prudent Layperson Violations
ACEP responded to new Harvard Pilgrim policy that will be implemented in New Hampshire on January 1, 2019, that will apply a new 50 percent coinsurance for policyholders who seek care in an emergency department if their final diagnosis is determined to be "nonemergent" based solely upon a list of diagnosis codes. In the letter, ACEP calls for Harvard Pilgrim to halt implementation of this dangerous policy that expects patients to be able to self-diagnose to seek emergency care. This policy follows efforts by other insurers to limit coverage of vital emergency care, including a similar Anthem policy already in effect in New Hampshire and several other states. Read the letter and the list of codes.

ACEP Leadership Meets with CORD, AACEM and ABEM During ACEP18
During the ACEP Scientific Assembly in San Diego, ACEP leadership met with related organizations to foster continued collaboration. Here are a few highlights from each meeting:

  • CORD is now co-branding a new Teaching Fellowship Course for residents. Teaching Fellowship has traditionally been focused on junior faculty, but there appeared to be the need for a shorter, directed course for residents. The first resident co-branded course was held in September 2018.
  • ACEP discussed the two upcoming workforce taskforces, and there was discussion about how current EM graduates are uncomfortable in rural settings. There was brief discussion of creating an 'austere medicine' fellowship or course. It was suggested that telemedicine may be a part of such a proposal.
  • AACEM and ACEP discussed prudent layperson and the lawsuit ACEP filed against Anthem in Georgia. Laura Wooster gave a brief update of our strategy. AACEM offered to help in current and any future cases through their contacts in the involved areas. The chairs also expressed interest in the Council resolution regarding scholarly protected time. We will contact the ACGME and send the resolution to the chairs. AACEM thanked ACEP for the Unscheduled Sedation paper.
  • ABEM announced they were seeking two new directors, one for SAEM's seat and one at-large. They are seeking more community-based directors, but the individuals need to have been oral examiners. ABEM described their changes to MOC, much of which was covered in their presentation at Council. ABEM said 22 of the 24 ABMS specialties are making alternatives to their current MOC.

There was a brief discussion about COMMB (Coalition Opposed to Medical Merit Badges) and acknowledgement and appreciation for the role ACEP played in eliminating the requirement for 15 hours of CME for trauma center verification. They have clarified the rules for point of care testing (such as fecal occult blood) which provide a workaround for ED physicians. They have created a form letter housed on the ABEM website that individuals can use to argue against mandatory ACLS and ATLS.

NY State DOH held a meeting with COMMB to discuss their requirement for current PALS for any provider that cares for children. In that meeting, NY State DOH expressed interest in an alternative course or ability to verify knowledge and procedural skills. COMMB also has met with the National Association of Medical Staff Specialists, the group that oversees credentialing. They do not set standards for credentialing but offered to write a joint white paper for their members outlining our MOC and training.

Leaders Meet with NIDA About Opioids
ACEP's Pawan Goyal, Sandy Schneider, Cynthia Singh and several other leaders met with the National Institute for Drug Abuse for a one-day meeting to discuss the opioid crisis.

ACEP Responds to ACGME's Proposed Change for Residencies
ACEP has written a response to the ACGME about a proposed change in Common Rules for Residencies and Fellowship programs that would eliminate EMS requirement for protected time for core faculty. 

Current ACEP Collaborations

  • ACEP met with the American Psychiatric Association regarding ED boarding of patients awaiting admission to a psychiatric hospital.
  • ACEP has also been working with the American Academy of Addiction Psychiatry on the opioid crisis.
  • In conjunction with AAAP, ACEP will be debuting a new EM-specific MAT Waiver training as a preconference to the Leadership &Advocacy Conference in May 2019.


October 2018

Want to catch up fast? Here’s a new edition of ACEP’s Capital Minute: 


ACEP Elects New President, President-Elect, Board Members and Officers
Vidor Friedman, MD, FACEP, of Maitland, Florida, assumed the ACEP Presidency during ACEP18. ACEP's Board of Directors elected Friedman in a special vote in June following the resignation of President-Elect John Rogers, MD, FACEP, and that election was ratified by the ACEP Council in San Diego.

William Jaquis, MD, FACEP, of Fort Lauderdale, Fla., was elected President-Elect during ACEP18 in San Diego. He will serve a 1-year term and will assume ACEP's Presidency at next year's meeting in Denver.

Two Board members were re-elected, and two new Board members were added during ACEP18 Council meeting in San Diego. Christopher S. Kang, MD, FACEP, FAWM, (Washington) and Mark S. Rosenberg, DO, MBA, FACEP, (New Jersey) were both re-elected for second three-year terms. L. Anthony Cirillo, MD, FACEP, (Rhode Island) and John T. Finnell, MD, FACEP, FACMI, (Indiana) were elected for their first terms. Read more about the new board members.

The Board also elected its executive committee:
• Stephen H. Anderson, MD, FACEP - Chair of the Board
• Jon Mark Hirshon, MD, PhD, MPH, FACEP - Vice President
• Mark S. Rosenberg, DO, MBA, FACEP - Secretary-Treasurer

Congress Passes Comprehensive Opioids Package
On Oct. 24, President Trump signed into law a comprehensive opioids package (H.R. 6) with two ED-specific provisions developed by ACEP. These provisions would authorize grants to expand the Alternatives to Opioids (ALTO) program and the ED-initiated Medication Assisted Treatment (MAT) program that develops best practices for providing a "warm handoff" of opioid use disorder patients to appropriate community resources and providers to keep them engaged in addiction treatment. Throughout the many months of Congressional activity on H.R. 6, ACEP worked closely with congressional leadership, House-Senate conferees, and the bill sponsors to ensure these provisions were included in the final package and using the ACEP-preferred legislative language. During the ACEP Leadership and Advocacy Conference last May, hundreds of ACEP members advocated for these provisions during the Capitol Hill visits with legislators and staff. Even more ACEP members in the 911 Network contacted their legislators about these bills by responding to action alerts over the past months. Read the press release.

In other opioid-related news, ACEP participated in a meeting with White House officials, federal agencies and other stakeholders to discuss best practices in combatting the opioid epidemic. The meeting focused on actions the Trump Administration has taken to date, a review of future projects, and policies established at state and local levels that have benefited patients and reduced misuse of opioids. Particular focus was placed on National Take Back Day on Oct. 27 and how meeting participants can help promote these drug collection sites

ACEP Releases New Information Papers
The following information papers were recently approved by the Board of Directors: 

Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline
ACEP organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which outlines the issues relating to staffing, practice and quality improvement. Read the guidelines and FAQ.

ACEP18 Breaks Attendance Record
About 7,500 attendees made the trip to San Diego for ACEP18, making it the largest annual meeting ever! If you were unable to attend, catch up by reading the ACEP18 Daily News. You can access all of the courses (and CME) with Virtual ACEP18. We'll see you next year in Denver.

Award Winners Honored During ACEP18
The following prestigious honors were bestowed during ACEP18 in San Diego:

  • John G. Wiegenstein Leadership Award: Nicholas Jouriles, MD, FACEP
  • James D. Mills Outstanding Contribution to Emergency Medicine Award: Thom Mayer, MD, FACEP, FAAP, FACHE
  • Award for Outstanding Contribution in Education: Corey Slovis, MD, FACEP
  • Award for Outstanding Contribution in Research: Lynne D. Richardson MD, FACEP
  • Outstanding Contribution in EMS Award: David E. Persse, MD, FACEP
  • Council Meritorious Service Award: James C. Mitchner, MD, MPH, FACEP
  • Colin C. Rorrie, Jr., PhD Award for Excellence in Health Policy: L. Anthony Cirillo, MD, FACEP
  • John A. Rupke Legacy Award: David Wilcox, MD, FACEP
  • Honorary Memberships: Marjorie A. Geist, RN, PhD, CAE, and Barbara Tomar, MBA

Emergency Physician Appointed to PTAC
Jennifer Wiler, MD, MBA, Executive Vice Chair and Professor in the Department of Emergency Medicine at the University of Colorado School of Medicine in Aurora, Colorado, was appointed to the Physician-Focused Payment Model Technical Advisory Committee on Oct. 18. PTAC provides recommendations to the Secretary of Health and Human Services on physician payment models.

ACEP Submits Comments in Response to PFS Schedule and QPP Rule
ACEP submitted a robust set of comments responding to the Calendar Year (CY) 2019 Medicare Part B physician fee schedule (PFS) and Quality Payment Program (QPP) proposed rule. This rule included numerous proposed policies that impact physician payments under Medicare, most notably a proposal that would streamline documentation requirements and create a blended payment rate for office/outpatient Evaluation and Management (E/M) level 2 through 5 visits (the proposal does NOT initially impact the emergency medicine E/M code set). The rule also proposes a set of policies related to the third year of the QPP-- the performance program established by the Medicare Access and CHIP Reauthorization Act (MACRA). Read the highlights of ACEP's response to the rule and our full set of comments.

ACEP Participates in Buprenorphine Discussion
On Oct. 4, ACEP, along with 10 other provider groups, met with top officials of the Trump Administration to discuss challenges with providing buprenorphine as Medication Assisted Treatment (MAT). ACEP member Reuben Strayer, MD, and ACEP staff participated on behalf of the College. The provider groups shared the barriers they faced in prescribing buprenorphine, including those brought by the X-waiver and training process, and offered suggestions for regulatory solutions.

ACEP Weighs in on Draft Legislation Regarding Out-of-Network Billing Issues
Dr. Friedman met with Sens. Bill Cassidy, MD (R-LA) and Todd Young (R-IN), two members of the Senate Bipartisan Price Transparency Workgroup, regarding their draft legislation on how to address out-of-network billing issues. ACEP leaders also met separately with the health staff of the Senators in the workgroup for a more detailed discussion of ACEP's positions, as well as submitting feedback in a letter as part of an ongoing conversation with this bipartisan workgroup that began in March 2018. Read ACEP's response letter.

ACEP Participates in Drug Shortage Listening Session
Dr. Friedman attended the Food and Drug Administration (FDA)'s listening session Oct. 10 on drug shortages with 10 physician groups to try to identify the root causes of drug shortages and develop solutions. Dr. Friedman shared the EM perspective, highlighting the common shortages experienced in EDs that affect the everyday practice of emergency physicians, and how shortages ultimately affect patients.

During the 2018 Leadership and Advocacy Conference, emergency physicians urged legislators to ask the FDA to look into the root causes of drug shortages and deliver recommendations to Congress on how to fix these significant problems affecting patient care. Thanks to the efforts of EM advocates, these letters secured more than 100 bipartisan signatories in the House and more than 30 in the Senate. In response only a few short weeks later, FDA Commissioner Scott Gottlieb announced the creation of this FDA Drug Shortage Task Force, and the Commissioner himself has made this issue one of his top priorities. ACEP will continue to be active in this effort as the Task Force delves further into this critical issue.


September 2018

Want to catch up fast? Here’s a new edition of ACEP’s Capital Minute: 

Winners of ACEP’s 50th Anniversary “What’s Your Moment?” Contest
We have winners! We got so many excellent submissions, and we are beyond proud of everyone who submitted. Congratulations to these incredible storytellers. Read their winning entries here.

  • 1st Place: Stephanie B Benjamin, MD
  • 2nd Place: Eligio S.V. Maghirang MD, FPCEM
  • 3rd Place: Brian K. Sloan, MD, FACEP
  • 4th Place: Jeffrey D. Lazar, MD
  • 5th Place: Laura Janneck, MD, FACEP

ACEP Responds to The New York Times Opinion by Glenn Melnick
ACEP President Dr. Paul Kivela responded to the op-ed with corrections on misinformation presented, and hopes for how these issues could be solved. Read the full response here.

“Insurance companies are taking advantage of hospital emergency departments, because they have a federal mandate to provide care, regardless of insurance coverage or ability to pay, giving negotiating power to the insurance industry. Unfortunately, health insurance companies are ignoring a real solution to "surprise" medical bills and misleading customers and the public when they blame physicians. The Fair Health database, which was developed in response to an insurance company that was fraudulently calculating payments for emergency care, is the best mechanism available to ensure transparency and to make sure insurance companies provide fair payments.”

Federal Advisory Committee Recommends ACEP-Developed Alternative Payment Model to HHS
On September 6, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) voted in favor of recommending ACEP’s proposed alternative payment model (APM), the Acute Unscheduled Care Model (AUCM), to the Secretary of the Department of Health and Human Services (HHS) for full implementation. ACEP’s model joins only 4 others of the 26 submitted to the PTAC to date that have been recommended for full implementation. The voluntary model aims to improve quality and reduce costs in Medicare by allowing emergency physicians to accept some financial risk for the decisions they make around discharges for certain episodes of acute unscheduled care, and ACEP believes that the AUCM has the potential to transform the way emergency care is delivered.. While the PTAC recommendation is a victory worth celebrating for emergency medicine, there is still a long road ahead before the model becomes operational. With PTAC’s endorsement, ACEP will begin discussions with the Centers for Medicare & Medicaid Services (CMS) about implementation.

ACEP Participates in NASEM Drug Shortage Workshop
On September 6, ACEP Board member Aisha Liferidge, MD, FACEP, participated in a two-day workshop hosted by the National Academies of Sciences, Engineering, and Medicine (NASEM) on medical product shortages during disasters and discussed the unique challenges facing emergency physicians and their patients during these crises. The workshop was planned after recent disasters and public health emergencies, such as hurricanes Harvey, Irma, and Maria and the Ebola outbreak, highlighted the impact that shortages of commonly used medical supplies, equipment, and pharmaceuticals had on health care delivery and emergency response. Panels explored opportunities to lessen the effects of medical product shortages through information sharing, improved supply-chain infrastructure, and enhanced collaboration among public, private, and non-profit stakeholders. The United States Assistant Secretary of Preparedness & Response, Dr. Robert Kadlec, and key members of his staff were in attendance.

Senate Passes Opioid Package
On September 17, the Senate voted 99-1 to pass a legislative package on opioidsthat includes two ACEP-developed bills to expand ED-focused tools for addressing the opioid epidemic. Since they were also part of the opioid package passed by the House of Representatives in July, the two ED-focused bills are now well-positioned to being passed into law later this Fall once Congress is able to reconcile the House and Senate versions into a final bill.

ACEP Contributes to Development of Fentanyl Safety Video for First Responders Released by Federal Workgroup
The Department of Justice (DOJ) hosted a White House event last month to announce the release of a safety video for first responders called Fentanyl: The Real Deal. The DOJ worked with nine other Federal agencies as well as 24 stakeholder groups, including ACEP, to produce written guidance and this video that enforces the guidance. The guidance and the video include the following science-based recommendations to help first responders protect themselves when the presence of fentanyl is suspected or encountered:

  • Actions first responders can take to protect themselves from exposure
  • Actions first responders can take when exposure occurs
  • Actions first responders can take when they or their partners exhibit signs of opioid intoxication

ACEP Participates in Drug Shortage Summit
On September 20, ACEP President Paul Kivela, MD, MBA, FACEP, participated in a drug shortage summit hosted by the American Society of Anesthesiologists, the American Hospital Association, and the American Society of Health-System Pharmacies. The summit focused on the national security aspect of drug shortages and ways to improve the resilience of the nation’s health care infrastructure. Many of the speakers were federal employees representing HHS, ASPR, FDA, CDC, and the Defense Logistics Agency (DLA) who engaged the attendees in discussions on how their programs could work better to facilitate patient care, improve transparency and communications, and more effectively utilize the supply chain capacity.

ACEP & The American College of Physicians
ACEP President Dr. Paul Kivela led a teleconference discussion this month with the American College of Physicians, on ACEP initiatives involving physician wellness, the opioid crisis,end-of-life issues, and how we could potentially work together to create greater cohesion. More on this as work continues.

August 2018

Want to catch up fast? Here’s a new edition of ACEP’s Capital Minute: 

ACEP President Responds to New York Times Medical Liability Article
"EDs are unique in that they have a federal mandate to screen and stabilize everyone who comes through the door, regardless of ability to pay. We also care for the most severely ill and injured patients who are at greatest risk of dying. Liability protections need to be in place for physicians who provide federally mandated emergency services. It would not only save a lot of money, but it would also help ensure that emergency physicians and the on-call medical specialists that are needed will be there." Read the full letter from Dr. Paul Kivela, visit https://nyti.ms/2OJzKaK

ACEP-led Provision Boosts Prescription Drug Monitoring Programs
An ACEP-developed provision that requires the Department of Defense to share controlled substance prescribing information of TRICARE beneficiaries with State Prescription Drug Monitoring Programs was successfully passed into law as part of H.R.5515, the John S. McCain National Defense Authorization Act for Fiscal Year 2019. ACEP staff worked closely with Representative Mike Turner (D-OH) to develop this legislative effort and ensure its inclusion in this year’s defense authorization bill.

ACEP Teams Up To Improve ED Sickle Cell Disease Care
Sickle Cell Care Coalition (EDSC3) hosted a one-day leadership summit on Thursday, August 16th, 2018 at the American Society of Hematology’s headquarters in Washington, D.C. The purpose of this summit was to identify concrete and specific actions to improve care in the emergency department for children and adults living with sickle cell disease (SCD). A variety of leaders from key organizations discussed current initiatives and how we can collaborate to effectively and efficiently disseminate best practices to improve the emergency department care for children and adults with SCD. The keynote address was presented ADM Brett P. Giroir, Assistant Secretary for Health at the U.S. Department of Health and Human Services (HHS).

National Suicide Prevention Week
September 10-16 ACEP will be taking part in National Suicide Prevention Week with a week-long campaign focusing on the multi-layered issues with mental health care in the ED. We’ll share and discuss treatment resources for civilians and veterans, including a new bedside tool, and barriers to psychiatric care for our patients.

We close out the week on September 17 by participating in the Council of Emergency Medicine Residency Directors (CORD)’s National Physician Suicide Awareness Day, where we focus on Doc-to-Doc resources for medical students, residents, and Attendings, and advocate for the removal of barriers to psychiatric care for physicians. 

Join the conversation, remove the stigma. Let’s realize #VisionZero. Follow us on Twitter (@ACEPnow) and Facebook (Facebook.com/ACEPfan).

Continuing ACEP Advocacy for Physicians and Patients:

  • ACEP was invited by AHIP, a trade association for commercial insurers, to participate in a meeting of payers seeking input on expanding use of non-opioid pain management. Other physician groups invited to participate were AMA, ACP, and AAFP.
  • ACEP contributed information to, and coordinated with, Sen. Claire McCaskill (D-MO) on her report detailing Anthem’s retroactive denials of emergency care coverage that was released late last month.
  • ACEP participated by invitation in a convening by the White House’s Office of National Drug Control & Policy on efforts to address the opioid epidemic. 
  • ACEP participated by invitation in a roundtable discussion on health care price transparency initiated by Senators Bill Cassidy (R-LA), Michael Bennet (D-CO), Chuck Grassley (R-IA), Tom Carper (D-DE), Todd Young (R-IN), and Claire McCaskill (D-MO). ACEP was one of only three physician associations in attendance (joining the AMA and the American College of Surgeons)—among the other groups participating were the American Hospital Association, insurers and brokers, and patient advocates.
  • ACEP was the only medical association invited to participate in a meeting on price transparency at the Department of Health and Human Services--Demetrios Kouzouka, Principal Deputy Administrator of CMS and Director of the Center for Medicare, attended the majority of the session. 
  • ACEP attended multiple listening sessions with the Centers for Medicare & Medicaid Services (CMS) to discuss proposals related to the CY 2019 Physician Fee Schedule and Quality Payment Program Proposed Rule.


July 2018

Want to catch up fast? Here’s a new edition of ACEP’s Capital Minute: 

ACEP Board of Directors Meeting - June 2018

For a full report of the actions taken and discussions had by the ACEP Board of Directors at the most recent meeting, click here.

ACEP Works with Lawmakers to Improve Your Practice

  • ACEP was invited to participate in a meeting at the Food and Drug Administration (FDA) on drug compounding. The FDA was seeking input from physician groups, and ACEP member Dr. Craig Manifold and ACEP staff Jeff Davis attended to provide the emergency medicine prospective.
  • ACEP led an effort to convene and draft a group response to the CMS request for information on price transparency included in the annual Inpatient Prospective Payment System proposed rule, that specifically asked for input on out-of-network and surprise bills, including those from emergency care. Eleven other medical associations and organization participated and signed onto the letter in addition to ACEP.
  • The Congressional drug shortage letter to FDA Commissioner Scott Gottlieb that ACEP developed and led, and ACEP LAC attendees asked their members of Congress to sign onto, closed with 107 House representatives and 31 Senators signed on—over a quarter of the entire Congress. ACEP also worked with the New York Times on a story it ran on the drug shortage issue, and referenced ACEP’s drug shortage survey as well as the Congressional letter.
  • ACEP and the Medical Association of Georgia (MAG) filed suit against Anthem's Blue Cross Blue Shield of Georgia in federal court in an effort to compel the insurance giant to rescind its controversial and dangerous emergency care policy that retroactively denies coverage for emergency patients. To read the lawsuit, visit newsroom.acep.org.
  • ACEP, AAEM, ACOEP, AOA, ACMT, CORD, EMRA, and SAEM join together to support the introduction of federal legislation to protect emergency physicians’ right to due process in the workplace if they are employed by a third party. The bipartisan bill, introduced by Rep. Chris Collins (R-NY) and Rep. Raul Ruiz (D-CA), would preserve the ability for emergency physicians to strongly advocate for patients by avoiding the mandatory waiver of due process rights which many emergency physicians are forced to comply with as a condition of employment. See more about this at newsroom.acep.org.

ACEP Works with Other Medical Societies for Patient Care

  • ACEP Senior Leadership recently attended the American College of Surgeons Committee on Trauma (ACS COT) meeting. The group discussed achieving greater involvement in the Trauma Center Verification Program. Also discussed was a revision of the REBOA statement.
  • ACEP participated in a small meeting of several medical specialty associations with America’s Health Insurance Plans (AHIP) and several private payers to discuss how to expand access to non-opioid treatments and other pain management strategies to address chronic low back pain.
  • As part of ACEP’s continuing Leader Visit Program, Drs. Jay Kaplan (University Medical Center – New Orleans), Abhi Mehrotra (University of North Carolina), and Scott Zeller (Vituity) met with several key members of the House and Senate on Tuesday to discuss innovative approaches to treating patients with emergency mental health conditions that provide access to more timely, appropriate care for emergency psychiatric patients and have been shown to reduce psychiatric boarding times in the ED, as well as hospital inpatient stays. The Members of Congress and congressional offices they met with are: Rep. Mike Burgess (R-TX), Rep. Janet Napolitano (D-CA), Sen. Lamar Alexander (R-TN), Dr. Raul Ruiz (D-CA), Sen. Bill Cassidy (R-LA), and Sen. Thom Tillis (R-NC).
  • ACEP and senior leadership of Centers for Clinical Standards and Quality (CCSQ) to met to discuss ACEP’s Quality Measures and ongoing support for CEDR. This meeting was very encouraging where CMS provided collaboration support and guidance for measure harmonization and validation for 2018 approved measures and 2019 proposed measures. CMS agreed to provide 2 speakers for ACEP’s July webinar on Quality and CEDR.


June 2018

  • Want to catch up fast? Here’s the Capital Minute: https://www.youtube.com/watch?v=xv2rI0QPUY4
    • Two opioid bills that ACEP was heavily involved with developing clear a major legislative hurdle
    • How ACEP advocacy directly leads to Congressional action on drug shortages
    • New updates on BCBS of Texas’s controversial emergency care policy
    • Recap of ACEP’s tele-town hall meeting about gun violence and prevention with Rep. Seth Moulton (D-MA)


  • Historic Meeting on Unscheduled Sedation Guidelines

ACEP hosted a multidisciplinary specialties group that perform unscheduled sedation, to create a set of consensus guidelines that benefits our patients. As all EPs know, there are often restrictions placed on the ability of EM physicians and nurses to provide the best care. CMS permits institutions to use specialty guidelines when constructing their own guidelines. However, to date, many guidelines have tried to encompass all sedation. The guidelines will be published in the future in the Annals of Emergency Medicine after other organizations endorse this work. The group welcomes input from other groups who feel that they are interested in these guidelines. Interested societies should contact ACEP (sschneider@acep.org) and they will be sent a draft of the document to comment on.


  • Notes from the ACEP & AHA Roundtable on May 22nd, 2018
    • Resilience and Well-Being
      • Dr. Jay Kaplan, MD, FACEP and ACEP Past President provided an update on ACEP’s work in well-being, including the 2017 EM Wellness Week initiative and the recent EM Wellness Summit as well as three main activities of a consensus paper to be submitted for publication, a survey on workplace issues contributing to lack of wellness and the formation of an EM wellness institute. 
    • Opioids
      • Laura Wooster, ACEP Associate Executive Director for Public Affairs, provided an update on ACEP’s advocacy work in the opioid area and the process for expansion of the ALTO program. Dr. Sandra Schneider, ACEP Associate Executive Director of Practice and Policy, talked about training materials and an app ACEP is developing to help expand ALTO. AHA confirmed support of ACEP’s federal legislative efforts through the POWER Act. The group discussed how AHA could advocate for less burdens on the waiver process to allow for easier prescribing of MAT. Dr. Paul Kivela, MD, MBA, FACEP and ACEP President, discussed ACEP support of CMT/EDIE and our work to expand that but discussed the limitations on resources because of new ways patients are presenting and seeking medications in the ED.


  • Drug shortages
    • Ms. Wooster provided an update on ACEP’s work to address the drug shortages. AHA co-signed two congressional letters asking FDA Commissioner Gottlieb to convene the FDA’s Drug Shortages Task Force along with other key federal departments and stakeholder groups in order to identify the root causes of drug shortages and make recommendations back to Congress on how to address them. Dr. Schneider discussed efforts to work with ASHP to have them disseminate alternatives for drugs in short supply. Dr. Schneider also shared information ACEP’s EMPRN network and offered the resource to AHA to gather information on critical questions. 


  • Notes from the SAEM Meeting

Drs. Kivela, John Rogers MD, CPE, FACEP, ACEP President-Elect, and Schneider met with all major EM organizations, where each organization updated their current work and future agendas. ACEP also met with SAEM and AACEM around the same topics. We looked for ways our organizations can work together better. 


  • ACEP Meets with The Joint Commission

Topics included our Geriatric ED Accreditation program, freestanding EDs, suicide screening and Pediatric Readiness. TJC reiterated its standard that universal suicide screening in the ED was required on patients with behavior health chief complaints. Where resources make it feasible, screening of other populations at risk within the population served is encouraged but not a standard. TJC also discussed the issue of inpatient and in-facility suicides. Their data shows that this is actually a more rare event than had been suggested. Nonetheless, they suggest that rooms that house patients with suicidal ideation be free of ligature risks. Among those who kill themselves in a hospital facility, most do so by hanging. 


  • Modern Healthcare & ACEP 

ACEP leaders met with the Modern Healthcare team, and discussed current issues which included Prudent Layperson and out-of-network billing, the Geriatric ED Accreditation program, and other potential topics for the magazine.


  • ACEP & ENA Updates on Partnership

ACEP leaders met with the Emergency Nurses Association, where the value of a closer working relationship with the ENA and our partners in our clinical work was discussed. The Geriatric ED Accreditation program and the sedation conference were discussed, as well as the problems associated with boarding and hospital crowding. 


  • Meeting with Representatives for the Good of EM

ACEP Board of Directors member Dr. Gillian Schmitz, MD, FACEP met with Congressman Will Hurd, on June 4th. They discussed drug shortages and give him a tour of the ED. Congressman Hurd was very receptive and signed on to the Drug Shortages letter ACEP members advocated for at #LAC18.


  • ACEP-Developed Opioid Bills Pass the House

Two pieces of Opioid legislation that ACEP developed and introduced to Congress have successfully passed the House of Representatives, and are moving to the Senate. The bills, the POWER Act and the ALTO Act were created by and introduced to Congress members. At LAC18 just last month, ACEP members advocated for the bills to their state representatives. Your advocacy works! 


  • Emergency Physician Elected to AMA Council

At the 2018 AMA Annual Meeting, ACEP Member Stephen K. Epstein, MD, MPP, FACEP was elected to the AMA Council on Medical Service. This council studies the social and economic aspects of medical care and recommends policies. Click here to read more about the elections, and here to learn more about the council. Congrats, Dr. Epstein!


  • ACEP Leader on Sickle Cell Care Collaborative

Dr. Jon Mark Hirshon, MD, PhD, MPH, FACEP and ACEP Board of Directors member, has been appointed to the Emergency Department Sickle Cell Care Collaborative (EDSC3), a group formed of representatives of governmental and other society groups. The collaborative is organizing a leadership summit on August 16th with multiple federal agencies, professional organizations and others to discuss improving ED care for sickle cell disease.


  • ED Benchmarking Alliance Update

The ED Benchmarking Alliance conducted its fourth ED Performance Measures Summit in February 2018. ACEP was represented by James J. Augustine, MD, FACEP, ACEP Board of Directors member. The focus of the meeting was definitions related to the Value of the ED. Click here for more information.


  • Pain Management Task Force Kicks Off

ACEP Board of Directors member Dr. Mark Rosenberg, DO, MBA, FACEP, attended the first HHS Pain Management Task Force Meeting and met with HHS Secretary Alex Azar, Surgeon General Dr. Jerome Adams, and Vanila M. Singh, M.D., chief medical officer, HHS Office of the Assistant Secretary for Health. The Task Force was established to propose updates to best practices and issue recommendations that address gaps or inconsistencies for managing chronic and acute pain. HHS is overseeing this effort with the U.S. Department of Veterans Affairs and U.S. Department of Defense. Click here for more.


Week of May 28, 2018

  • Leadership and Conference 2018 Round-up
    • 512 emergency physicians representing ACEP went to Capitol Hill and met with legislators from 46 states in 363 meetings to advocate for action on drug shortages, emergency medicine opioid bills, and for putting the medical back in medical preparedness.
    • As well, 766 messages were sent through email, Twitter, and Facebook to legislators prior to the Hill visits through our Phone2Action push.
    • Nearly 200 registrants attended congressional fundraisers and dine-around events coordinated by NEMPAC.
    • Assistant Secretary for Preparedness and Response Dr. Robert Kadlec talked about the importance of strengthening medical surge capacity.
    • Senator Bill Cassidy (R-LA) emphasized the importance of transparency for healthcare consumers
    • Congresswoman Kyrsten Sinema (D-AZ) talked about the need for a national conversation about realistically managing pain.
    • The Surgeon General keynoted the first-ever ACEP Solutions Forum, which highlighted innovative solutions to the opioid epidemic and end-of-life issues from emergency departments nationwide.
  • Get your copy of "Bring ‘em All: Chaos. Care. Stories from Medicine’s Front Line. Celebrate the depth and diversity of emergency medicine with ACEP's poignant new 50th anniversary book, which reveals how far the specialty has come in its relatively short, vibrant life. Famed photographer Eugene Richards, influential author of The Knife and Gun Club, captures the breathtaking moments that comprise the lives and careers of American emergency physicians. Through a collection of 50 stirring photo essays, clinicians from across the country share their perspectives and insights on life and death amidst an ever-changing medical landscape. The book makes an excellent gift for your department, your group or your residency. Pre-order today.
  • ACEP responded to a letter from the Texas Insurance Commissioner to BCBS Texas that expressed his concern with their ED denials program for their out-of-network HMO policyholders but suggested it could be improved by adding features of the Anthem program. ACEP's letter urged the Texas Insurance Commissioner to avoid such policy features.
  • ACEP recently joined with 80 national medical, public health, and research organizations to send a joint letter to House and Senate leaders asking for $50 million in funding for the CDC to conduct public health research on firearms injury prevention.  Read the Senate letter and House letter.
  • Two more ACEP emergency physicians testified on opioids in front of Congressional Committees. Tim Westlake, MD, FACEP, testified before the House Judiciary Committee in a hearing titled “Challenges and Solutions in the Opioid Abuse Crisis.” Charles Pattavina, MD, FACEP, testified in front of the Senate Aging Committee on the issue of seniors and opioids.
  • ACEP was invited by the Center for Medicare and Medicaid Innovation to advise their efforts on developing new payment models for rural health. ACEP President-Elect John Rogers, MD, FACEP attended.
  • ACEP Member Scott Zeller, MD visited the Center for Medicare and Medicaid Innovation to propose that they consider developing a demonstration project to test a wider implementation of the Alameda Model, a regional dedicated psychiatric emergency service.
  • ACEP is planning an Opioid initiative under its E-QUAL program, which will focus on building toolkits, as well as education and training webinars and podcasts. The AHA has keen interest in participating, and ACEP leadership is committed to collaboration with AHA on Opioids.

Week of April 16, 2018

  • Want a rapid rundown of what’s happening on Capitol Hill? Don’t miss this Capital Minute, where ACEP reports on testifying before congress on opioids, new MEDPAC recommendations on freestanding EDs, ACA exchange information, comments from ACEP on the government proposed conscience rule, and the very latest on #LAC18. Click here to watch now.
  • ACEP has launched the Geriatric Emergency Department Accreditation Program (GEDA). GEDA recognizes that one-size ED care does not fit all patients. Older people in the ED have presentations, needs, dispositions, and outcomes that are specific to their age range. A geriatric ED may be either a separate space designated for older adults, or more likely, the integration of best practices for older adults. Learn more about the program at https://www.acep.org/GEDA/.
  • After careful consideration of several very qualified and talented candidates, ACEP has chosen Gerald Beltran, DO, FACEP to be the ACEP representative to the National Disaster Life Support Foundation Board of Directors. The foundation is not-for-profit, and dedicated to the establishment and propagation of standardized, all-hazards, multi-disciplinary, and competency-based training programs for first responders in mass casualty situations.
  • ACEP recently led the development and drafting of two emergency medicine-focused bills that were introduced in Congress last month, aimed at addressing the growing opioid epidemic. ACEP Board member Mark Rosenberg, MD, FACEP was invited by the House Energy & Commerce Health Subcommittee to testify on these two bills—his testimony before the Committee can be watched here.
  • In late March, ACEP was invited by the Congressional House Ways & Means Health Subcommittee to participate in a roundtable on reducing administrative burdens for physicians in the Medicare program. ACEP Board member Jon Mark Hirshon, MD, FACEP participated and shared with the Subcommittee a number of regulatory burdens facing emergency physicians, and ACEP’s recommended solutions.
  • ACEP continues its advocacy work, both with regulators and in the media, to oppose Anthem’s dangerous policy to retroactively deny coverage of emergency department visits by its policyholders that it deems as “non-emergent”. ACEP’s public relations work on the issue led to this NBC Nightly News piece on Anthem’s actions.
  • ACEP submitted a response to the Department of Health and Human Services’ proposed rule around enforcing so-called “conscience protections ”for providers, which as written would allow health care providers to deny treating a patient if they had any religious or moral objections, and to do so without ensuring any continuity of care or referral to another provider. ACEP strongly voiced its objected to the proposed rule in the response, noting that both by law and by oath, emergency physicians care for all patients seeking emergency medical treatment, and that denial of emergency care or delay in providing emergency services on the basis of race, religion, sexual orientation, gender identity, ethnic background, social status, type of illness, or ability to pay, is unethical. In late January when the proposed rule was first announced by HHS, ACEP and EMRA responded with a joint media statement.

Week of March 19, 2018

  • Need to catch up fast on ACEP advocacy and leadership activities? Check out this week’s Capital Minute, where we report on new ACEP-supported legislation about opioids that is now before Congress, new CDC data regarding opioid overdoses and emergency patients, more congressional pressure being applied to Anthem insurance, ACEP Board of Directors member Dr. Jon Mark Hirshon talking to lawmakers on Capitol Hill about administrative burdens, and the announcement of LAC speakers. Click here to watch now.
  • ACEP Board of Directors member Mark S. Rosenberg, DO, MBA, FACEP has been appointed to the Department of Health and Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force (PTMF). The PTMF was created to determine whether there are gaps or inconsistencies in pain management best practices among federal agencies, and propose recommendations on addressing gaps or inconsistencies. Click here to learn more about the PTMF.
  • ACEP and CMS Center for Clinical Standards and Quality (CCSQ) met on March 1 to discuss Quality Measures policy, process, and the future vision for CMS’ approach to Meaningful Measures. The meeting was very productive and provided insight to the ACEP team in preparation for developing the next generation of quality measures, validating existing measures, and their applicability to ACEP’s Quality Clinical Data Registry, known as Clinical Emergency Data Registry (CEDR).
  • Laura Wooster, ACEP’s Associate Executive Director of Public Affairs, represented ACEP in a day-long meeting in DC held by HHS’ Assistant Secretary for Preparedness and Response, Dr. Robert Kadlec, to gain stakeholder input on how to implement his vision for a national medical disaster system. Dr. Kadlec will be sharing more on this vision when he joins ACEP's Public Policy Town Hall during the Leadership and Advocacy Conference on May 21.
  • ACEP Board member Jon Mark Hirshon MD, PhD, MPH, FACEP participated in a roundtable held by the House Ways & Means Health Subcommittee on its “Red Tape Initiative” to reduce provider administrative burdens. Dr. Hirshon talked about administrative burdens in the Medicare program that impact emergency physicians, and provided recommendations for addressing them.
  • Last month, ACEP joined with the American Hospital Association and the American College of Radiology in a joint letter to Anthem Chief Clinical Officer Craig Sammit, MD, to state concerns with the insurer’s policy to retroactively deny coverage for emergency visits it deems as non-emergent. ACEP also has worked closely on the Anthem issue with Senators Ben Cardin of Maryland and Claire McCaskill of Missouri, who last week wrote a joint letter to U.S. Secretary of Health and Human Services Alex Azar and Department of Labor Secretary Alexander Acosta stating concerns on the Anthem policy and seeking information on whether it violates federal regulation.
  • Last week, two emergency medicine opioid bills that ACEP was heavily involved in developing were introduced in Congress. The “Alternatives to Opioids (ALTO) in the Emergency Department Act” would provide $30 million (over three years) to establish a demonstration program to test nationally the ALTO protocol developed at St. Joseph’s Regional Medical Center by ACEP Board member Dr. Mark Rosenberg—the program uses alternative pain management protocols to limit the use of opioids in the emergency department.  Additionally, the “Preventing Overdoses While in Emergency Rooms (POWER) Act” would provide $50 million (over five years) in grants to establish policies and procedures for administering Medication-Assisted Treatment (MAT) in the emergency department to opioid overdose patients with subsequent referral to community providers.
  • ACEP President Paul Kivela, MD, MBA, FACEP was formally invited by the National Academy of Sciences (NAS) onto a panel to discuss "Leading Changes at the Ground Level" (of clinical medicine/healthcare administration), at the workshop titled Engaging the Private Sector Health Care System in Building Capacity to Respond to Threats to the Public’s Health and National Security. Dr. Kivela worked with ACEP's EMS and Disaster Sections of Membership for his discussions.

Week of February 8, 2018

Members of ACEP and ACEP staff met with the VA to discuss care of geriatric patients in VA emergency departments. Among the issues discussed were ways to identify veterans who present to our EDs and connecting them with VA outpatient resources – especially those with mental health issues. Also discussed was the potential participation of VA hospitals in the ACEP Geriatric ED Accreditation program.

Senior ACEP staff and representatives of other medical specialties met with the Patient Centered Outcome Research Institute (PCORI) on January 26th to discuss ways of disseminating the research findings they funded. A few studies were highlighted, including one by ACEP member Erik Hess, MD of the University of Alabama Birmingham on chest pain risk stratification and shared decision making. 

ACEP Board of Directors Member Aisha Liferidge, MD FACEP along with senior ACEP staff attended a 2-day conference with the National Institute of Drug Abuse on January 26th and 27th to discuss potential treatment of patients with opioid addiction. ACEP member Gail D’Onofrio, MD FACEP led the meeting. Dr. D’Onofrio is the Chair of Emergency Medicine at Yale and is a well-respected researcher in substance abuse disorders. 

On January 24th, ACEP’s President Dr. Paul Kivela and members of ACEP’s senior staff, Loren Rives, Laura Wooster, and Sandy Schneider, met with CMS to discuss mental health and sedation. CMS was very supportive of emergency physicians’ ability to screen all patients with emergency conditions, including those with mental health issues. They continue to agree that emergency physicians are ‘uniquely qualified’ to perform sedation. More clarification to come.

ACEP President Dr. Paul Kivela recently met with Sen. Bill Cassidy (R-LA) to discuss: 

  • S.1530 psychiatric boarding in the emergency department (Cassidy is lead Republican on the bill)
  • ACEP’s interest in the Senate’s reauthorization of the Pandemic and All Hazards Preparedness Act (PAHPA)
  • Out-of-Network billing for emergency services

During the meeting, Dr. Cassidy agreed to address ACEP members during #LAC18, to provide an update on the latest health care initiatives being considered by Congress. He will be speaking at 8:45 a.m. on Tuesday, May 22nd.

Week Of January 15, 2017

  • Laura Wooster, ACEP Associated Executive Director for Public Affairs takes you through the first of 2018 and the issues that are important to ACEP members and their patients. They include new developments with Anthem's controversial emergency care policy, legislative priorities and updates on veteran's health issues. Click here for the latest ACEP news in the ACEP Capital Minute.
  • ACEP President Paul Kivela, President-Elect John Rogers, and ACEP staff met with leaders of the American Society of Anesthesiologists to discuss their sedation polices and potential impact on emergency medicine practice. They also discussed collaboration and strategies to ensure reasonable out-of-network reimbursement.
  • In late December, ACEP President-Elect John Rogers and ACEP’s Associate Executive Director for Public Affairs, Laura Wooster, met with representatives of Anthem to discuss Anthem’s announced policy in several states to deny payment for patient visits to the ED that ACEP contends are in violation of federal and state law protecting patients according to the prudent layperson standard
  • In December, ACEP’s Board held its annual strategic planning meeting. Among many issues discussed that impact the specialty, the Board discussed ways to overcome challenges to fair reimbursement, how to enhance ACEP’s engagement with members in social media, quality measures and ACEP’s clinical data registry (CEDR), patients with mental health disorders, seeking improved relations with other emergency medicine organizations, and assessing the efficiency of ACEP’s Board.


Week Of December 11, 2017

  • Want a high-speed rundown of what’s going on in Washington, DC? Check out ACEP’s Capital Minute here.
  • ACEP’s Associate Executive Director for Public Affairs, Laura Wooster, worked with an Associated Press reporter to develop a story on Anthem’s damaging policy to retroactively deny coverage for emergency department care—the syndicated article was picked up by more than 200 outlets in November including The New York Times, Time Magazine, ABC News, and The Washington Post, bringing national attention to the insurer’s assault on the prudent layperson standard.
  • ACEP President Paul Kivela, Past President Becky Parker and other ACEP leadership recently met at our office with leaders of EDPMA, EMAF, and PFC (Physicians for Fair Coverage) to discuss coordinating strategy and resources around the out-of-network battles that will be occurring in various states over the next year.
  • ACEP was invited to a meeting of specialty societies, state medical associations, specialty boards and the American Board of Medical Specialties to discuss the need for changes in Maintenance of Certification. It is very clear that there is significant discontent with the current programs in all specialties, and ABMS acknowledges the need for significant change. The specialty societies and state medical associations expressed the need for transparency of finances and process, re-establishing trust among the groups, flexibility of testing, retaining self-regulation and alternatives to the high-stakes periodic examination. While some changes to periodic assessment are already underway within various individual Boards, the ABMS is starting a process to examine continual competency assurance. It is clear that Boards will be encouraged to develop innovative alternatives to the current process. At the ACEP Council meeting, emergency medicine's Board, ABEM, announced that they, too, would be looking at alternatives to the current Maintenance of Certification program.
  • ACEP has had discussions with Veterans Administration (VA) staff regarding a variety of programs and awareness efforts for the two organizations to work more closely together to help achieve our respective missions. Some of the projects under discussion include creating tools to identify VA patients when they present for emergency care, education on military/veteran health issues, participation in EMS Week 2018, and participation in the Geriatric ED Accreditation program.
  • ACEP is collaborating with the American College of Healthcare Executives (ACHE) for Patient Safety initiative, a national leader in patient safety. ACEP has added a Patient Safety Sub-committee under the umbrella of the Quality and Patient Safety Committee (QPSC). Through this collaboration, ACEP expects to establish a vision and culture for patient safety for emergency medicine and contribute to the national movement toward patient-centered safety. More details are available here.
  • ACEP is working closely with the American Hospital Association (AHA) on a number of initiatives: a half-day workshop on physician wellness and resiliency that we intend to offer before LAC; a hospital flow conference that ACEP would offer in conjunction with an AHA meeting next summer; and discussions with AHA around their support for ACEP and state hospital associations regarding attacks on the prudent layperson standard. Details on these to come later.
  • ACEP and the AHA have also partnered to lead opioid-related education, training, awareness, best-practice development, and research. Some of the potential topics for future collaboration are:
    1. Collaboration with the National Institutes of Drug Abuse (NIDA) on Opioid Initiatives, including co-branding of Emergency Quality Network (E-QUAL) Opioid project
    2. Joint clinical policies on opioid usage
    3. Awareness of opioid issues for providers
    4. Awareness of opioid issues for patients/community
    5. Participation in Behavioral Health Toolkit and Dashboard development and deployment
    6. Emergency Department Information Exchange (EDIE)
    7. Alternatives to Opioids (ALTO)
    8. Publish stories of success
    9. Explore joint research opportunities and funding

Week of Nov. 10, 2017 

Members of ACEP and ACEP staff met with the VA to discuss care of geriatric patients in VA emergency departments. Among the issues discussed were ways to identify veterans who present to our EDs and connecting them with VA outpatient resources – especially those with mental health issues. Also discussed was the potential participation of VA hospitals in the ACEP Geriatric ED Accreditation program.



Senior ACEP staff and representatives of other medical specialties met with the Patient Centered Outcome Research Institute (PCORI) on January 26th to discuss ways of disseminating the research findings they funded. A few studies were highlighted, including one by ACEP member Erik Hess, MD of the University of Alabama Birmingham on chest pain risk stratification and shared decision making. 

ACEP Board of Directors Member Aisha Liferidge, MD FACEP along with senior ACEP staff attended a 2-day conference with the National Institute of Drug Abuse on January 26th and 27th to discuss potential treatment of patients with opioid addiction. ACEP member Gail D’Onofrio, MD FACEP led the meeting. Dr. D’Onofrio is the Chair of Emergency Medicine at Yale and is a well-respected researcher in substance abuse disorders.

On January 24th, ACEP’s President Dr. Paul Kivela and members of ACEP’s senior staff, Loren Rives, Laura Wooster, and Sandy Schneider, met with CMS to discuss mental health and sedation. CMS was very supportive of emergency physicians’ ability to screen all patients with emergency conditions, including those with mental health issues. They continue to agree that emergency physicians are ‘uniquely qualified’ to perform sedation. More clarification to come.

ACEP President Dr. Paul Kivela recently met with Sen. Bill Cassidy (R-LA) to discuss: 

  • S.1530 psychiatric boarding in the emergency department (Cassidy is lead Republican on the bill)
  • ACEP’s interest in the Senate’s reauthorization of the Pandemic and All Hazards Preparedness Act (PAHPA)
  • Out-of-Network billing for emergency services

During the meeting, Dr. Cassidy agreed to address ACEP members during #LAC18, to provide an update on the latest health care initiatives being considered by Congress. He will be speaking at 8:45 a.m. on Tuesday, May 22nd.

Week of Oct. 23, 2017

  • ACEP Board leaders Becky Parker, Paul Kivela and Bill Jaquis, along with ACEP senior staff and Dr. Alison Haddock, Chair of ACEP’s State Legislative committee, met with senior executives of Cigna insurance on October 12. This was a follow-up meeting to one held in July.

    ACEP and Cigna discussed the need to protect the prudent layperson standard as a matter of patient safety and patient access to care. Cigna sought ACEP’s guidance on ways to engage more ED groups to contract to be in their networks. Both organizations share a commitment to combatting the opioid crisis and discussed their efforts. Cigna is interested in working with ACEP to promote the use of interoperable emergency department information exchanges such as the EDIE/PreManage program of Collective Medical Technologies that is supported by ACEP. The groups agreed to follow up on things discussed and meet again. Cigna expressed a strong interest in having a collaborative relationship with ACEP.
  • Earlier this week, ACEP President Dr. Becky Parker sent a letter to Senator Alexander and Senator Murray regarding ACEP’s support of the bipartisan Alexander-Murray agreement. The agreement was released late Tuesday evening to provide critical stability for the individual health insurance marketplace, ensuring that millions of Americans have continued access to the health coverage they need and deserve.

    This legislation is a good-faith bipartisan effort that will help limit increases in health insurance premiums and preserve important consumer protections, such as the Essential Health Benefits (EHBs) package that includes emergency services, while also providing additional flexibility for states to implement innovative approaches to coverage. For the tens of millions of patients that receive care in the emergency department each year, the Alexander-Murray agreement provides much-needed assurance that their care will continue to be covered.

    Further, this approach is proof that lawmakers on both sides can collaborate on patient-centered solutions that help improve our entire health care system. By providing this important short term stability, policymakers, physicians, providers, and other stakeholders and experts can continue working to address the other challenges facing our health care system. ACEP applauds Senators Alexander and Murray for their bipartisan agreement and urges Congress to act quickly to enact this vital legislation.

Week of Oct. 9, 2017

  • ACEP President Dr. Rebecca Parker talks about the latest attempt to repeal and replace the Affordable Care Act, a high-level meeting ACEP had with the Department of Health and Human Services and work that ACEP members are currently doing in hurricane-ravaged Puerto Rico. This it the latest that ACEP is working on in Washington, D.C., for emergency physicians and their patients. See the Capital Minute here.
  • On Oct. 2, ACEP President Dr. Rebecca Parker met with the leadership of the Department of Health and Human Services and the Centers for Medicare and Medicaid Services to discuss innovations in Medicare that benefit emergency patients and Physicians.
  • On Sept. 29, ACEP President Dr. Rebecca Parker, President-Elect Dr. Paul Kivela, and Immediate Past President Dr. Jay Kaplan, along with ACEP’s senior management team, met with senior staff of the American Hospital Association in Chicago at AHA headquarters. A variety of things were discussed, but ACEP and the AHA have agreed to work together on a series of projects to address workplace violence, patient flow and boarding, the opioid crisis, EMTALA and protecting the prudent layperson standard. Other areas in which the two organizations have expressed interest in working together include physician resilience and wellbeing, geriatrics, quality measures, and the future of the ED.
  • ACEP, along with every major Emergency Medicine organization, participated in a summit meeting convened by the American Board of Emergency Medicine (ABEM) to discuss modifications and alternatives to the ABEM Continuous Certification (ConCert™) Examination. ACEP Vice President Dr. William Jaquis attended the meeting, which took place October 2-3 and reviewed the role of the ConCert™ Examination in maintaining a credential that would best serve the interests of both the public and emergency physicians. ABEM will continue to solicit input from stakeholder organizations and ABEM-certified physicians. ABEM anticipates announcing specific examination options and a timeline for implementation, in spring 2018.
  • ACEP Chair of the Board Dr. John Rogers was interviewed on Top Docs about the new Anthem BCBS policy about emergency visits and their refusal of claims for what they consider non-emergent visits. To see the entire interview, click here.
On Oct. 2, the Nevada College of Emergency Physicians & ACEP issued a joint statement about the mass shooting in Las Vegas, which reads in part, "The incredible emergency response in such a short timeframe — from the physicians, nurses and emergency medical services in Nevada, as well as law enforcement — has been nothing less than miraculous. While the shock and grief from yet another heinous mass killing and wounding are still fresh, we remain devoted to preparing our nation to best manage the consequences of such violent active incidents. Our prayers go out to the many injured who are still fighting for their lives." Watch ACEP President Dr. Parker comment on the incident.

Week of Sept. 25, 2017

  • ACEP President-Elect Dr. Paul Kivela met with the Board of Directors of the Emergency Nurses Association (ENA) recently and addressed the General Assembly of the ENA at their annual meeting. Dr. Kivela discussed with ENA leadership the need to work more closely together on issues of workplace violence and other issues of mutual concern to our members.
  • CMS released the most current version of its proposed ED Patient Experience of Care (EDPEC) survey for feasibility testing. CMS has been developing this survey of the last few years due to the Consumer Assessment of Healthcare Providers & Systems (CAHPS) that is currently used in hospital outpatient settings being largely inappropriate for the ED setting. ACEP shared strong concerns with CMS on initial versions of EDPEC, and due to these efforts, the questions regarding pain have been changed to be much more appropriate to how care is delivered in the ED. CMS will be testing this new version, and ACEP will continue to monitor these efforts and provide feedback to the agency as the survey moves closer to implementation. 
  • ACEP played an active role in defeating the proposed Graham-Cassidy Senate health care reform bill. ACEP sent a letter to Congress, issued a press release, and was featured in many high-profile media reports about opposition to the bill, including Meet the Press, The New York Times, The Washington Post and others. ACEP President Dr. Rebecca Parker was quoted in an article in MedPage Today.
  • ACEP President-Elect Dr. Paul Kivela, members Dr. John Proctor and Dr. Les Zun (representing the American Association for Emergency Psychiatry) and ACEP staff sat on The Joint Commission’s Technical Expert Panel on universal suicide screening in the ED. Others at the meeting included the American Psychiatric Association, National Institute for Mental Health, American Federation for Suicide Prevention and SAMSHA. There was support for continuation of The Joint Commission standard that limits mandatory screening in the ED to those patients who present with mental health problems. However it was noted that there is significant progress being made to develop more reliable screening tools. It is recognized that screening alone does not reduce suicide rates. There was support for an increase in mental health resources 24/7, and evidence based treatment alternatives to hospitalization. Hospitals with available and accessible resources for rapid referral to mental health follow-up should consider screening of additional high-risk populations for suicide such as adolescents and, when feasible and referral resources are available, screen all patients for suicide ideation. 


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