May 19, 2017
Volume 61, Issue 20


WHA Comments on Medicaid Waiver Proposal
Recommends DHS seek additional funding, suggests improvements

On May 19, WHA submitted comments to the Department of Health Services (DHS) on its draft amendment to the state’s Medicaid childless adult demonstration project. The new proposal includes several new policies, such as imposing premiums, emergency department copayments, work requirements and drug testing. The proposal also includes a change to the federal policy that limits services in Institutes for Mental Disease (IMD).

The original waiver for providing services to the childless adult population was approved in late 2013 and allowed the state to expand eligibility to childless adults with income up to the poverty line (100 percent FPL). This was considered a "partial expansion" by the previous federal Administration, and thus Wisconsin was not eligible for the higher federal funding that was given to states that expanded coverage to adults with income up to 133 percent of the federal poverty level (FPL). WHA has for months advocated that Wisconsin’s partial Medicaid expansion should be funded in an equitable manner compared to states that took the full Medicaid expansion under the Affordable Care Act.

In its comments, WHA recommends to DHS that it now seek enhanced federal matching funds for the partial expansion. In doing so, WHA describes Wisconsin as a model for avoiding gaps in coverage and notes other states are now considering changes to their programs that align with Wisconsin. In Arkansas, for example, recently passed legislation requires the state modify its current Medicaid waiver to reduce the income threshold for coverage from 133 percent FPL to 100 percent FPL, like Wisconsin’s program. Arkansas is an expansion state and is expected to ask the federal government to maintain the higher match it currently receives.

"As states seek flexibility for their programs, including as expansion states seek ways to reform their programs and reduce costs for their Medicaid programs, the principle that Medicaid should be a safety net for all in poverty can resonate if states are assured of enhanced funding," wrote Eric Borgerding, WHA president/CEO.

In addition to the funding question, WHA also provided comments about the implementation of other policies included in the waiver proposal. WHA noted in particular the state’s commitment to increasing treatment options for individuals with substance use disorders. WHA also expressed support for the intention of the overall proposal to engage participants in maintaining and improving their overall health and incenting the efficient use of health care resources.

At the same time, WHA expressed concern about some provisions that would result in a person’s disenrollment from the Medicaid program. The imposition of premiums is an example.

"WHA’s members are the health care safety net," wrote Borgerding. "Individuals who fail to pay their premium and are disenrolled will still seek care at their doors, and our members will continue to serve them. Unfortunately, this will mean higher uncompensated care."

The draft waiver proposal also includes copayments for emergency department (ED) utilization. The copayment would be $8 for the first emergency room visit and $25 for each visit after that within a year. Further, providers would be required to collect the copayments. In its comments, WHA notes individuals with income below poverty likely will not be able to pay, and this will essentially result in a provider rate cut, increasing the Medicaid shortfall even more. Instead, WHA recommends DHS collect the copayment directly. WHA also believes the proposal could discourage appropriate use of the emergency room and recommends the proposal be narrowed to non-emergent use only.

The waiver proposal includes a 48-month time limit and work requirements. Any month in which the participant does not meet the work requirement would apply to the 48-month limit, and once a person meets the 48-month limit he/she would be disenrolled for six months. DHS proposes to limit the application of these policies to people age 19-49, and would allow for exemptions for individuals with mental illness, disabilities and other circumstances. WHA encouraged DHS to consider additional exemptions for people with medical conditions that might prevent them from being able to meet the work requirement.

WHA believes health risk screenings are a positive practice and helpful if used appropriately to address care needs. WHA also supports the provision to waive the current limits on services provided by IMDs. With respect to the substance use provisions, WHA remains concerned about significant gaps in availability of treatment. While Wisconsin has made gains in the past several years in expanding substance abuse treatment resources, considerable additional investments are still needed. WHA has been and will continue to partner with and support efforts to combat substance abuse and increase access to and the availability of substance abuse treatment for individuals suffering from addiction.

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WHA Physician Leaders Council Discusses PDMP, AHCA
Council provides feedback on WHA members’ integrated physician enterprise needs


The WHA Physician Leaders Council met May 11 and discussed a range of topics impacting physicians and physician practice within WHA’s member hospitals and health systems, including:

AHCA Update

WHA President/CEO Eric Borgerding and Jenny Boese, WHA vice president, federal affairs and advocacy, provided a report to the Council on the latest developments related to the AHCA in both Washington, DC and Madison, including WHA policy priorities and advocacy strategies. WHA along with hospital and health system leaders were in Washington, DC May 9 and met with both of Wisconsin’s U.S. senators. The key message of those meetings was the need to make key improvements to the AHCA in the Senate to protect Wisconsin’s coverage gains.

For more information about the AHCA and WHA’s discussions with Wisconsin’s U.S. senators, see www.wha.org/pubarchive/valued_voice/WHA-Newsletter-5-12-2017.htm#1.

PDMP Functionality and Interoperability

Matthew Stanford, WHA general council, provided the Council with an update on ongoing discussions with state officials regarding the Prescription Drug Monitoring Program (PDMP), including efforts to expedite interoperability of the PDMP data with electronic health records (EHRs), clarify requirements and address delegation issues.

Stanford discussed the WHA letter signed by WHA Physician Leaders Council Chair Steve Kulick, MD, requesting additional clarity regarding physician discipline related to the PDMP mandate, and the subsequent resolution by the Controlled Substances Board that provided additional clarity regarding that Board’s intent to use discretion in making referrals to licensing boards for non-compliance with the mandate (see www.wha.org/pubarchive/valued_voice/WHA-Newsletter-3-17-2017.htm#6).

Stanford also shared joint efforts by WHA and the Wisconsin Medical Society to clarify the ability of physicians to satisfy the PDMP review mandate by delegating the review to another individual as permitted by existing principles of medical delegation, as well as other clarifying language intended to create additional options for EHR connections to the PDMP data. (See story on the joint memo submitted by WHA and the Wisconsin Medical Society to the Controlled Substances Board and the Board’s action below.) Additionally, during the meeting, the Joint Finance Committee unanimously approved a recommendation to amend the state budget bill to include that clarifying change in statute regarding medical delegation (see www.wha.org/pubarchive/valued_voice/WHA-Newsletter-5-12-2017.htm#4).

Council members continued to talk about the benefits of having access to the PDMP database, but also raised concerns about the length of time the web-based PDMP can take to use as well as the utility and effectiveness of some of the alerts provided by the PDMP. For example, one member said for an average child psychiatrist seeing 25 patients per day, the total time that it takes to access the web-based PDMP adds up to around an hour of extra time in the physician’s work day. Others noted that especially for physicians in a multi-specialty clinic setting, some of the ePDMP alerts were not useful or created false positives. By moving to a flexible approach to interoperability with EHRs that focuses on the sharing of data and enabling providers to choose what analytics are most relevant to their practice, some of these concerns could be addressed.

Council members also expressed interest in learning more about newly available PDMP functionality for medical coordinators and supervisors. WHA staff said it would work with the Department of Safety and Professional Services (DSPS) to organize a WHA webinar for physician leaders that can better introduce and explain the new PDMP functionality.

WHA activities supporting members’ integrated physician enterprise

The Council continued a dialogue from its last meeting on how WHA can best support its members’ integrated physician enterprise now and in the future. The Council is a key component of WHA’s efforts to continuously define and identify how best WHA can meet members’ needs in support of members’ integrated physician enterprise.

"As WHA’s members’ focus has evolved beyond the traditional ‘walls’ of the hospital to a presence as local and regional integrated health systems, WHA’s focus has similarly evolved," said WHA Chief Medical Officer Chuck Shabino, MD. "The physician component of our members’ enterprise is significantly larger, and WHA has been evolving to respond to those changes by enhancing WHA activities to incorporate, from the system prospective, physician issues, opportunities and initiatives."

Physician retention and engagement

Building upon the 2016 WHA Physician Engagement and Retention Toolkit, the Council discussed the need for additional education or resources to help physician leaders and their organizations further engage and retain their physicians. Staff presented and sought feedback on potential options WHA could develop and provide to help physician leaders and their organizations regarding engagement and retention. In the coming weeks, look for additional announcements from WHA on new engagement and retention resources for physician leaders.

Legislative and regulatory update

WHA staff provided an overview of several additional current WHA legislative and regulatory advocacy efforts impacting physicians and physician practice within WHA’s member hospitals and health systems.

One of WHA’s budget advocacy efforts is to increase Wisconsin’s investment in the state’s GME matching grant program to help expand access to GME programs in Wisconsin.

"Wisconsin’s aging physician workforce and aging patient population is creating challenges for the state’s health care delivery system. Data shows Wisconsin needs between 2,000 and 4,000 additional physicians by 2035," said Shabino. "We know that graduate medical education is a key factor in where physicians end up practicing, and funding GME is a successful model to recruit and retain physicians in Wisconsin."

Andrew Brenton, WHA assistant general counsel, provided an update to the Council on developing rulemaking that would impact level III and IV trauma centers, and in particular sought input from the Council regarding draft proposed standards that would place specific responsibilities on physicians. Brenton told the Council WHA staff has been working with the Department of Health Services (DHS) since DHS first proposed the development of a new rule in 2016 and that the rule has several more steps to go, including a public hearing, before the rule is finalized. Brenton said WHA will keep the Council informed as the rule further progresses.

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Wisconsin Hospitals State PAC & Conduit
Next contributor list June 9

Contributions to the Wisconsin Hospitals State PAC and Conduit continue to come in at a pace of roughly $6,000 each week. To date, the fundraising campaign is at the $118,000 mark, putting it over the one-third mark for the 2017 fundraising goal of $312,500. A total of 111 individuals have contributed to date. Roughly half of the individuals on WHA’s 40-member staff have committed to contribute a total of $35,000 in 2017.

"The 2017 fundraising campaign is well underway and has sustained a strong pace throughout the first quarter of the year," said WHA President/CEO Eric Borgerding. "As the campaign continues, I believe everyone who values Wisconsin hospitals and health care in our state should participate—better candidates lead to better legislators who craft better laws."

The next full contributor list will run in the June 9 edition of The Valued Voice. To be on the list, log onto www.whconduit.com and make your contribution or call Jenny Boese at 608-268-1816 or Nora Statsick at 608-239-4535.

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WHA, WMS Make Joint Proposal on PDMP Rule to Facilitate EHR Interoperability

On May 12, the Controlled Substances Board (CSB) held a hearing and took votes on CSB 4, a rule governing Wisconsin’s Prescription Drug Monitoring Program (PDMP).

During that meeting, the Board voted to make a change to the rule language so it would be consistent with amended statutory language recommended the day before by the Joint Finance Committee that would align PDMP review requirements with accepted practices of agency and medical delegation (see www.wha.org/pubarchive/valued_voice/WHA-Newsletter-5-12-2017.htm#4). The Board also voted to request the Department of Safety and Professional Services review its agreement with its PDMP vendor to help facilitate the integration of the PDMP with electronic health records (EHRs).

WHA and the Wisconsin Medical Society jointly provided testimony to the Board recommending additional clarification to regulations created by the Board in emergency rule regarding the ePDMP mandate in Wisconsin. These comments focused on facilitating EHR integration and providing regulatory clarity regarding the review mandate to achieve a maximally functioning PDMP system that is carefully tailored to balance and recognize impacts on care delivery efficiency, clinical efficacy and quality of care, and the professional medical judgment of physicians and other prescribers.

"Achieving a maximally functioning PDMP system is particularly important for physicians and their health systems as they are under significant pressure to provide health care in the most efficient and cost-effective manner possible," said Matthew Stanford, WHA general counsel. "Those and other pressures are also contributing to ever-increasing rates of physician burnout, which ultimately impacts access to physician care in Wisconsin. Thus, it is important that regulations and processes are carefully tailored to balance and recognize impacts on care delivery efficiency, clinical efficacy and quality of care, and the professional medical judgment of physicians and other prescribers."

For additional questions about the CSB’s actions as well as the recommendations proposed to the CSB, contact Stanford at mstanford@wha.org.

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WHA Presents Emergency Preparedness Conference, September 20 in Madison
International Risk Communications Expert Vincent Covello will keynote event

On September 20, the Wisconsin Hospital Association is sponsoring the "WHA Emergency Preparedness Conference: Ready to Respond." This important, one-day conference will feature national experts who will share communication and preparedness lessons learned from real world events and focus on current threats facing health care organizations, including workplace and community violence and highly infectious diseases. Attendees will have the opportunity to collect strategies to enhance their current emergency management programs, practice them through interactive exercises, and integrate those preparedness and communication strategies into daily operations.

Vincent Covello, PhD, will keynote the conference and offer a deep-dive session in the afternoon specifically for public information officers and health care public relations professionals.

Covello is a nationally and internationally recognized trainer, researcher, consultant and expert in crisis, conflict, change and risk communications. Over the past 25 years, he has held numerous positions in academia and government. Covello was a senior scientist at the White House Council on Environmental Quality in Washington, D.C., a study director at the National Research Council/National Academy of Sciences and the director of the risk assessment program at the National Science Foundation. Covello has authored or edited more than 25 books and published over 75 articles on risk assessment, management and communication. Covello will share principles, strategies and practical tools for communicating effectively in a high stress situation.

Chris Sonne and William Castellano, both of HSS EM Solutions, will share best practices and lessons learned from live active shooter scenarios, as well as direct tabletop exercises and a practical, scenario-based training exercise, during a special afternoon session focused on preparing for an active shooter.

Additional sessions include a look at infectious disease outbreaks and what hospitals can do to better prepare; as well as the role of governmental agencies, including the Department of Health Services and the Department of Public Health during an emergency.

This conference has been designed for hospital emergency preparedness directors, emergency department directors and physicians, infection prevention staff, department directors, public relations professionals and public information officers.

This conference is September 20 at the Sheraton Hotel in Madison. The registration fee is $225 per person. The full agenda and online registration are available at www.cvent.com/d/b5qw08. An event brochure is also included in this week’s packet. Seating is limited—WHA highly recommends registering early.

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Plan to Attend 2017 Rural Health Conference, June 21-23
Make hotel reservations by May 31

Registration is now open for the 2017 Wisconsin Rural Health Conference, June 21-23 at Glacier Canyon Lodge at The Wilderness Resort in Wisconsin Dells. This annual event is the statewide forum for examining the issues that impact small and rural hospitals most, networking and collaborating with colleagues, and bonding with your team of senior staff and members of your hospital board of trustees.

Make attendance at this year’s conference a priority by registering today at www.cvent.com/d/w5qpcq. A conference brochure is included with this week’s packet. Also, make your hotel reservations at Glacier Canyon Lodge as soon as possible. Reservations must be made by May 31 to get the group’s discounted rate. Reservations can be made by calling 800-867-9453 and referencing Leader #358670.

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WHA Launches Physician Quality Academy

Physicians and providers from hospitals and health systems across the state attended the first session of the WHA Physician Quality Academy May 10. The Academy is designed to provide knowledge about quality improvement tools and principles to increase the likelihood that a physician will be more successful in and comfortable with his/her quality leadership role. The first session focused on designing and conducting quality improvement projects, engaging physician colleagues in quality improvement and measurement, physician profiles and the role of physician leaders in quality work.

"WHA is a recognized leader among hospital associations nationwide in offering our members the support and training necessary to successfully implement quality improvement projects in their organizations," according to WHA President/CEO Eric Borgerding. "The WHA Physician Quality Academy is a new resource that will assist our hospitals and health systems engage their physicians and help them lead quality improvement efforts within their health care organizations."

The format for the Academy combines didactic learning, exercises and generous time for discussion. "The academy participants were highly engaged throughout the day with discussion about how to apply the quality concepts being presented," said Kelly Court, WHA chief quality officer. "I was very impressed with the willingness of everyone to participate and share their experiences and advice with one another. This culture of sharing is very similar to what we see in our quality work with their non-physician counterparts."

Registration is still open for the second cohort of the academy on September 29 and November 3. The full event agenda and online registration are available at www.cvent.com/d/wvq5nm.

The Academy is jointly provided by AXIS Medical Education and WHA. AXIS Medical Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for physicians. AXIS Medical Education designates this live activity for a maximum of 10 AMA PRA Category 1 Credit(s)TM.

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Fast Facts from the WHA Information Center: May is National Bike Month

It’s the perfect time to get out and ride with your family and friends. But, be careful! According to the WHA Information Center, in 2016 there were 5,977 emergency room visits in Wisconsin hospitals due to a bicycle-related injury. 34.2 percent of the total visits occurred in children ages 5-14, 18.4 percent in young adults ages 15-24, and 25.4 percent in adults ages 45 and older. Men accounted for 70.7 percent of those visits.

For more information on bicycle safety, visit: www.cdc.gov/motorvehiclesafety/bicycle/index.html.

Data provided by the WHA Information Center (WHAIC). WHAIC is dedicated to collecting, analyzing and disseminating complete, accurate and timely data and reports about charges, utilization, quality and efficiency provided by Wisconsin hospitals, ambulatory surgery centers and other health care providers.

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