October 30, 2015
Volume 59, Issue 43


Ryan Elected Speaker of the House 
Budget deal hits hospital Medicare payments


It has been a busy week in Washington, DC, including swift passage of a two-year budget deal by the U.S. House and the U.S. Senate and the election of Wisconsin’s first ever Speaker of the U.S. House.

“As the first Speaker of the House to hail from our great state, the Wisconsin Hospital Association congratulates Paul Ryan on this historic day,” said WHA President/CEO Eric Borgerding. “WHA, along with our member hospitals and health systems, look forward to working with Speaker Ryan to pursue policies that build on Wisconsin’s tradition of embracing innovation and delivering the high quality patient care that is a hallmark of our state.”

Ryan’s election came on the heels of quick House passage of a two-year budget deal negotiated, in part, by outgoing Speaker John Boehner. The Bipartisan Budget Act of 2015 (BBA) passed the House on October 28 by a 266-167 vote. Wisconsin Representatives Kind, Moore, Pocan and Ryan voted in support. Reps. Duffy, Grothman, Ribble and Sensenbrenner voted against. The U.S. Senate passed the bill early October 30 by a 64-35 vote. Sen. Baldwin voted in support while Sen. Johnson voted against. 

To pay for the cost of the two-year budget deal, several Medicare reductions impacting hospitals and other providers were included: Prior to the House vote, WHA expressed opposition in a letter to Wisconsin’s entire Delegation about additional Medicare cuts. “As a reminder, Wisconsin hospitals and health systems are already experiencing the impacts of well over $4 billion in Medicare reductions from past Congressional actions, including ongoing sequester cuts, bad debt reductions and coding offsets among others…Wisconsin stands committed to a high-value approach to care delivery, which is why we have consistently opposed arbitrary reductions both on policy grounds and the negative impact those have on our providers.”


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Wisconsin’s Border States Participate in First Compact Commission Meeting
Compact states target July 2016 for first expedited licenses


On October 27 and 28, the 11 current member states of the Interstate Medical Licensure Compact convened the governing body for the Interstate Medical Licensure Compact at a meeting in Chicago. The governing body, called the Interstate Medical Licensure Compact Commission, is made up of two members of each participating states’ medical licensing boards. 

Wisconsin’s border states of Illinois, Iowa and Minnesota have all adopted the Interstate Medical Licensure Compact, and representatives of those states participated in the meeting this week. Representatives of Wisconsin’s Medical Examining Board were in the audience, but were not able to vote at the meeting because Wisconsin has yet to adopt the Compact into law.

During the meeting, the Commission set a goal for when states could begin issuing expedited licenses under the Compact, discussed start-up planning to achieve that goal, and discussed the role of the Interstate Commission vis-a-vis the Compact’s member states’ medical boards.

The Commissioners established a goal to have an infrastructure in place to enable states to issue expedited licenses under the Compact as early as July 2016. Commissioners were anxious to begin issuing expedited license in their states, but wanted to make sure the process to do so is “set up right, right from the start.” 

The Wisconsin State Assembly has passed the Compact with a vote of 95-1, but the legislation must still move through the Senate and be signed by the Governor before it can be enacted. If the legislation does not move through the full Legislature this session, Wisconsin will be left behind while our border states can take advantage of this streamlined process. As WHA testified in front of the Assembly and Senate Health Committees, the Compact is a tool that will help to address physician access issues in rural and urban communities across Wisconsin.

Several committees were also formed to begin the implementation process, including funding, budget, technology, bylaws, personnel and communications. The Commissioners anticipate the committees and the full Commission will meet frequently over the coming months to meet its target date for member states to begin issuing expedited licenses.

The Commissioners also emphasized the Commission’s charge is limited and reaffirmed that the Commissioners are not interested in usurping their own states’ medical practice laws. 

“This Commission and the Compact’s role is focused on creating a process for expedited licenses,” said Mark Bowden, executive director for the Iowa Board of Medicine. “This is not another layer of bureaucracy. Physicians must be locally accountable and the Compact achieves that. As a Commission, we may see this as self-evident, but it makes sense to reiterate as other states consider joining the Compact.”

Dr. Mark Thomas, member of the Minnesota Board of Medical Practice and elected as the first vice chair of the Commission, similarly affirmed the Commission’s limited charge focused on enabling expedited licensure. “I’m fiercely states’ rights. I’m not going to give away my state’s governance authority over physician practice to another entity.”

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Thiesfeldt Withdraws Legislation to Prohibit Mandatory Flu Vaccination Policies

Rep. Jeremy Thiesfeldt (R-Fond du Lac), in a joint statement with Sen. Frank Lasee (R-De Pere) and the Wisconsin Hospital Association, agreed to withdraw legislation that he has drafted and introduced prohibiting employers from requiring employees to receive an influenza vaccination as a condition of employment. 

In an agreement reached with Thiesfeldt, WHA committed to sending a memo to human resource directors and infection preventionists that reminds them of WHA’s toolkit recommendations related to medical and non-medical exemptions to mandatory influenza vaccination policies. The memo also reminds members of existing guidelines established by the Equal Employment Opportunities Commission (EEOC) related to these exemptions. 

“WHA wants to thank Rep. Thiesfeldt for the weeks of open dialogue and communication on this issue,” said Kyle O’Brien, WHA senior vice president, government relations. “This conversation has resulted in a non-legislative solution that has satisfied the concerns of Rep. Thiesfeldt while also preserving an important tool used by WHA members to protect patients from influenza.”

For more information, see a copy of the WHA memo and the joint press release.

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Wisconsin Insurance Exchange Rates Increase Less than National Average
Exchange enrollment period starts Sunday, November 1 


Wisconsin insurance rate increases for the second lowest cost silver plans, also known as the benchmark plans, available on the exchange were below the national average, according to the U.S. Health and Human Services Department (HHS). 

HHS said that of across all the states that participate in the federally-facilitated exchange website, healthcare.gov, the cost of the benchmark plan will increase on average 7.5 percent in 2016, compared to an average 4.7 percent increase in Wisconsin. These increases do not take into account the premium tax credits that help about 90 percent of enrollees in Wisconsin offset their premium costs. 

According to the HHS data, rates in some states will climb by as much as 35 percent in 2016. The analysis does not include rates for states like Minnesota that operate their own state-based insurance exchanges. Joanne Alig, WHA senior vice president for policy & research, said the fact that premiums are going up less than the national average in Wisconsin was expected. 

“This shows what we have suspected for a while—that the market takes time to adjust—and we saw that some insurers in other states had underpriced plans initially, and now are adjusting their rates as they have more detailed claims experience for the population,” said Alig. 

The HHS Fact Sheet on insurance exchange premium changes by state is available here: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-26-2.html.

As the next open enrollment period for the 2016 benefit year is set to begin Sunday, November 1, the federal HHS has made its website available early this year for those who would like to begin to compare plans. Visit https://www.healthcare.gov to review plan options. Also in anticipation of the open enrollment period, the Wisconsin Office of the Commissioner of Insurance (OCI) this week released their 2016 interactive map which shows the health plans by county. (See http://oci.wi.gov/healthcare_ref/find_health_insurer.htm.) 

A major change for Southeast Wisconsin is the announcement by Anthem that it will not offer plans on the exchange in Milwaukee, Racine and Kenosha counties. Anthem is contacting its members in these areas informing them that they will need to return to the exchange to select a new insurer for 2016. 

Hospitals and health systems are continuing their efforts this year to assist their patients and members of their communities with enrollment in the exchange. In 2015, over 200,000 people in Wisconsin signed up for coverage through the federal exchange. Additional data on these 2015 enrollments has recently been released by HHS as well. On October 28, HHS released a report indicating that of those who re-enrolled for coverage from 2014 to 2016, 36 percent chose a new plan through the exchange. This report can be found at http://aspe.hhs.gov/sites/default/files/pdf/134556/Consumer_decisions_10282015.pdf.

County-level data for 2015 for all enrollees is also available, including number of re-enrollments, plan metal level, and number of people receiving tax credits. This information is available at: 
http://aspe.hhs.gov/basic-report/2015-plan-selections-county-health-insurance-marketplace.

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WHA’s New Task Force on Telehealth Identifies Barriers, Opportunities

Telehealth is increasingly vital to our health care delivery systems, enabling health care providers to connect with patients and consulting practitioners across vast distances. Hospitals are embracing the use of telehealth technologies because they offer benefits such as virtual consultations with distant specialists, the ability to perform high-tech in-home patient monitoring and more convenient and cost-effective, high-quality care options. Telehealth has moved into the mainstream. 

In August, WHA surveyed their Physician Leaders Council (PLC) and found that telemedicine is currently being used, and hospitals and health systems hope to expand its use in the future. However, PLC members identified multiple barriers for expanding the use of telemedicine, with reimbursement cited as the most common issue. These factors, along with more recent developments including the Wisconsin Medical Examining Board’s (MEB) adoption of draft telemedicine language, provided the impetus for WHA creating a task force. The WHA Task Force on Telehealth held its first meeting October 26.

Thought leaders from throughout the state convened and begin laying the groundwork for multiple telehealth strategies and initiatives that pose particular relevance for WHA members. The 16-person Task Force reviewed the current telehealth landscape both nationwide as well as in Wisconsin. 

“WHA has certainly done their homework in preparing for this first meeting,” remarked Tom Brazelton, MD, UW Hospital medical director for telehealth. David Mortimore, HSHS care integration and delivery innovation manager, added, “What WHA is doing is really groundbreaking. Getting us together in the same room discussing issues that affect us all will definitely move the entire issue forward.”

Task Force members then began to review MEB’s draft language on telehealth. Members identified multiple points of concern. WHA will continue the detailed analysis of the draft language and will synthesize member’s comments. The Task Force will continue to meet on a regular schedule to address issues pertinent to WHA members’ policies and strategic initiatives around telehealth.

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WHA Submits Comment Letter on Proposed 340B Changes
Expresses concerns with multiple provisions 


On Monday October 26, the Wisconsin Hospital Association submitted a comment letter to the Health Resources & Services Administration (HRSA) on its proposed 340B guidance. In developing its comment letter, WHA discussed the proposed guidance with a cross-section of its membership. 

“A cross-section of the hospitals we represent qualify for the 340B program and find it an essential component in their ability to help ‘stretch scarce federal resources as far as possible, reaching more eligible patients and providing more comprehensive services’ as Congress intended,” said WHA President/CEO Eric Borgerding in WHA’s letter. “[O]ur smallest, rural hospitals to our large, urban Disproportionate Share Hospitals demonstrate the commitment 340B-covered entities have to utilizing program savings to better serve Wisconsin patients and communities. Beyond this and consistent with program intent, 340B savings allow covered entities to have the capacity to provide more access to more services to patients.”

As such, WHA expressed concerns with several elements of the proposed guidance that could substantially limit hospitals’ ability to use the 340B program. Several concerns revolved around HRSA’s proposed six-part definition of a patient. Several of the new criteria would restrict use of discharge prescriptions, restrict use of infusion-only services and require physicians to be employed or serve as independent contractors of the hospitals. In order to utilize 340B drug discounts, a hospital must meet all six parts of the new definition. 

“While WHA appreciates the time and effort HRSA took to provide for more clarity around the ‘definition of a patient’…[w]e believe the new six-pronged test fundamentally restructures the definition in a way that will significantly limit a covered entity’s ability to utilize the program, thereby reducing the ability to provide as many services to as many patients as possible,” read WHA’s letter. “While WHA recognizes HRSA’s intention of trying to provide for more clarity between the various parts of this program—the prescription/order, the patient, the provider, the outpatient setting, and the covered entity—the linkage it creates is at times inappropriate, belies the complexity of health care organizational structures and the policies’ impact in practice.” 

WHA also commented on other provisions, including a change to the definition of a covered outpatient drug. Finally, WHA recommended HRSA provide a delayed effective date upon issuing final guidance in order to allow providers time to adjust. 

The comment period closed October 27. HRSA will now review comments before issuing its final guidance. 

Read WHA’s full comment letter.

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Annual WHA Physician Leadership Development Conference, March 11-12, 2016
Early bird discount available; register today


Registration is now open for the 11th annual “WHA Physician Leadership Development Conference.” The 2016 event is scheduled Friday, March 11 and Saturday, March 12, and will be held at The American Club in Kohler. The full conference brochure, with final agenda, registration and resort information, is included in this week’s packet. Online registration is available at http://events.SignUp4.net/16PLD.

This year’s conference will include a full-day session with Stacy Nelson, MEd, EdD, focusing on the tools needed to tackle conflict and challenges and the strategies to change culture, thoughts and actions in your organization. In addition, participants will learn to run an effective meeting and be able to use group dynamics to build support and deal with disruptive personalities effectively in a half-day session with Michael Guthrie, MD, MBA, FACPE.

Both Nelson and Guthrie are nationally-recognized faculty from the American Association for Physician Leadership (AAPL), formerly the American College of Physician Executives, and both will discuss important and practical leadership skills that help physician leaders move beyond their clinical training and take a new approach to managerial decision-making and problem solving.

A discounted “early bird” registration fee is available to those registering by January 15.
Additionally, a “host” registration option is available for senior-level hospital representatives (non-physicians) who accompany one or more of their physicians to the conference but do not need CME credit. 

Each year, attendees express to WHA the value of attending the conference as a team—physician leader and management leader—allowing for invaluable informal, one-on-one conversation and team building during the event. WHA invites you to consider taking advantage of this opportunity at the 2016 event.

More information and registration is available at http://events.SignUp4.net/16PLD.

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Assembly Passes WHA-supported State Health Insurance Oversight Bill
Bill requiring JFC to approve Group Insurance Board changes passes 90-2


The Wisconsin State Assembly passed legislation October 27 that would require any change to the state employee health insurance plan proposed by the Group Insurance Board to be reviewed and approved by the Legislature’s Joint Finance Committee.

Assembly Bill 394, authored by Rep. John Nygren (R-Marinette) and Sen. Alberta Darling (R-River Hills), passed the Assembly by a vote of 90-2 and now moves over to the Wisconsin State Senate for consideration and passage. WHA supports this legislation and its Senate companion, SB 312.

The Group Insurance Board has used its current authority to consider significant changes to the state employee health insurance program, including the concept of moving the program from a fully-insured to a self-funded insurance model for 250,000 state employees, without approval from the state Legislature. Such a change could pose a risk for the state program. While some studies show a modest savings to the state, others show such changes could result in significant budget instability and cost increases to the state.

In a press release introducing the legislation, Nygren and Darling said, “Right now, an important voice isn’t at the table when changes are made to state employee benefits: the voice of the taxpayers. To remedy this problem, we have introduced a bill that will ensure legislative oversight to benefit changes for state employees.”

They went on to state that changes being considered by the Group Insurance Board right now could “have the potential to negatively impact both the health care marketplace and the economy.”

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WHA Member Forum: New EHR Meaningful Use Requirements for 2015 & Beyond
What hospital leaders need to know


On October 6, 2015, the Centers for Medicare & Medicaid Services (CMS) released a joint rule that finalizes proposals made in two separate 2015 proposed rules regarding the meaningful use requirements of the EHR Incentive Program. While the joint rule provides some flexibility for hospitals and physicians in 2015 and 2016, other aspects of the joint rule may raise the bar for provider performance starting in 2015 and may result in health care providers incurring Medicare penalties for failure to meet reporting objectives that are unnecessarily difficult to achieve without significant expense or disruption to patient care workflow. 

This complimentary WHA Member Forum webinar will discuss important provisions of the joint rule, highlighting new compliance provisions for meaningful use “modified Stage 2” (2015 through 2017) and meaningful use “Stage 3” (beginning in 2018).

This webinar will be held November 11 from 10 - 11 a.m. There is no fee for WHA hospital and corporate members to participate, but pre-registration is required. This WHA Member Forum webinar series is intended for and limited to staff of WHA hospital and WHA corporate members only, as a benefit of membership. Sign-up information, as well as more information about this webinar, may be found at http://events.SignUp4.net/15MeaningfulUseWebinar

For more information contact Andrew Brenton, WHA assistant general counsel, at 608-274-1820 or abrenton@wha.org.

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Senators Urge FTC to Investigate Saline Solution Makers

AHA News Now reported that a bipartisan group of U.S. senators urged the Federal Trade Commission to investigate possible illegal collusion by saline solution manufacturers. “Since the saline shortage began in late 2013, suppliers are reported to have increased their prices by 200%-300%,” Sens. Richard Blumenthal (D-CT), Mike Lee (R-UT), Amy Klobuchar (D-MN) and Orrin Hatch (R-UT) said in a letter to FTC Chairwoman Edith Ramirez. 

The letter stated, “This equates to increased annual costs to individual hospitals in the range of hundreds of thousands to millions of dollars. One health care expert has claimed that this could make the saline solution shortage the most expensive drug shortage in U.S. history. Even more troubling, hospitals have reported that all three saline suppliers are imposing even greater price increases on customers who do not also purchase additional non-saline products, effectively tying saline sales to other products such as the pumps, tubing, and catheters through which saline is delivered to the patient.” Lee and Klobuchar are chairman and ranking member, respectively, of the Senate Judiciary Subcommittee on Antitrust, Competition Policy and Consumer Rights, and Hatch is former chairman of the full Judiciary Committee.

Wisconsin hospitals have also been deeply affected by the shortages and dramatic price increases in saline solution.

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WHA’s Transforming Care at the Bedside begins Cohort 4

One of WHA’s most successful quality programs, Transforming Care at the Bedside (TCAB) has far exceeded expectations since the first cohort launched in February 2011. Bringing the skills of improvement to the hospital bedside continues to have strong interest from around Wisconsin. The fourth group of 12 hospital units to start the 18-month collaborative met at Glacier Canyon Lodge in Wisconsin Dells October 13 and 14. For the first time, three emergency rooms join the acute care units in TCAB. To see a summary of the Kick-Off Event and meet the participating teams, go to: www.wha.org/pubarchive/special_reports/2015tcab10-13.pdf.

By the conclusion of the two-day meeting, teams chose ideas for improvement in each of the four TCAB pillars: Patient-Centered Care, Patient Safety, Teamwork, and Efficiency. Teams also learned key skills to implement the changes they select. 

According to TCAB Project Manager Stephanie Sobczak, “We can’t assume that meeting and talking about a problem equates to improvement. Only by trying a new process with the caregiving staff and patients during patient care will their co-workers invest in the design and ultimately buy into the idea.” Most importantly, “This is how improvement in hospitals happens,” according to Sobczak.

These TCAB teams will continue to use tools and strategies through monthly webinars, and connect with other TCAB hospitals across the state. Teams prioritized the topics that are of most interest to them, and members of WHA’s quality staff or guest speakers will provide content. Next, the team will be oriented on data submission and learn elements of LEAN to organize their units to become more efficient. This cohort will conclude in April 2017.

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Gullingsrud Elected to WHA Board

Tim Gullingsrud, CEO, Hayward Area Memorial Hospital, will represent the Wisconsin Hospital Association Vikingland region on the WHA Board of Directors. Gullingsrud replaces Board member Gordy Lewis, CEO, Burnett Medical Center, who served from 2010 -2015.

Gullingsrud joined Hayward Area Memorial Hospital in 2011. His previous experience includes Essentia Health, where he was a regional administrator, and serving at McKenzie County Memorial Hospital in North Dakota and Liberty County Hospital and Nursing Home in Montana, serving as administrator with each of those organizations. Gullingsrud was also a division manager with the Dakota Clinic in Jamestown, North Dakota.

Vikingland is one of WHA’s seven regions. Each region elects a representative to the WHA Board to serve a three-year term.

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