December 6, 2013
Volume 57, Issue 49
Bill to Delay Medicaid Changes and Sunset of HIRSP Moves to Senate
On December 4, the state Assembly voted to make short-term changes to the Medicaid program by extending coverage for three months to an estimated 75,000 adults, while delaying for three months Medicaid coverage for childless adults with incomes below the poverty line. The delay is being proposed in response to the ongoing problems with enrollment in private coverage through the federal exchange.
The bill, which is under consideration during the Special Session called by Governor Walker, also extends the sunset date for the state’s Health Insurance Risk-Sharing Program (HIRSP) from December 31, 2013, to March 31, 2014. The bill was first taken up by the state’s Joint Finance Committee December 2. The Committee amended the proposal to maintain the current cost-sharing formula for HIRSP, which is funded with a combination of member premiums, discounts from providers, and an assessment on insurers. The share of the program’s costs from each of these parties is set in statute.
As part of an annual reconciliation process, HIRSP policyholder premiums, insurer assessments and provider discounts are adjusted to account for any surplus or deficit based on the extent to which their payments over the year deviated from their required share of program costs. The bill as originally written would have instead allowed any surplus, regardless of whether it was attributed to premiums or to providers, to be used to fund the insurer portion of program costs. In a WHA-backed amendment, the Joint Finance Committee changed that provision to maintain the current funding formula. The amendment was adopted unanimously.
"The intention of this amendment is that there are three separate silos that premium payers, insurers and providers have had attributed to them for the surplus that exists in HIRSP," said Joint Finance Committee co-chair Rep. John Nygren (R-Marinette) during the committee’s deliberations. "It was my intention, and those on (co-chair) Senator Darling’s side as well, that we should keep those silos of dollars separate from each other and they shouldn’t be used for other purposes…the surplus that is attributed to premium payers will go back to premium payers, the surplus that is attributable to providers will go back to providers and the surplus that is attributable to insurers will go back to insurers."
The bill now moves to the Senate, which is expected to take up the proposal the week of December 16.
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At the end of their December 3, 2013 meeting, the Worker’s Compensation Advisory Council (WCAC), which includes five representatives of organized labor and five representatives of management, voted to support a fee schedule to reimburse hospitals, doctors, and other practitioners who provide health care services to injured workers through the Worker’s Compensation program. When describing what will be introduced in the Legislature as the biennial Worker’s Compensation bill, the Council outlined what they termed a two-step plan:
There will be other significant provisions in the bill, including:
WHA Executive Vice President Eric Borgerding said hospitals, physicians, and other providers strongly oppose the Council’s proposal. “They call it a two-step plan. I call it a one-two punch.”
Borgerding noted the strength of the Wisconsin system. “The Labor and Management representatives on the Council and health care providers agree that Wisconsin has one of the best Worker’s Compensation systems in the country. Injured workers receive excellent care efficiently, which results in injured workers in Wisconsin returning to work faster and at a lower cost than in nearly any other state,” he said.
Given the excellent system, Borgerding questioned the Council’s decision. “If the Council gets its way, new government agency staff will be hired to establish how much doctors, hospitals, and other practitioners who take care of injured workers are paid for their services. That’s government rate setting. When has government rate setting improved quality or efficiency? When has it reduced costs?”
The Legislature generally considers and votes on the WCAC’s bill during its spring floor session. WHA and the other provider organizations are calling on members of the Legislature and the Walker Administration to reject the Council’s plan and protect Wisconsin’s excellent Worker’s Compensation system.
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Medicaid Advisory Group Reviews 2014 Hospital Rates
Reminder for physicians to attest to receive primary care payment increase
The Medicaid Advisory Group (MAG) discussed several important payment and policy issues at the December 5 meeting in Madison.
Brett Davis, the state’s Medicaid Director, briefed the group on the Governor’s proposed delay in implementing changes to the Medicaid program (see related story in this issue). Davis indicated that they are still under negotiations with the federal government, but hope to come to agreement soon on obtaining the necessary approvals to move forward, should the Senate approve the bill currently moving through the Legislature. If the bill is enacted, Davis noted that they would like to begin to accept applications for childless adults with income below the poverty line around mid-January for coverage beginning April 1.
DHS staff also presented an overview of the RAC audit process, and encouraged hospitals to attend WHA’s webinar, The Medicaid RAC: What Your Hospital Needs to Know As HMS Goes Live in Wisconsin, on Monday, December 9, from 3 - 4 p.m. The webinar is free, but registration is required and is limited to WHA members and corporate members. Registration is available online at: http://events.SignUp4.com/13MedicaidRAC1209.
Hospital fee-for-service rates and details on the process for setting the rates were also discussed. These rates will go into effect beginning January 1, 2014. Hospitals will continue to be paid based on EAPGs for outpatient services. DHS staff noted that the five percent risk corridor for EAPGs will no longer be in effect beginning January 1.
Finally, DHS reminded the group of the primary care physician payment increase for the Medicaid program. In order to receive payments, physicians must first complete an attestation. This is an extremely important step in the process. Providers must submit this attestation by December 31, 2013, or they will forego receiving the rate increase retroactive for 2013 services. DHS also noted that they will be monitoring HMO payments to ensure payments are passed through to physicians appropriately and in a timely manner. A recent ForwardHealth document provides information about the attestation process, in the September 2013 ForwardHealth Update (2013-44), titled "Policy Clarifications for the Affordable Care Act Primary Care Rate Increase Provider Attestation."
Materials from the December 5 meeting, along with other information about the Medicaid Advisory Group can be found on the WHA website at www.wha.org/MAG.aspx.
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As federal attacks on hospital payments continue, WHA will utilize tools to help explain complex federal proposals that seek to cut payments to all types of hospitals. This week WHA released an infographic on critical access hospitals (CAHs) and the role they play across the state of Wisconsin.
In early January, Congress will likely be in the midst of negotiations on how to fund the federal government and deal with the debt ceiling, which is why the Wisconsin Hospital Association will lead a trip to Washington, DC on January 8, 2014. Currently Congress is facing four deadlines:
Many Hospital Payments Targeted, Your Presence Needed in DC January 8
All of these deadlines mean Congress must find dollars in order to fund government, fix the SGR, and address the debt ceiling. A few of the hospital payments that continue to be targeted are:
The January 8, 2014 trip to Washington, DC will be to fight against these cuts and discuss other hospital issues. WHA encourages hospitals to consider traveling to DC for this trip. WHA will coordinate, schedule and staff Hill visits on January 8, 2014 with Wisconsin’s Members of Congress. If you plan to travel to DC for this event, let WHA’s Jenny Boese know at 608-268-1816 or firstname.lastname@example.org.
Read more about WHA’s ongoing efforts at our "Protect Hospital Care" webpage at: www.wha.org/protect-hospital-care.aspx.
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Physician leaders must represent both clinical and managerial interests, and each year at WHA’s "Physician Leadership Development Conference," faculty from the American College of Physician Executives (ACPE) focus on exactly that. The annual conference benefits both new and seasoned physician leaders, and focuses on 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.
This year’s event will feature David Nash, MD, internationally recognized for his work in quality outcomes management, medical staff development and quality-of-care improvement, focusing on the role physician leaders play in supporting a culture of quality improvement. In addition, Tim Keogh, PhD, will focus on building the communications skills physician leaders need to gain influence, cooperation and colleague engagement.
WHA’s ninth annual Physician Leadership Development Conference is scheduled Friday, March 14 and Saturday, March 15, 2014, at The American Club in Kohler. Registration is now open at http://events.SignUp4.com/14PLD. As a reminder, the special room rate at The American Club is only available until February 20 or until the room block fills (which it does quickly each year), so plan to register and make your hotel reservations today.
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. ACPE is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. ACPE designates this live activity for a maximum of 12 AMA PRA Category 1 Credits.TM Physicians should only claim credit commensurate with the extent of their participation in the activity.
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Matthew Hunsaker, MD has been named campus dean for the Medical College of Wisconsin (MCW)-Green Bay, effective January 1, 2014. Hunsaker currently serves as director of the Rural Medical Education Program and associate professor at the Department of Family and Community Medicine at the University of Illinois College of Medicine at Rockford.
Hunsaker will lead and manage MCW’s community-based medical education program and serve as the primary liaison for the health system, academic and community partners in the Green Bay area, as well as with MCW’s Milwaukee campus. Hunsaker will also collaborate with leadership at MCW’s Central Wisconsin campus and with the local health systems, including Aurora BayCare Medical Center, Bellin Health, Hospital Sisters Health System-Eastern Wisconsin Division and Prevea Health—to help identify physician preceptors and clerkship directors, and to advocate for and support an increase in graduate medical education positions. He will also collaborate with MCW-Green Bay’s academic partners—Bellin College, St. Norbert College and the University of Wisconsin-Green Bay—around teaching faculty, curriculum and student resources.
Hunsaker will coordinate the Community Advisory Board with regard to the implementation of the community-based medical education program, monitoring of achievement of program goals, enhancement of program visibility and support, and development of community relationships and support.
Student recruitment will begin in spring 2014, with matriculation at MCW-Green Bay anticipated for July 2015. The search continues for the campus dean for MCW-Central Wisconsin, which is expected to begin admitting students in July 2016.
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Front-line nurses are focused on the needs of the patient and they can readily identify the challenges that stand between them and good patient care. The problem is that sometimes they don’t have the time to create the tools they need to address the issues.
At Froedtert & the Medical College of Wisconsin Froedtert Hospital in Milwaukee, front-line nurses put the WHA Transforming Care at the Bedside (TCAB) program to the test to see if it would work in reducing the rate of pressure ulcers in a high-acuity surgical intensive care unit (SICU). The unit focused their efforts on improving the bedside report. The team developed a report template to use during the bedside shift report and used it as a guide when they checked in on patients. The report prompted the nursing staff to check medication infusions, reposition the patient and assess the condition of the skin, and review the electronic medical record. Physicians and the SICU critical care team were reminded to document pressure ulcers, especially those present on admission.
Did it work? The results speak for themselves.
"We have decreased our pressure ulcer rate by doing a quick skin assessment during bedside shift report, and we have improved documentation and skin assessment of pressure ulcers," according to Drew Pooni, clinical nurse specialist for the SICU. "Staff is proactive in preventing pressure ulcers with high risk patients, and they are using products that reduce friction between the patient and their bedding."
The unit reports that they have improved safety of the hand-off report between the SICU and operating room (OR) by changing the process of how report is delivered. This win-win was possible by collaborating with the OR nurses to learn each department’s workflow. We learned the current reporting system was not working for either department and needed to be improved. We now have a safer hand-off report with the OR, and both departments have improved relationships.
The Froedtert team credits WHA and the TCAB program for providing them with the tools they needed to empower staff nurses to improve work conditions, patient care and safety in their units.
"Staff nurses sometimes don’t feel like they have the power to change things for the better. After becoming a part of the TCAB project, the TCAB nurses feel empowered to find possible solutions, do small tests of change and adapt, adopt or abandon the possible solutions," said Annie Tobin, RN, SICU.
The TCAB nurses are now the leaders for their unit, and they are showing that positive change is one way to sustain improvements in activities such as the bedside shift report. Sharing the results of the improvements at unit meetings, unit newsletter and e-mails are techniques that the unit is using to sustain and foster the gains the team has made to date. TCAB has also been presented at Froedtert’s own Nursing Research Conference this past fall. Other units and departments are interested in what the SICU’s frontline staff has been able to accomplish and are interested in learning more about TCAB.
"Doing small tests of change is much easier than doing a big change all at once," said Scott Besag, RN. "TCAB does require work, and once you have a few easy wins, more and more staff will choose to apply TCAB to issues rather than complain about them without any resolution."
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The Centers for Medicare & Medicaid Services (CMS) on November 27 released three final rules for calendar year (CY) 2014—the outpatient prospective payment system (PPS)/ambulatory surgical center (ASC) rule and the physician fee schedule (PFS) rule. Highlights of these final rules follow.
Outpatient PPS/ASC Final Rule
Payment Update: The final rule includes a 2.5 percent market-basket update, minus a 0.5 percentage point productivity reduction and an additional 0.3 percentage point reduction required by the Patient Protection and Affordable Care Act (ACA). This results in a net market-basket increase for CY 2014 of 1.7 percent for those hospitals that publicly report data on 24 quality measures. For hospitals that do not report, the net update will be negative 0.3 percent.
Physician Supervision: CMS will end, as of December 31, its moratorium on enforcing the direct supervision policy for outpatient therapeutic services provided in critical access hospitals (CAHs) and in small rural PPS hospitals. WHA will continue to urge Congress to provide relief from this short-sighted policy. CMS also revised its conditions of payment for hospitals and CAHs to require that individuals furnishing these outpatient therapeutic services do so in accordance with state law.
CAH Physician Certification: CMS finalized several new policies related to inpatient admission and review criteria, including physician certification and admission order requirements. In subsequent guidance, CMS also stated that, as a condition of payment, physicians at critical access hospitals (CAHs) must certify that a beneficiary may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH. The requirement has caught hospitals by surprise. WHA is working with the Rural Wisconsin Health Cooperative, the American Hospital Association and others on a potential legislative fix.
Payment of Hospital Outpatient Visits: CMS finalized its proposal to collapse the current several levels of codes for hospital outpatient clinic visits (including current procedural terminology (CPT) codes 99201-99205 for new patients and CPT codes 99211-99215 for established patients) and replace them with one new code representing a single level of payment for all outpatient clinic visits. CMS will assign the new code to a new ambulatory payment classification (APC) with the payment rate for all outpatient clinic visits based on the total mean costs of Level 1 through Level 5 clinic visit codes for new and established patients in the CY 2012 outpatient PPS claims data. However, CMS did not finalize its proposal to similarly collapse the Type A and Type B emergency department (ED) visits codes. Rather, the agency will maintain five levels of codes for each of these types of visits.
Packaging Policies: CMS finalized, with some modifications, its proposals to package the costs of the following items and services into the payment for other services to which they are integral, ancillary or supportive:
CMS did not finalize its proposals to package the costs of ancillary services or diagnostic tests on the bypass list.
Outpatient Quality Reporting: CMS has chosen to require reporting of four of the five quality measures it had proposed. The measures that are required for reporting in October 2014 are:
CMS indicated that the Centers for Disease Control and Prevention are working on further specifications that will improve the ability of hospitals to report data for the inpatient and outpatient programs without incurring substantial burden.
CMS also removed two measures that were previously required: (1) provision of the transition record with specific elements included for discharged ED patients; and (2) the measure of a cardiac rehabilitation patient referral from an outpatient setting. CMS determined that the transition record measure could not be implemented with the current level of specificity and that the cardiac rehabilitation measure was too burdensome.
Treatment of CAH Method 2 Physicians under the Electronic Health Record (EHR) Incentive Program: Currently, physicians who provide services in the outpatient departments of CAHs and have their services billed by the CAH under Method 2 are prevented from participating in the EHR Incentive Program. CMS has finalized its proposal to remedy this problem and allow these physicians to participate in the program for 2013.
Quality Improvement Organization (QIO) Changes: CMS finalized many changes to the QIO program that will allow the agency to be more flexible in contracting with organizations to perform either quality improvement activities or oversight functions, including allowing the option for regionalized QIOs. Additional details will be spelled out in CMS’s request for proposals, but this flexibility will improve hospitals’ relationships with their QIOs.
ASC Changes: For CY 2014, CMS is increasing payment rates under the ASC payment system by 1.2 percent. This increase is based on a projected Consumer Price Index for All Urban Consumers update of 1.7 percent minus a 0.5 percentage point productivity reduction required by the ACA. For ASCs that fail to meet the ASC Quality Reporting Program requirements, the net update would be negative 0.8 percent. Further, CMS finalized a requirement that ASCs also report the two endoscopy/ polyp surveillance measures and the cataract visual function measure that have been added to the hospital outpatient quality reporting program.
Medicare Physician Fee Schedule Final Rule
Payment Update: Without additional congressional action, CMS estimates that Medicare physician payments will decline by a mandated 20.1 percent on January 1, 2014, due to the flawed Sustainable Growth Rate (SGR) methodology. The current SGR "patch"—protecting physicians from mandatory payments reductions—expires December 31, 2013. Congress continues to work on a potential long-term solution to the SGR formula, but that effort will not likely be completed by December 31. Therefore, it is anticipated Congress will adopt a short-term patch, perhaps up to three months, to allow Congressional work on broader SGR reform to proceed.
Outpatient Therapy Cap Applies to CAHs: Currently, CAHs are not subject to the outpatient therapy cap, although the cost of outpatient therapy services provided in CAHs accrues towards the cap. However, in the final rule, CMS finalized its proposal to apply the therapy cap fully to services delivered in a CAH, beginning January 1.
Complex Chronic Care Management: CMS finalized its proposal to explicitly pay physicians and qualified non-physician practitioners (NPP) for care management services provided to patients with two or more complex chronic conditions. This includes non-face-to-face care management provided by clinical staff members.
Telehealth Services: CMS finalized its proposal to expand the definition of a rural health professional shortage area to allow payment for telehealth services originating in certain rural areas of Metropolitan Statistical Areas.
Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO): In a reversal from the proposed rule, CMS opted to retain the GPRO-web interface reporting option for group practices of 25-100 eligible professionals (EPs). However, CMS finalized its proposal to allow group practices of 25 or more EPs to use vendors to report the Clinician Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) patient experience survey, and to count that reporting towards partially fulfilling 2014 PQRS reporting requirements and the CY 2016 payment adjustment.
Value-Based Modifier (VBM): CMS finalized its proposal to increase the amount of payment at risk for upward or downward adjustment under the VBM from 1.0 percent in CY 2015 to 2.0 percent for CY 2016. The adjustment will continue to be based on performance on measures of quality and cost of care. CMS also finalized its proposals to decrease the group size of physicians subject to the VBM from 100 or more to 10 or more EPs and to not apply downward payment adjustments to groups of 10-99 EPs.
Medicare Shared Savings Program: CMS finalized its proposal to incorporate fee-for-service Medicare data submitted by the Medicare Shared Savings Program and Pioneer Accountable Care Organizations (ACOs) into setting its quality benchmarks under the Medicare Shared Savings Program. In addition, the agency had proposed using Medicare Advantage data to set quality benchmarks but did not finalize that proposal. Further, as AHA urged, the agency did not finalize its proposal to artificially adjust ACO scores on measures whose performance is "clustered" (i.e., a six or less point spread between the 30th and 90th percentiles).
EHR Incentive Program: CMS finalized its proposal to add options by which EPs may report clinical quality measures under the Medicare EHR Incentive Program. These options include use of qualified clinical data registries and a group reporting option for EPs who are part of a Comprehensive Primary Care Initiative practice site.
The outpatient PPS/ASC final rule and the PFS final rule will be published in the December 10 Federal Register. Watch for WHA detailed rule summaries and hospital specific impact analysis of the outpatient PPS rule in the coming weeks.
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Where do you go when you need a doctor and you don’t have insurance? More and more hospitals are establishing free clinics to serve those who do not have a "medical home." Every effort is made to connect patients with follow up care and even help them obtain the medical supplies or prescription drugs that they need.
"The Outreach Clinic helped me turn my life around."
Ryan Lundgren has struggled with chronic health problems much of his life. By his mid-30’s he had already faced complications from uncontrolled diabetes, retinal bleeding, partial toe amputation, bone infections, a broken shoulder – "I lost two of my last three jobs because of my illnesses." Ryan says his "wake-up call" was a heart attack in May 2011. He knew he needed to make drastic changes, but without a job or health insurance, he didn’t know where to start. "I didn’t have the information or motivation to do it on my own. I felt like giving up and accepting that I wasn’t going to live much longer."
Ryan got the help he needed at Froedtert Health Community Memorial Hospital’s Community Outreach Health Clinic. The team of nurse practitioners, student nurses and volunteers takes a wholistic approach, which is just what Ryan needed to deal with his many interrelated health conditions. "(nurse practitioners) Linda, Jen and (volunteer nurse) Anita really worked to help me get better so I wouldn’t need to come to the clinic every week," says Ryan. They arranged for eye surgeries for his retinal bleeding, which interfered with his vision and his ability to hold a job. They provided physical therapy for his shoulder injury and monitored his progress. They helped him enroll in pharmaceutical assistance programs so he could get low-cost insulin and other medications and provided follow-up care while he recovered from his heart attack. Most important of all, they helped Ryan understand that he had choices, that his health was something he could take charge of by eating differently and becoming more active.
Today, Ryan is 100 pounds lighter, exercises regularly and says he feels great. "I used to take insulin injections four times a day; now I don’t need it at all." He’s learned to manage his diabetes by monitoring his blood sugar levels and eating accordingly. Ryan is back at work now at a delivery job, but still with no health insurance. He comes to the clinic now for check-ups and to reinforce his healthier habits. He can’t say enough about the "terrific people" at the clinic. "Their support has made a major difference for me. They are there for the right reasons, to help people get well, and they made me believe I could do it."
Outreach Clinic staff estimate that about 60 percent of clinic patients have one or more chronic conditions, putting them at-risk for more severe health problems if left untreated. Staff not only provide immediate assistance for the patient’s presenting health concern, but work to address other health issues that have gone untreated. Many are struggling with depression, anxiety or other mental issues exacerbated by unemployment, family problems and financial stress. Patients often need help in identifying and accessing other services, obtaining referrals and follow-up care. In short, Outreach Clinic patients tend to require more time and more intensive, personalized services than insured patients whose needs are less urgent and complex.
Froedtert Health Community Memorial Hospital, Menomonee Falls
Twin Counties Free Clinic
Twin Counties Free Clinic is a partnership of volunteers, dedicated to providing basic health care services to the uninsured and under-insured adults of Marinette, WI and Menominee, MI counties. Aurora Health Care has been a key supporter of the Twin Counties Free Clinic (TCFC) for over 11 years in multiple ways. The Aurora Marinette Menominee Clinic provides space for TCFC on a weekly basis and multiple Aurora doctors and family nurse practitioners provide care to the clinic’s patients. Jean Mlsna, a director with the Aurora Medical Group, is an active member of the TCFC’s board where she gives of her time, talents and support in so many ways. Since opening their doors in 2000, the Twin Counties Free Clinic has provided over 6,900 clinic visits to residents in the area (47 percent men, 53 percent women). In addition to patient visits, the clinic also provides over $40,000 in medications annually to clients who require a prescription to remain well but could not otherwise afford it.
Aurora Health Care, Milwaukee
Submit community benefit stories to Mary Kay Grasmick, editor, at
Read more about hospitals connecting with their communities at www.WiServePoint.org.
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