April 4, 2014
Volume 58, Issue 14


Apology Legislation Passes Senate on Bipartisan Vote
Bill moves to Governor for final action

The Wisconsin State Senate has approved legislation that, according to Charles Shabino, MD, chief medical officer at WHA, "would encourage open conversation among providers, patients, and the patients’ families." Assembly Bill 120 provides that a statement, gesture, or conduct that expresses apology, benevolence, compassion, condolence, fault, liability, remorse, responsibility, or sympathy to a patient or the patient’s relative or representative would not be admissible into evidence in a civil action, administrative hearing, disciplinary proceeding, mediation, or arbitration regarding the health care provider as evidence of liability or admission against interest.

The bill, which passed the Assembly on a voice vote, garnered the support of 19 senators while 14 senators opposed the bill. Sen. Tim Cullen (D-Janesville) and Sen. Kathleen Vinehout (D-Alma) joined nearly every Republican in voting in favor of the legislation. Sen. Glenn Grothman (R-West Bend) was the only Republican senator to vote against the bill.

Shabino previously said, "Statements of concern by providers involved in patient care can allow the patient, family, and provider to move toward solution and resolution. These positive outcomes are more difficult to achieve when there are barriers to good communication."

The bill now moves to the Governor for his consideration.

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WHA Advocacy Day Tops 700
Final countdown begins for registration

Registrations for WHA’s Advocacy Day April 16 topped 700 this week, but we want to see if we can reach last year’s stellar record of 900! So pull out the stops and register your groups right now for this important event. You won’t want to miss this informative day.

Governor Scott Walker is confirmed as the luncheon keynote, and the confirmed legislative panel includes three members of the Legislature’s powerful budget-writing committee, the Joint Finance Committee. Those are Sen. Alberta Darling (R-River Hills) and Rep. John Nygren (R-Marinette), committee co-chairs, and Rep. Cory Mason (D-Racine) who also serves on the committee. Rounding out the panel is Sen. Julie Lassa (D-Stevens Point), ranking member of the Senate Committee on Economic Development and Local Government.

The morning keynote is nationally-known pollster Larry Sabato, professor of politics and director of the University of Virginia’s Center for Politics (www.centerforpolitics.org) and creator of the website and weekly e-newsletter, "Sabato’s Crystal Ball."

Attendees will head to the State Capitol to meet with their legislators or legislative staff in the afternoon. The legislative visits are important and make a strong statement about how employees, trustees and volunteers care deeply about their local hospital and that they’re willing to take action to protect them. When you register for Advocacy Day, make sure to select the legislative visits option to ensure your voice is heard.

Please make Advocacy Day a priority again this year by joining your peers in Madison April 16. A brochure and registration information is available online at: http://events.SignUp4.net/14AdvocacyDay0416.

For Advocacy Day questions, contact Jenny Boese at 608-268-1816 or jboese@wha.org. For registration questions, contact Sherry Collins at scollins@wha.org or 608-274-1820.

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WCMEW Expands Focus to Encompass Team-based Care

Evidence is mounting that the predicted shortage of primary care physicians will precipitate an even greater interest in team-based care. In Wisconsin, many hospitals and health systems have already implemented this care model in some clinical areas.

The team-based care model was one of several issues discussed at the Wisconsin Council on Medical Education and Workforce (WCMEW) at their April 1 meeting at WHA headquarters in Madison. WCMEW has been primarily focused on issues related to the physician workforce; however, as the physician shortage deepens and the demand for care increases, care models will evolve.

"WCMEW’s role is in facilitating education and collaboration that will help providers plan for an uncertain future while ensuring that we can continue to deliver high-quality, high-value care," according to Chuck Shabino, MD, WHA senior medical advisor. "We are actively reaching out to hospitals, provider groups and health systems to find out what care models are working, identifying the challenges and looking to advance team-based care in Wisconsin."

WCMEW is sponsoring a one-day summit in fall 2014 that will showcase successful team-based care models in Wisconsin. Hospitals, physicians and health systems will be asked to participate in the summit by presenting posters and participating in panel discussions. More information on the summit will be available this summer.

MCW Green Bay Campus on Target to Admit First Class July 1, 2015

William Hueston, MD, senior associate dean for academic affairs at the Medical College of Wisconsin (MCW), said the development of the two MCW community-based medical school programs are moving forward at an "outstanding pace." Hueston said the Green Bay campus is on schedule to have 20 students start medical school there July 1, 2015. The students in Green Bay will receive the same classes that are offered on the Milwaukee campus.

"Our goal is to recruit students from Wisconsin who will go into family medicine, psychiatry and general surgery and who see themselves practicing in a small town in a smaller practice," Hueston said.

Hueston said a student entering either the Green Bay or the central Wisconsin campus will be able to complete their education in three instead of four years, which will save them nearly $50,000 in tuition. It is not an accelerated curriculum, according to Hueston, rather they create five more months over the three years by having less time off.

Work on the Central Wisconsin campus continues, and Hueston said the plan is still to admit the first class of medical students there in 2016.

MCW, UWSMPH Share Match Day Results: More Residency Positions Needed

WCMEW members Ken Simon, MD, Medical College of Wisconsin, and Byron Crouse, MD, University of Wisconsin School of Medicine and Public Health, shared their Match Day results. Wisconsin medical students are continuing to show a growing interest in primary care careers, but only 32 percent of Wisconsin medical school graduates will stay in state to complete their first year residency. That is slightly less than the number of graduates who stayed in state in 2013. (See Match Day article below)

"We must continue to add more in-state residency positions to keep pace with the increases in class sizes of our two medical schools," said George Quinn, WHA senior policy advisor.

Quinn updated the group on the status of the new GME grant programs that were funded in the state budget. In 2014, grants were awarded for expansion of existing programs in family medicine, psychiatry and general surgery. The new first-year positions were filled in the Match. The grant program for funding new programs is now underway. Quinn said that seven organizations have applied for funding to create new programs.

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President’s Column: Recent Physician Payment Debacle Symptom of Larger Health Care Divide

Congress failed this week to enact a permanent Medicare physician payment reform initiative, a plan crafted in rare bipartisan accord that would have resulted in good public policy that promised a movement to value-based payment.

But the bipartisan legislation wasn’t "paid for." So it wasn’t surprising that the not-so-small task of finding $130 plus billion to pay for permanent SGR reform became an impossibly heavy lift.

Realistically there were only five broad funding options, and the first three (do nothing, repeal the ACA, and a gimmick that used defense funds) were political non starters. So that left Medicare beneficiary "savings" (also a non-starter in an election year) and another round of Medicare provider cuts.

WHA’s opposition to funding SGR "fixes" with hospital cuts is well known and won’t be rehashed here. Fortunately, a majority in Congress seem to have heard that message. But the end result is another one-year "patch" that will take us into the next Congress.

The latest "patch" bill is a mixed bag. The good: rural hospital "extenders" were extended a year, ditto with blocking a 24 percent physician payment cut. Also found on the "good" list is a further delay of the outrageous "two-midnight" rule.

The "bad" list is dominated by two big items: 1) No permanent "fix" for 12 months and 2) A "where did that come from" one-year ICD-10 delay. The latter is unsettling and deeply disappointing given the time and resources hospitals, health systems and clinics have spent in anticipation of going live October 1 with the new coding system.

Some believe the ICD-10 delay was a sop thrown to the AMA (longstanding opponent of ICD-10) due to the permanent fix going down. Others say no. Regardless, the surprise delay represents just how difficult it has become to address necessary health care reform in the turbulent D.C. environment.

Steve Brenton
President

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Health Care Transparency Continues to Evolve as Consumer Engagement Grows
Health care leaders agree that more needs to be done, but by whom?

If you build it, they will come may be true for baseball fields, but so far that isn’t the case for health care transparency-related websites and other resources that have been created over the past few years. While the amount of data that is publicly accessible on health care prices and quality of care has increased dramatically in Wisconsin, a state that is considered a national leader in transparency, consumers are still not frequently using it to make health care decisions. That has not stopped organizations like the Wisconsin Hospital Association and the Wisconsin Collaborative for Healthcare Quality from developing transparency websites that are considered some of the best in their class.

At a briefing sponsored by Wisconsin Health News and Badger Bay April 1, Steve Little, president/CEO of Agnesian HealthCare, Fond du Lac, joined panelists Mark Thompson, MD, chief medical officer of Monroe Clinic; Dianne Kiehl, executive director of the Business Health Care Group; Jo Musser, chief executive officer of the Wisconsin Health Information Organization (WHIO); and Michael Hamerlik, president/CEO of Wisconsin Physicians Service Insurance Corporation for a discussion on health care transparency. Tim Bartholow, chief medical officer, WEA Trust, moderated the panel.

"Transparency has evolved greatly over the past 10 years as consumers have assumed more fiscal responsibility. That has gotten their attention," according to Little. "People want to know how good you are and what is it going to cost. We have made strides to be transparent, and transparency is an important component to providing quality health care. But we still have a ways to go."

Wisconsin is unique in that WHIO has a huge amount of claims data that is available for quality improvement and for health decision-making support activities here that is not available in other states, according to Musser. However, there are multiple challenges in developing a website or other resource that consumers will actually use.

While the goal is to provide information for decision making, Thompson said in his organization—Monroe Clinic—transparency is tied to their mission, which is to improve community health, so the data must be "actionable and based on outcomes."

As an insurer, Hamerlik pointed out that consumers need data, but sometimes the information they can access is not the data they need or not in a format they can understand.

"If we don’t provide real information, we will be stuck on rating systems based on ‘rating your own doctor’ and it could measure the wrong thing," according to Hamerlik. "And once we see some good data, what good does it do if that doctor is not in your network?"

A lively discussion erupted over the question of who has responsibility for making pricing information available to the consumer.

"Providers have to simplify it and be straightforward—at the end of the day the consumer is going to want to know what this is going to cost them out of pocket," according to Hamerlik.

That comment was later challenged by WHA Executive Vice President Eric Borgerding, who noted that a lot of the focus on price transparency and the place where that must be delivered is on the provider side. Yet, he pointed out, the majority of health care spending is not with providers, it is in premiums. The insurer sets the out-of-pocket and co-pays and ultimately determines what the patient will pay. Borgerding asked what steps the insurance industry is taking to give their subscribers the information they need so they know their out-of-pocket expenses before they incur the cost.

"When someone is told they need an MRI, the first thing they want to know is how much it is going to cost," Hamerlik said. "We need to be more transparent as insurers because people may have a $5,000 deductible. We have a lot of room for improvement."

Little said WHA’s PricePoint can give consumers an idea about the gross price of an inpatient procedure, but hospitals do not have the details about patients’ insurance plans that would be necessary to give them an accurate estimate on their out-of-pocket costs. He added that unlike car repairs, people are highly variable and can have conditions or complications that make it very difficult to predict the final cost of an inpatient procedure.

And while price is important, Kiehl pointed out that price is not always the most important consideration. She repeatedly brought the panel back to the importance of quality in the health care equation.

"The most important factor is that you get good quality care and a good outcome," Kiehl said. "I think quality is an important component in the value proposition."

As employers focus on reducing health care costs and adopt high-deductible health plans, Kiehl said she reminds employers that they have an obligation to educate employees on how to use health care. She said she is seeing a growing interest in employer-sponsored on-site clinics as the business community looks to have better access to care and a more direct relationship with providers.

"Education is nice; however, it doesn’t always work. Plan design is important. Basic access to preventive care delivered in a narrow network, and managing behavior through incentives reduces health care costs," Thompson said.

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Report Shows Wisconsin Hospitals’ Infection Rates Lower than Nat’l Levels
CLABSI rate 55 percent lower than national baseline; CAUTI 21 percent lower

A new report released by the Centers for Disease Control and Prevention (CDC) shows infection rates in Wisconsin hospitals are lower than national levels. The report provides a state-by-state breakdown of health care-associated infections and shows that infection rates are decreasing across the country. A Wisconsin-specific fact sheet is here: www.cdc.gov/hai/pdfs/stateplans/factsheets/wi.pdf.

Wisconsin was among the 21 states that had significant decreases in central line-associated bloodstream infections between 2009 and 2010, which the report noted helps contribute to the progress seen on a national level. That progress has stemmed from a series of initiatives since 2009 by the Wisconsin Hospital Association, as well as from projects by individual hospitals.

"In 2011, we really started seeing some dramatic decreases," said WHA Chief Quality Officer Kelly Court.

Wisconsin hospitals have made better than average progress in reducing both catheter-associated urinary tract infections (CAUTI) and central-line associated bloodstream infections (CLABSI), but there is room for improvement in reducing surgical site infections.

"We are not just preventing infections," Court said. "We are saving lives." For every 10 patients with a central line infection, one or two will die.

The occurrence of CLABSIs in Wisconsin hospitals was 55 percent lower than the national level and 21 percent lower than it was in 2011. The CLABSI rate in neonatal intensive care units was 36 percent lower than the national level and 10 percent lower than it was in 2011.

The CAUTI rate was 13 percent lower than the national level and 17 percent lower than it was the previous year.

"Wisconsin hospitals are absolutely committed to delivering the highest quality, safest care possible and to driving infection rates even lower," said Court. "This report is evidence that their commitment and efforts are making a difference."

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AHA Annual Meeting in Washington, DC May 4-7

The American Hospital Association (AHA) Annual Meeting will be held May 4-7 in Washington, DC. WHA will coordinate a number of special member events during this meeting, including a luncheon issue briefing, a members-only dinner and Hill visits with Wisconsin’s Members of Congress.

Every year, Wisconsin hospital leaders provide essential insight to their Members of Congress during legislative visits. Attendance at the Annual Meeting is not required to participate in WHA events or Hill visits. To facilitate Hill visits, WHA staff will make appointments with members of the Wisconsin delegation on your behalf.

For details or to register for the AHA Annual Meeting, log on to www.aha.org/advocacy-issues/annual-meeting/14-index.shtml.

If you are planning to be in Washington for this event, please contact Jenny Boese, vice president, external relations & member advocacy, at jboese@wha.org or 608-268-1816.

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Hospital Leaders Meet With Rep. Petri
SGR, ICD-10 discussed

Fifteen hospital leaders from across the Congressional District of Rep. Tom Petri met with him at Agnesian Healthcare March 31. The meeting with Petri was requested to express a growing frustration health care leaders have with Congressional attacks on Medicare reimbursements.

"The health care industry is changing at a rapid pace," said Agnesian President/CEO Steve Little. "The message we want to leave with you is that this environment is complex and is significantly impacted when government continues to arbitrarily reduce reimbursement rates. There are consequences."

The group discussed the $4 billion in reimbursement cuts Wisconsin hospitals and health systems have already seen through previously enacted Congressional policies and told Rep. Petri, "enough is enough."

Top of mind for the group was Congressional action this week on the Sustainable Growth Rate. Though aggressive efforts have been made this year to finally repeal the much-maligned Sustainable Growth Rate (SGR), the cost of total repeal continues to confound Congress. Congress instead passed legislation to "patch" the SGR for another year, until March 31, 2015. Without action, physicians would have faced a 24 percent payment cut. Under the package, physicians will see a 0.5 percent increase through the end of this year (Dec. 31, 2014) and a 0 percent increase from January 1, 2015 – March 31, 2015.

In a surprise move, the SGR patch legislation also included a one-year delay of ICD-10. The group told Rep. Petri that this most recent example is how Congress throws a wrench into the efforts of proactive, leading states like Wisconsin who were already investing and preparing for the October 1 go-live date. Further, the group told Petri that the year long delay will now cost those same Wisconsin hospitals and systems millions more dollars.

The House of Representatives approved the SGR patch legislation on voice vote. The Senate approved the bill by a 64-35 with both Wisconsin Senators Johnson and Baldwin voting against. After the Senate vote, U.S. Senator Tammy Baldwin released a statement about her vote which included the following:

"I strongly support protecting seniors’ retirement security by ensuring that doctors who serve Medicare patients receive fair payment for their work. However, this bill is a missed opportunity to reduce Medicare costs and enact significant health care reforms to eliminate today the flawed Medicare payment formula. I am also disappointed that the bill penalizes Wisconsin health systems that have made significant investments to upgrade their health technology, and now will be prevented from doing so for another year.

"Wisconsin’s physicians, health systems, and seniors want to continue moving forward toward a health care system that rewards quality of care over quantity of services. They are right to recognize, as I do, that the time is now for Washington to take action on putting in place real reforms that do just that. Unfortunately this legislation doesn’t do that and while I oppose it, I will continue my work across party lines on reforms that provide a real and long-term fix to a broken system," Baldwin said.

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Match Day Results Show Slight Dip in Number of Med School Grads Staying in WI

"Match Day" results revealed that Wisconsin medical students are continuing to show a growing interest in primary care careers, but only 32 percent of Wisconsin medical school graduates will stay in state to complete their first-year residency. That is slightly under the number of graduates who stayed in state in 2013. "Match Day" is when graduating medical school seniors across the country learn where they will be going for their first-year residency training.

Wisconsin’s two medical schools, the Medical College of Wisconsin and the University of Wisconsin School of Medicine and Public Health graduated a total of 358 medical students in 2014. The Wisconsin Academy of Rural Medicine (WARM) reported that two-thirds of their 20 graduates will stay in Wisconsin.

UW School of Medicine & Public Health

Medical College of Wisconsin

2013

2014

2013

2014

Medical school graduates who chose primary care (%)

46%

44%

38%

43%

Medical school graduates who will begin first-year residency in WI (%)

38%

33%

31%

30%

According to the Wisconsin Hospital Association report, "100 New Physicians a Year: An Imperative for Wisconsin," almost half of the physicians who complete a residency in Wisconsin stay here. That percentage jumps to 80 percent if the student is a Wisconsin native and attended both medical school and completed an in-state residency here, according to the WHA report. Where a physician does his or her residency is a leading indicator of where they will practice medicine.

"It is critical that we increase the percentage of graduates that enter a Wisconsin residency program, especially primary care, so we can count on those physicians to establish a practice in Wisconsin in the future," according to Chuck Shabino, MD, WHA senior medical advisor. In addition, Shabino said Wisconsin must increase the number of in-state residency positions.

The Medical College of Wisconsin will begin admitting students to its Green Bay campus in 2015. WHA has been enthusiastic about the plan to increase the medical school class size in Wisconsin, but is concerned about having an adequate number of residencies available for the new graduates.

"It’s imperative that we create more residency positions in Wisconsin so we can keep these physicians in our communities," Shabino added. "If we don’t, we’ll lose these doctors to other states."

Governor Scott Walker included several initiatives in the state budget that are aimed at increasing capacity in Wisconsin’s medical schools and expanding opportunities for medical school graduates to complete their residency training here.

"The Governor’s strong support of strengthening our medical education infrastructure in Wisconsin will go a long way toward increasing capacity in Wisconsin’s medical schools and expanding opportunities for medical school graduates to complete their residency training here," said WHA Executive Vice President Eric Borgerding.

Walker provided $5 million in state funds for graduate medical education (GME) initiatives in Wisconsin. The funding is being used to expand current residency programs ($1.5 million) and to develop new residency programs through creation of multi-stakeholder consortia. Both these initiatives target specialties identified as high need including family medicine, internal medicine, pediatrics, psychiatry and general surgery. The new positions in existing residency programs created by the first grants awarded in 2014 (family medicine, psychiatry and general surgery) were all filled in the match.

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WHA Offers Webinar on Updates to ACA’s Employer Shared Responsibility

The IRS recently released the final employer shared responsibility rules under the Patient Protection and Affordable Care Act (also called the "Pay or Play" rules). Now that the final regulations are out, it is time for employers to take action.

WHA is offering a member forum on this topic via webinar April 23. This webinar will focus on the new changes included in the final regulations, including guidance on on-call employees, transition rules providing additional time for full compliance, and on new rules handling employee hour decreases. In addition, this webinar will cover the critical steps that must be taken by employers, including how to determine, and document, which employees are "full time" under the new guidance; how to count on-call hours; and required and optional plan amendments.

Hospital HR professionals, CEOs, COOs, and CFOs will benefit most from participation in this webinar. There is no cost to participate in this WHA Member Forum, but pre-registration is required. Register at http://events.SignUp4.net/14PayOrPlay0423. If you cannot participate in the live webinar, there is an option to request an audio recording.

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