May 23, 2014
Volume 58, Issue 21


Wisconsin Medicare Spending 15% Lower than National Average
WI Medicare spending lower than nat’l average on most medical services

Wisconsin Medicare spending per beneficiary is 15 percent lower than the national average and per-capita costs are less for most services, according to data presented at the Wisconsin Collaborative for Healthcare Quality (WCHQ) Assembly May 14 in Madison.

Niall Brennan, acting director of the Centers for Medicare and Medicaid Services (CMS) Office of Enterprise Management, said while outpatient spending for Wisconsin Medicare beneficiaries is above the national average, that is "probably good because people are probably seeking care at the right service level and not over-utilizing ER or inpatient care."

Brennan pointed out that spending for other services; such as, evaluation and management, procedures, tests, imaging, and Part B drug use are lower than the national average. Wisconsin Medicare beneficiaries are "generally healthier than the rest of the country," and the prevalence of chronic disease is lower than the national average, except for kidney disease.

"Wisconsin is a low-cost, high-value provider. While the CMS data is only for Medicare and Medicaid patients, it can serve as a proxy for the consistently high standards of care that we provide to all patients, regardless of payer," according to WHA Executive Vice President Eric Borgerding.

Wisconsin is widely recognized as a national leader in reducing readmissions, a point that Brennan illustrated by showing the improvement that has been made here in reducing readmissions.

"Wisconsin’s readmissions rate decreased 1.24 percentage points from 2008 through 2013, which is really pretty spectacular," Brennan said.

Brennan said the CMS initiatives that are aimed at driving down readmissions are working, such as the national Partnership for Patients and projects like WHA’s Partners for Patients.

"You can see it in the data—the readmissions rate was unchanged between 2007 and 2011, then in 2012-2013, it started to drop and continues to decline," according to Brennan. "Reducing readmissions does more than just save money; it improves the quality of life."

"The CMS data underscore what many of us have known for years about the culture of collaboration in Wisconsin. The shared commitment among those who provide, pay for, and receive health care to dramatically improve the value of that care is borne out by these and many other indicators of quality and cost for both hospital and physician services," noted Chris Queram, president/CEO of WCHQ.

There are just over 662,000 Medicare beneficiaries in the state, which is 1.8 percent of the national fee-for-service population, and the Medicare program spending in Wisconsin is around $5 billion. About 30 percent of the Medicare population in Wisconsin is enrolled in a Medicare Advantage plan, which Brennan said is relatively high.

CMS is the largest single payer for health care services in the United States, with 2.5 billion claims submitted annually. Brennan said CMS also receives billions of other "non-claim" data points. Significant additional data sources are coming soon, such as data from the health insurance exchanges, electronic medical records, and County Health Rankings that CMS is incorporating into their database.

WCHQ publicly reports and brings meaning to performance measurement information that improves the quality and affordability of health care in Wisconsin. Learn more at WCHQ.org.

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New Medicaid Enrollment Numbers Released

On May 19, Gov. Scott Walker and the Wisconsin Department of Health Services (DHS) released the latest BadgerCare/Medicaid enrollment numbers showing that 81,731 newly-eligible childless adults began receiving BadgerCare benefits in April 2014, and 62,776 individuals with incomes above the federal poverty level no longer met the program rules on April 1, 2014 and were disenrolled from the program.

For those who were disenrolled, subsidized coverage could be available through the insurance exchange. These individuals have until May 30, 2014 to apply for exchange coverage under a special enrollment period. It is not yet known how many of the 62,776 may have taken up such coverage. DHS staff is reportedly working on a data match with the federal government, but that match is not expected to be complete until sometime in June.

Many additional questions remain about the overall impact of the policy changes implemented over the past several months at both the state and federal level, including how many previously uninsured are now covered in the exchange, how many with low incomes that don’t qualify for Medicaid have obtained coverage, and how many have paid premiums and will continue to pay premiums.

"There are nearly 82,000 newly-enrolled childless adults in the Medicaid program—which is a positive development—and it is close to the Department’s estimates of 83,000 that could obtain coverage under Medicaid in 2014," according to Joanne Alig, WHA senior vice president, policy & research. "WHA and its member hospitals and health systems throughout the state have been making significant investments in human and financial resources to help people sign up for coverage both through Medicaid and through the insurance exchange."

The statewide and county-by-county enrollment numbers can be found at: http://badgercareplus.org/enrollmentdata/enrolldata.htm.

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HHS Issues Letter to AHA Regarding Payments to Qualified Health Plans

In a letter to the American Hospital Association (AHA), the Department of Health and Human Services (HHS) indicated that it will not prohibit payments from private, not-for-profit foundations to qualified health plans on behalf of individuals who enroll in coverage via the health insurance exchange marketplaces. AHA had sought clarification after recent guidelines from HHS created uncertainty about their official position.

In the letter, Secretary Kathleen Sebelius wrote that HHS does not intend to issue further guidance on the topic, and indicated that "as a general matter, such payments are not prohibited by HHS’s rules to the extent they are provided in a manner consistent with the February 7, 2014 FAQ." The FAQ stated that the department did not discourage such subsidies provided by private, not-for-profit foundations, but those payments must meet certain criteria. Such criteria include that the payments be based on financial status, do not consider the enrollee’s health status and cover the entire policy year.

The letter from HHS to AHA, the February 7 FAQ and additional materials on this topic can be found on WHA’s website at: www.wha.org/EnrollmentResources.aspx.

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Court Accepts WHA Amicus Brief in Damages Cap Case

The Court of Appeals has accepted the joint amicus brief filed by the Wisconsin Hospital Association and the Wisconsin Medical Society in Fiez v. Keevil, et. al, a medical liability case challenging the constitutionality of the statutory cap on damages applicable to state employees.

The Wisconsin statutes cap damages recoverable against state employees, including state-employed physicians, at $250,000. The defendant in the case, Dr. Keevil, is a University of Wisconsin cardiologist. A jury found Dr. Keevil negligent and determined the plaintiffs in the case were injured in an amount in excess of the damages cap. The trial court reduced the award of damages consistent with the statutory cap. The plaintiffs appealed, arguing the statutory cap on damages violates their right of equal protection and the jury right and remedy clause of the Wisconsin Constitution.

The amicus brief, written by Attorney Guy DuBeau, Axley Brynelson, asked the court to consider the broader context in which the statutory cap on damages applicable to state employees operates. DuBeau wrote on behalf of the amici, "It is for good reason that our Supreme Court cautions the judiciary is not as well positioned as the Legislature to make the economic, social and political judgments involved in a matter like this."

Watch The Valued Voice for updates on this case.

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CMS Proposes New Meaningful Use Delay

On May 23, CMS will officially publish proposed rulemaking that would permit some hospitals and eligible professionals to delay compliance with updated meaningful use and certified EHR requirements for 2014. If finalized, hospitals and eligible professionals having difficulty acquiring version 2014 EHR technology would be permitted in 2014 to continue to use 2011 EHR technology and to delay compliance with Stage 2 meaningful use.

A 60-day comment period on the proposed rule will begin when the proposed rule is published. The rule will not be finalized until a final rule is published sometime after the comment period.

WHA is still analyzing the proposed rule and will provide additional information and updates in future editions of The Valued Voice. A copy of the proposed rule and notice can be found here: www.federalregister.gov/articles/2014/05/23/2014-11944/medicare-and-medicaid-electronic-health-record-incentive-programs-for-2014-health-information.

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WI Rural Health Conference, June 18-20: Register Today
Hotel registration deadline is May 28

Register today to join your colleagues at the 2014 Wisconsin Rural Health Conference, June 18-20, the premier statewide forum for examining issues that impact rural hospitals. As a reminder, hotel reservations must be made by May 28 to ensure a reservation and to receive the special conference group rate.

Due to other events at The Osthoff Resort and nearby Road America during that time, it is very likely that no hotel rooms will be available to conference attendees after May 28. It is recommended that you make your hotel reservations immediately if you plan to attend.

This year’s conference will include an outstanding opening keynote session by Stephen Klasko, MD; the ever-popular state of Wisconsin health care session presented by Tim Size, executive director, Rural Wisconsin Health Cooperative, and WHA President Steve Brenton; and a closing session by Dave deBronkart, otherwise known as ‘e-Patient Dave.’

The annual Wisconsin Rural Health Conference is a great way for hospital executives, leadership staff and trustees to examine the issues that impact small and rural hospitals while networking and collaborating with colleagues. Register for the conference by June 4, but most importantly, make your hotel reservations as soon as possible at The Osthoff Resort but before the deadline date of May 28. Online registration and full conference information are available at http://events.SignUp4.net/14Rural.

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WHA Submits Testimony to U.S. Ways & Means Committee on RACs, Two Midnights
NGS hosts webinar on two midnights

The Wisconsin Hospital Association submitted written testimony for the official committee record of the May 20 hearing of the U.S. House Ways & Means Committee on the impacts of the Recovery Audit Contractors (RAC). WHA’s testimony highlighted the Wisconsin experience with the RAC program and support for three bipartisan legislative solutions: RAC reform (HR 1250); two midnight policy reform (HR 3698); and critical access hospital 96-hour rule reform (HR 3991). Read WHA’s written testimony at: www.wha.org/pdf/WHAStatement_medicare5-20-14.pdf.

"While WHA and our providers support fighting ‘waste, fraud and abuse’ in government health care programs," began the WHA statement submitted by WHA President Steve Brenton, "we believe it is important to understand that there is a cost borne by the health care delivery system when those programs are overly-complex, poorly-structured or redundant."

In describing that burden, WHA provided information on its recent Wisconsin-specific RAC survey, which indicated the following:

During the hearing, multiple members of the U.S. Ways & Means Committee expressed frustration to the Centers for Medicare & Medicaid Services (CMS) testifier, Deputy Administrator Sean Cavanaugh, about the impact of the RACs and two midnights policy. Cavanaugh admitted that the agency has heard provider concerns surrounding the two midnight policy and that "the agency’s goal is to have clear rules that hospitals understand, not to penalize them."

To that end Cavanaugh told the Committee that CMS is looking at other options for reimbursing hospitals for short inpatient stays and has also requested comment on short stay policy in its recent FY 2015 Inpatient Prospective Payment Systems rule.

Another testifier, Ann Sheehy, MD, from the University of Wisconsin School of Medicine and Public Health and who practices as a hospitalist at the University of Wisconsin Hospital & Clinics (Madison), testified on experience with the RAC program and the two midnight rule. She focused, as did other testifiers, on the inherent problems with a time-based policy for inpatient admissions, especially that it works to undermine the medical judgment of the treating physician.

"The two-midnight rule does not distinguish between clinical populations because it is a time-based policy with no basis in sound clinical judgment," Sheehy said in her written testimony.

Further, Sheehy said, "The two-midnight rule and observation status in general negatively impact the delivery of good patient care…Medicare policy should be aligned with clinical realities and should also be rooted in allowing physicians to provide the care patients need. I would caution, however, that observation reform, whether it is legislative or regulatory, will not be successful unless there is concurrent reform of the federal auditing programs that enforce observation rules."

To that end, WHA continues to express support for three pieces of bipartisan legislation that would make much-needed improvement to the RAC program and subsequent problems.

"[Audit] programs must be more effectively deployed and take into account the downstream impacts they have which are ultimately borne by the health care delivery system, payers and patients," WHA’s written testimony closed. "Congress can do much to ensure a more effective approach by passing the following three bipartisan bills:

While the U.S. House Ways & Means Committee hearing was ongoing, the U.S. House Oversight Committee was also holding a hearing on the RACs. Committee members—Democrats and Republicans alike—expressed outrage at the impact of the RAC program on small businesses, rural areas and hospitals. Of particular concern was the RAC’s aggressive denial of claims, which has lead to a two plus year backlog at the Administrative Law Judge level for Medicare appeals.

Subcommittee Chair James Lankford and other committee members made pointed comments about this backlog and other RAC issues to CMS testifier Dr. Shantanu Agrawal, deputy administrator and director for the CMS Center for Program Integrity. Agrawal eventually did state that revisions to the RAC program, including requiring RACs to look at provider performance and adjust focus accordingly. Lankford told Agrawal that this should require RACs to both request fewer records from those providers and have a longer time period between record requests.

Agrawal stated the new RAC scope of work and CMS RAC contracting process is currently ongoing.

NGS to Host Two Midnight Webinars
NGS is offering several webinars to educate providers on CMS’s policy related to inpatient hospital and critical access hospital admissions for payment purposes. NGS indicates the webinars are intended for utilization review, case management, compliance, nursing, and staff education. Physicians, as well as members of clinical, administrative, coding and financial staff and other clinical personnel who have key roles in making the correct decision between inpatient and outpatient status for patient population are also encouraged to attend. The Two-Midnight Rule webinars will be held at the following dates and times:

To register, log onto www.NGSMedicare.com, click on Jurisdiction 6 Part A. Click on Education & Training >Training Events Calendar. Click on the date of the Two-Midnight Rule webinar(s) that you would like to attend. Your registration is complete only when you receive a confirmation at your email address immediately after submitting your registration.

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WHA Health Law Manuals June 5 Webinar Features Informed Consent

WHA will launch its months-long complimentary webinar series June 5 from 12 – 1:30 p.m. with a presentation of the WHA Consent Manual. This webinar will cover the general concept of consent to medical treatments and procedures, including methods for documenting consent and capacity for giving consent. It will also cover the legal basis upon which health care personnel may be requested to assist law enforcement officers in the procurement and testing of specimens. Refusal to consent and advance directives will also be addressed.

WHA members are encouraged to register for this webinar on the WHA Consent Manual as well as any or all of the other webinars in the series. Sign-up information and additional information about each of the eight webinars in the series can be found at http://events.SignUp4.net/HealthLawManual. Attorneys in attendance may earn CLE credit.

The June 5 webinar will be presented by Heather L. Fields and Nicole S. Rosen of the law firm of Reinhart Boerner Van Deuren.

The Health Law Manuals are available for WHA members to view and download. WHA members who would like access to the manuals should contact webmaster@wha.org to request a username and password.

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MCW-Green Bay Receives Accreditation Approvals; Will Begin Recruiting Medical Students

The Medical College of Wisconsin’s new campus in Green Bay (MCW-Green Bay) received approval from two key accrediting bodies and will begin recruiting medical students in the next month for the new campus, which is expected to welcome its inaugural class in July 2015.

The Higher Learning Commission expanded its current accreditation of MCW’s main campus in Milwaukee to include MCW-Green Bay, and the Liaison Committee on Medical Education (LCME), the accrediting body specific to medical schools, determined the school to have the resources necessary to open its doors to students in July 2015.

"Our curriculum and development teams have worked tirelessly to ensure the highest quality medical education for the students who attend the new campus," said Joseph E. Kerschner, MD, MCW executive vice president and dean of the Medical School. "It is exciting that we will leverage tele-education in a new way to connect students and educators at both campuses. The foundation of this program is true partnership and collaboration."

The new campus is expected to enroll 20-25 students per year in a collaborative educational model that engages multiple partners. Students will complete their coursework in three years, rather than four, which will lower their debt burden upon completing the medical education.

For more information about the application process, visit the MCW website at www.mcw.edu/MCW-Green-Bay.htm.

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Froedtert & the Medical College Expand Improvement Capacity Community-wide

It takes community-wide awareness and action to help reduce hospital readmissions. Across the state, health systems and hospitals are focusing their efforts on reducing readmissions. The staff in the quality department at the Wisconsin Hospital Association has been helping hospitals learn how to reduce readmissions through the use of quality improvement tools.

Froedtert & the Medical College of Wisconsin Community Memorial Hospital, Menomonee Falls, has been leading a group of local organizations in a community-based care transitions program aimed at reducing readmissions. The group is comprised of representatives from the various groups within the Froedtert system, home health and long-term care facilities that are not directly affiliated with the health system.

At the invitation of Diane Ehn, vice president of quality and performance improvement for Froedtert & the Medical College Community Hospital Division, WHA Quality Improvement Advisors Travis Dollak and Tom Kaster led a group of 20 individuals from the community coalition through several discussions and exercises around creating sustainable improvement.

"We’ve made some great progress this past year, but to maintain and sustain our efforts, we felt we needed to improve the group’s basic knowledge around quality improvement methodologies," according to Ehn. "That is why we asked WHA to do a half-day training here."

During the session, Dollak and Kaster asked the participants to form smaller, mixed groups. Then, each group practiced writing aim statements, developed small tests of change, selected appropriate measures, and discussed strategies for sustaining results.

Kaster said by mixing up the groups, "we added an element of fun to the activity by having participants share personal experiences and relate those to real clinical examples to show that quality concepts can be used for any process or system you want to improve."

Ehn asked the groups to develop their next steps, which included incorporating what they had learned into their routine the following day at their respective organizations.

"Throughout the day it was great to see the group work together," according to Dollak. "Both Froedtert & the Medical College community hospitals are already making excellent progress in reducing readmissions. But they are now working to take their improvement to the next level by expanding their own knowledge about quality improvement and sharing it with other organizations in the community."

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Wisconsin in Top Ten for Percent of Physicians Selecting Family Medicine Residencies

The Wisconsin School of Medicine and Public Health was one of ten of the nation’s 126 allopathic medical schools that were recognized by the American Academy of Family Physicians (AAFP) for contributing the most to the pipeline of family physicians.

Each year the AAFP presents its Family Medicine Top Ten Awards to honor medical schools that—during a consecutive three-year period—graduated the greatest percentage of students who chose first-year family medicine residency positions. AAFP noted that the top ten schools used a combination of student outreach, admissions policies that target students from rural and medically underserved areas, clinical rotations that emphasize positive experiences in family medicine, faculty involvement in medical school committees, strong student-run family medicine interest groups and financial aid packages that minimize student debt to increase interest in family medicine.

The Wisconsin Academy for Rural Medicine (WARM), started in 2008, provides specialized training for medical students at the University of Wisconsin School of Medicine and Public Health in Madison. WARM’s goal is to increase the number of physicians practicing in rural areas of Wisconsin. WARM will enroll 26 students this fall.

The shortage of rural physicians is projected to increase, as reported in the WHA report, "100 New Physicians a Year: An Imperative for Wisconsin." As current rural physicians retire and the population ages, there will be a need for more physicians.

"The changing environment of medicine combined with the fact the demand for care is projected to increase more rapidly than the supply of physicians is a call to action, and our medical schools are responding by promoting family medicine," according to Chuck Shabino, MD, WHA senior medical advisor. "Our challenge in the future is to ensure that we have a sufficient number of in-state residency positions to ensure that we retain the physicians that we educate in Wisconsin."

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Call for Nominations: 2014 Global Vision Community Partnership Award
Nominations due to WHA Foundation by July 15

Honor one of your hospital’s community health projects by submitting a nomination for a 2014 Global Vision Community Partnership Award, presented by the WHA Foundation.

This competitive grant award is presented to a community health initiative that successfully addresses a documented community health need. The Award, launched by the WHA Foundation in 1993, seeks to recognize and support ongoing projects that support community health.

Any WHA hospital member can nominate a community health project. The project must have been in existence for a minimum of two years and must be a collaborative or partnership project that includes a WHA member hospital and an organization(s) within the community. The official call for nominations for the 2014 Award is included in this week’s packet.

Nominations are due July 15, 2014. Nomination forms can also be found on the WHA website at www.wha.org/global-vision-comm-partnership.aspx.

For more information about the Award, contact Jennifer Frank at jfrank@wha.org or 608-274-1820.

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Presentation Proposals for WCMEW Event Due June 6

The Wisconsin Council on Medical Education & Workforce (WCMEW) is sponsoring a day-long conference November 12 in Wisconsin Dells and organizers are seeking proposals from Wisconsin health care leaders who wish to showcase their successful patient-centered, team-based care teams.

Presentations are needed for three panel presentations, 30 poster presentations and a conference compendium. Panel topics are Mission and Driving Force, Team Interaction and Culture and Patient Population Served and Outcomes.

More detailed information regarding the event and presentation proposals can be found at https://www.wisconsinmedicalsociety.org/_WMS/resources/medigram/2014/05082014/team_based_care_conference_invite.pdf. Applications for participation are due June 6. To apply online, go to https://adobeformscentral.com/?f=7BoYOb4rNwe7Mz27lTI8Ag#. For more information about the application process, e-mail Julie Wills at julie.wills@wismed.org.

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Size, Petasnick Receive Honorary Degrees from Medical College of Wisconsin

Two Wisconsin health leaders, Tim Size and William Petasnick, received honorary doctoral degrees from the Medical College of Wisconsin, Milwaukee, during commencement exercises May 16. Mary-Claire King, PhD, professor in the departments of medicine and genome sciences at the University of Washington, was also honored.

In a speech to graduating medical college students the evening before commencement, Size emphasized the importance of collaboration and the role of a physician in the community.

"I believe that physicians are called to not only uphold their discipline but also to work collaboratively with other professions and those outside of health care to improve the health of their patients and our communities," Size told the graduates.

Size noted that 40 years ago, he and Petasnick were recruited at the same time to fill two open positions on the administrative team at the University of Wisconsin Hospital.

Size is the executive director of the Rural Wisconsin Health Cooperative. He is also vice-chair of WHEFA, the state’s bond authority for health and educational facilities, and he currently serves as the founding co-chair of the National Rural Health Foundation to support the development of the next generation of rural health leaders.

Bill Petasnick was the chief executive officer of Froedtert Health for more than 19 years. He was WHA Chair in 2000 and received WHA’s Distinguished Service Award in 2005. He remains active in health care and health policy as a member of the Froedtert Health board of directors, the chair of the Health Forum Board, and a strategic advisor and board member to several private health care organizations and companies.

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Member News: Lentz Named President of Aspirus Wausau Hospital

Darrell Lentz has been named president of Aspirus Wausau Hospital (AWH) effective immediately. He had served as interim hospital president since November 2013. Prior to that, Lentz was AWH vice president of finance from January 2011 through October 2013.

A native of Maine, Lentz has more than 16 years of experience in the health care and financial industries, including 14 years of management and executive leadership. Prior to joining Aspirus, he served as chief financial strategic operations officer for University Hospitals and Health System, a five-hospital health care system that is part of the University of Mississippi Medical Center.

Lentz earned an MBA from Southern New Hampshire University, Manchester, New Hampshire, and a Bachelor of Science degree in finance from Bentley University, Waltham, Massachusetts.

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