May 5, 2017
Volume 61, Issue 18


WHA Board Members Testify in Support of Rural Health Care Legislation
Borgerding encourages committee to leverage successful “grow-our-own” workforce strategy

Rural hospital leaders, along with WHA President/CEO Eric Borgerding, testified before an Assembly Committee May 3 in support of a package of workforce, quality improvement and population health legislation known as the Rural Wisconsin Initiative. The legislative package provides matching grant funding for the training of advanced practice clinicians and allied health professionals in rural Wisconsin hospitals, state support for the expansion of quality improvement work provided by WHA and a one-time matching grant program to provide seed money for the development of medical wellness facilities and programs in rural Wisconsin.

Borgerding began his testimony by commending the work of Committee Chair Rep. Nancy VanderMeer in leading the effort to enact the Interstate Medical Licensure Compact in Wisconsin, a bipartisan piece of legislation that provides a voluntary, expedited path of licensure for physicians who are looking to practice in multiple states. 

“The physician licensure compact is a great example of a bipartisan effort to identify, enact and now implement one strategy to address the health care workforce,” said Borgerding. “The bills you are hearing today will, hopefully, be the next example of that great work.”

Testifying along with Borgerding were 2018 WHA Board Chair Bob Van Meeteren, president/CEO, Reedsburg Area Medical Center and WHA 2017 chair of the Council on Rural Health; Charisse Oland, CEO, Rusk County Memorial Hospital, Ladysmith; and George Quinn, executive director, Wisconsin Council on Medical Education and Workforce.

In his testimony, Borgerding discussed the needs that exist in Wisconsin’s hospitals—but even more so in rural Wisconsin hospitals. Borgerding said one in ten advanced practice clinician positions in Wisconsin hospitals remain vacant, with allied health professional shortages climbing back to pre-recession levels. Borgerding also described the new and changing allied health professional positions that are becoming increasingly in demand with an enhanced focus on population health.

“Our members are increasingly using, and thus seeing greater demand, for professions that are taking on new and expanded roles as we focus not just on the care, but increasingly the overall health of patients outside the ‘walls’ of the hospital,” said Borgerding. “We regularly hear from members, who are looking to the future of value-based payment and population health, that there is an increasing demand for roles as patient care navigators, nurse case managers and social workers. These are allied health professionals that play important roles in health care delivery today and in the future.”

Borgerding described how the workforce legislation before the Committee for advanced practice clinicians and allied health professionals is modeled after a successful matching-grant initiative proposed by Gov. Scott Walker in the 2013-15 biennial budget to expand capacity for physician residency experiences in Wisconsin. Borgerding said the residency program created by Walker has spurred a nearly $22 million investment by the state and private sector partners in creating more residency capacity, especially in rural Wisconsin.

“Applying this same concept to training for advanced practice clinicians and allied health professionals will expose more individuals to rural communities and help address rural workforce shortages. This ‘grow our own’ strategy is another great example of bipartisan policymaking that is the blueprint for much of the legislation before you today,” said Borgerding.

Van Meeteren discussed the lengths Reedsburg Area Medical Center has gone to train, educate and successfully recruit surgical technician staff in his facility. At one time, Reedsburg Area Medical Center had three out of their five surgical technician positions vacant. At the same time, Madison Area Technical College had a two-year waiting period to get into the surgical technician program. Van Meeteren said Assembly Bill 224 would help create flexible, local training programs for allied health professionals, using hospitals as clinical rotation sites. 

Several provider groups registered and testified in support of this package of legislation, including the Wisconsin Academy of Physician Assistants, Wisconsin Academy of Nutrition and Dietetics and the Wisconsin Association of Nurse Anesthetists. Beverley Speece, MTS, PA-C, on behalf of the Wisconsin Academy of Physician Assistants, provided testimony in support of the bill and said “Advanced practice clinicians (APCs), such as the over 2,000 PAs like me in Wisconsin, play a crucial role in rural hospitals and clinics because patients in rural areas rely on APCs as a primary care access point.”

In addition, Oland also testified on legislation, Assembly Bill 222, which would create a medical wellness grant program in rural communities. Oland discussed her area’s population health rankings, especially how their rankings are impacted by the community’s inability to access exercise opportunities. She was joined by Rusk County Memorial Hospital’s Director of Rehabilitation Tony Schotzko, DPT, who testified to the necessity of having access to wellness facilities for patients, especially when considering the future population health model communities across the country are trying to achieve.

Finally, WHA Chief Quality Officer Kelly Court was joined by two rural hospital quality improvement directors, Rob Pasbrig, Columbus Community Hospital and Shelly Egstad, Tomah Memorial Hospital, to testify in support of Assembly Bill 255, which provides state financial support to expand the services provided by WHA’s quality improvement program. Both Pasbrig and Egstad testified to the unique challenges they both face, needing to “wear many hats” in a rural hospital including quality improvement, risk management, compliance and others. They stated the tools provided to them by the Wisconsin Hospital Association’s quality improvement program have helped their organizations achieve substantial and measurable improvement in patient care.

“As in any small business or hospital, I wear many hats on a daily basis and am often faced with competing priorities. Typically in larger hospitals, one person would oversee each one of these areas. While the work is indeed challenging, I don’t do it alone. The quality staff at the Wisconsin Hospital Association has provided significant guidance and resources to aid in our success. Our organization would not be where it is today without the support that is offered,” said Egstad in her testimony supporting Assembly Bill 255. 

The Rural Wisconsin Initiative, which includes Assembly Bill 222, Assembly Bill 224, Assembly Bill 227 and Assembly Bill 255, will now move forward to a vote in the Assembly Committee on Rural Development and Mining.

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U.S. House Passes American Health Care Act
Wisconsin legislators split on party lines

On May 4 the U.S. House of Representatives narrowly approved HR 1628, the American Health Care Act (AHCA), by a vote of 217-213. All but 20 House Republicans voted in favor and all Democrats voted against the bill. Wisconsin’s House Members split on party lines with Republicans Sean Duffy, Mike Gallagher, Glenn Grothman, Jim Sensenbrenner and Paul Ryan voting in favor while Democrats Ron Kind, Gwen Moore and Mark Pocan voted against. 

“Wisconsin’s hospitals are the safety net of our health care system, where the uninsured turn to, and receive, care when they are unable to obtain needed care anywhere else. This is why WHA’s top priority, top ACA-related concern, has been sustaining the coverage gains, the 38 percent reduction in our uninsured we have achieved since 2014 under our hybrid model of coverage,” said WHA President/CEO Eric Borgerding. “While the ACA certainly has flaws and needs repair, we remain very concerned with the impact the AHCA will have on our uninsured rate and the success of the highly-touted ‘Wisconsin Model’ in expanding coverage to our most vulnerable low income and aging populations.” 

An earlier vote scheduled in late March was canceled due to lack of votes. While there were various issues in play at that time, the disagreement boiled down to moderate Republicans expressing concerns with various AHCA provisions impacting coverage options and costs for individuals versus “Freedom Caucus” conservatives who wanted the bill to go even further, such as rolling back the Affordable Care Act’s insurance requirements. Various amendments popped up over the course of the last month, including several in the last week, which allowed Republican leadership to cobble together just enough votes to pass the bill. 

The House-passed amendments allow for states to waive insurance coverage requirements, such as essential health benefits and community rating, as well as to provide an additional $8 billion in funding for high risk pools to help individuals with pre-existing conditions. WHA does not believe the AHCA nor these amendments adequately address or protect Wisconsin’s unique coverage model. 

While the bill now moves to the U.S. Senate for action, many Republican senators have already gone on record expressing concerns with the House legislation. With no Democratic senators expected to vote in favor of the AHCA, Senate Republicans can only lose two votes, which makes prospects in the Senate that much more difficult. 

“WHA will continue to work with both state and federal lawmakers to protect the Wisconsin Model as debate now shifts to the U.S. Senate,” Borgerding said. “In fact, I am heading to the airport right now bound for Washington, D.C.”

The Wisconsin Hospital Association will continue to advocate to both U.S. Sen. Ron Johnson and Tammy Baldwin that necessary improvements to the AHCA are needed. In particular, WHA and our members continue to be concerned with ensuring affordable coverage for low-income and high-risk populations.

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Panel Ponders Medicaid Waivers, AHCA, Funding Impacts to Providers, Patients 
Borgerding: “We have to be smart about how Medicaid premiums are collected, levied” 

As Congress debated the American Health Care Act (AHCA) in Washington, several health care leaders participated in a panel discussion in Madison May 4 sponsored by WisPolitics on the impact the AHCA and Wisconsin’s Medicaid waiver request would have on hospitals and patients here.

WHA President/CEO Eric Borgerding was joined by John Russell, president/CEO, Columbus Community Hospital; Jon Peacock, research director, Wisconsin Council on Children and Families; and, Wisconsin Medicaid Director Michael Heifetz. WisPolitics President Jeff Mayers moderated the discussion.

Responding to what is working in Wisconsin with Medicaid reform, Russell said covering people who are at or below 100 percent FPL is definitely positive; however, Medicaid reimbursing hospitals at 65 percent of cost is a serious issue. 

Borgerding said a recent study by the Business Group on Health estimated one-third of the price of health care in southeastern Wisconsin is cost shifted due to Medicaid and Medicare underpayments. 

Medicaid is not perfect; reimbursement should be higher in some areas, according to Peacock, but it is a “cornerstone” of our health care system because it serves 1.2 million people. Without it, there would be a surge in uncompensated care, he said. 

Heifetz said Medicaid is working. No other state has achieved the coverage that Wisconsin has with its expansion model, according to Heifetz, and the program is in a good financial place and is stable. 

On the AHCA, Borgerding said any plan that Congress puts forward should recognize the Wisconsin Model that expanded coverage to 100 percent FPL, but did not receive any additional funding to cover that population. Russell said Wisconsin lawmakers should work together on a bipartisan plan to access the additional funding.

If the AHCA passes, in the short term, Heifetz does not see any challenges for Wisconsin. Longer term, the Governor has supported the per capita model that caps spending per enrollee vs. block granting the program, he said. 

“It’s not the draconian cuts that many have predicted for years, but it will require a more aggressive management of the budget line,” Heifetz said. “We are a low-spend, high-quality state, and that does not always get rewarded.”

Borgerding said reforms being discussed in the AHCA could punish non-expansion states like Wisconsin. Some populations must be carved out, such as those who are blind, disabled or elderly, which should be subject to a different, higher cap. Then, there is an issue of funding, and as Heifetz pointed out, Wisconsin is a low-spend state, which would set a lower base. 

WHA is monitoring very closely how subsidies would be paid out because “income-based subsidies are critical to Wisconsin because it allowed us to reject expansion because there was a more affordable option in the exchanges,” according to Borgerding.

While Peacock worries that a change in how Medicaid is funded could lower spending in the program and trigger rationing at the state level, Heifetz disagreed. He said the AHCA is not rationing care, but rather, is managing it or shifting the payment model in ways that are necessary. 

“Let’s move forward on payment reform and things of that nature that improve quality where WHA and others have led on these things,” Heifetz said. “Wisconsin leads on this and we can expand on that and help other states manage this problem.” 

On the Medicaid waivers and eligibility requirements, Borgerding said it is important that the proposals be soundly implemented. 

“We have to be very smart and realistic about how premiums are collected and levied,” Borgerding said. “The same is true for co-pays. These folks are making less than $12,000 a year, so the likelihood of collecting a co-pay in the ER is unlikely. We suggest the co-pay be collected by the State, not taken as a cut in reimbursement to our providers.”

Russell said people do not always fit the resource if they see an ER when a primary care clinic would have been more appropriate. 

“If people lose their eligibility, they will continue to seek treatment, and hospitals will not ‘steer them away from care,’” Russell said.

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Reminder: Register by June 7 for the 2017 Wisconsin Rural Health Conference
Glacier Canyon Lodge at The Wilderness Resort, Wisconsin Dells June 21-23, 2017

**Make your hotel reservations today. Room block will soon be full.**
More information and online registration available at
www.cvent.com/d/w5qpcq

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Jacobson Joins Health Care Leaders to Discuss Medicaid, ACA, Health Reform
Rakowski on Medicaid program: “Providers are pulling more than their fair share” 

Changes to the Medicaid program “won’t be easy,” but Department of Health Services Secretary Linda Seemeyer said implementing nominal premiums, drug testing and other elements included in Wisconsin’s childless adults waiver will give recipients “a little skin in the game.”

Speaking at a luncheon sponsored by the Public Policy Forum, Inc. in Milwaukee May 3, Seemeyer said the 48-month limit on Medicaid eligibility for childless adults has been among the most controversial aspects of the waiver. However, she emphasized that if the person is working or is training for a job, they would not lose their Medicaid coverage. Seemeyer cited a Marquette poll that found 79 percent of the people who participated generally did not view a work requirement negatively. 

Following Seemeyer, Forum President Rob Henken moderated a panel discussion on the ACA and the implications health reform could have on patients, providers and payers in metro Milwaukee. The panelists included: Catherine Jacobson, CEO, Froedtert Health and WHA Board Chair; Bevan Baker, commissioner, City of Milwaukee Health Department; Mark Rakowski, vice president, Children’s Community Health Plan; and, Julie Schuller, MD, president/CEO, Sixteenth Street Community Health Centers. 

The ACA was not about cost, but was about coverage, and Jacobson said that was a “phenomenal benefit” across the state. Both Baker and Jacobson emphasized the importance of helping people access the right care at the right time in the right place and in addressing the social determinants of health that are often barriers to getting that care. 

Jacobson noted though that before we can get to the social determinants, and “before you can have access to care, you must first have coverage.” 

She added that federal health reform efforts must recognize and reward Wisconsin’s model for Medicaid expansion. About 130,000 more childless adults with income below poverty now have Medicaid coverage, and about 240,000 people in Wisconsin signed up for coverage in the insurance exchange in 2017. 

On the Medicaid waiver, Jacobson and Schuller shared their concerns about the impact of eligibility changes. Schuller said even very small changes in program requirements and payments can have very large impacts on the population they serve.

Jacobson said WHA has spent a lot of time reviewing the impact of the waiver, and she emphasized that as a health care leader and employer she fully understands the goal to engage patients in the cost of their care and in their overall health. For the Medicaid population, however, she remains concerned about the significant ramifications of not paying a small premium—losing coverage. They will still need care and will seek it in the emergency room. She also expressed the concern of the ramifications to providers of uncollected co-payments, which will simply resolve as a reimbursement cut to providers. 

Related to the requirement for drug screening and testing, Baker noted the significant time and resources that are pouring into the opioid epidemic. He is concerned hurdles are being put in place for people with drug addiction to stay on Medicaid and get the care they need. 

From the Medicaid managed care perspective, Rakowski described the significant participation by health plans, with 15 health plans participating in managed care plans in Wisconsin, as being far different from other states. He added the strength in southeast Wisconsin is on the provider side—all the health systems and FQHCs participate in Medicaid. While there is not much money for providers in the program, “there is a commitment to that population.”

“Providers are pulling more than their fair share on this,” Rakowski said. “We also have a really strong relationship with the Department of Health Services…and we have 700,000 individuals in the BadgerCare program and our outcomes continue to improve every year.”

Rakowski said unlike insurers in other states, the provider-sponsored health plans in Wisconsin are staying in the exchange. While the exchanges are not a “profit center,” it is a way for their patients and their families to access affordable health care. 

Jacobson said Wisconsin started in a better place on premium rates, not that rates have not increased, but the provider-sponsored plans can balance that, take some losses and provide coverage with their members. “That is the heart of Wisconsin’s success,” Jacobson said.

Sixteenth Street Clinic is on the frontlines of caring for the “poorest of the poor.” Schuller said Milwaukee has made great strides over the past five to ten years in the health care system as a whole in leveraging the strengths of the system. 

The community health care centers fill in the gaps, and Schuller said they are very appreciative of the help they receive from health care systems and Medicaid HMOs, but “it is a fragile system.” 

All of the panelists voiced concerns about workforce shortages. Jacobson said the aging of the population in Wisconsin is significant for what it will mean for health care needs and workforce needs. 

In addition to workforce, panelists also seemed to agree on the need to address health care costs in the long term, particularly the need for more resources for prevention and care management up front as a way to address long-term health care costs. 

Link to Milwaukee Public Policy Forum: www.wiseye.org/Video-Archive/Event-Detail/evhdid/11508

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Grassroots Spotlight: Ministry Health Care Leaders Meet with Rep. Shankland


Rep. Katrina Shankland (D-Stevens Point), a member of the Legislature’s budget-writing committee, the Joint Finance Committee (JFC), met with local hospital leaders at Ministry St. Michael’s Hospital in Stevens Point to discuss Medicaid funding. Shankland also serves as the Assistant Minority Leader for Democrats in the State Assembly. 

During their meeting, participants discussed the need to address in the state budget bill inadequate Medicaid reimbursements. Those reimbursements resulted in over $1 billion statewide that went unpaid to Wisconsin hospitals for treating Medicaid patients. Hospital leaders highlighted the importance of increasing funding to the Medicaid Disproportionate Share Hospital program, one of the smallest Medicaid DSH programs in the country, among other Medicaid funding improvements. 

The JFC completed its round of public hearings on the state budget and has now begun the task of voting provision-by-provision on the items in the biennial budget bill. This process is expected to continue through the month of May.

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WHA’s Borgerding Featured at WMGMA 2017 Annual Conference

Leaders working in medical practice management throughout Wisconsin will gather May 24-26 in Elkhart Lake for the Wisconsin Medical Group Management Association (WMGMA) 2017 Annual Conference. WHA President/CEO Eric Borgerding will be one of the featured speakers, presenting a state and federal health care policy update to attendees during the luncheon on May 25.

The 2017 conference is focused on the theme of managing the velocity and density of health care change. In addition to Borgerding, the agenda includes featured speakers Suzanne Falk, associate director of government affairs for the national Medical Group Management Association (MGMA), and Brian Gittens, EdD, SPHR, associate dean of HR, equity and inclusion for the UW School of Medicine and Public Health. The conference will also include 14 concurrent session topics of interest to medical practice management professionals.

The WMGMA 2017 Annual Conference will be held May 24-26 at The Osthoff Resort in Elkhart Lake. Registration is now open at https://wmgma.site-ym.com/events/EventDetails.aspx?id=908213.

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WHA Offers Education on Newly Available Expedited Physician Licensure Process

With the Interstate Medical Licensure Compact’s voluntary expedited licensure process recently becoming operational, WHA will offer a 45-minute webinar on how the new Compact process can help physicians more quickly receive a Wisconsin medical license or a license in another state if the physician already holds a medical license in a Compact state. 

WHA General Counsel Matthew Stanford will present information on eligibility, which states are participating in the Compact; completing the application process, applicable fees, how to maintain a Compact expedited license and considerations for utilizing the Compact expedited process versus the traditional licensure process. 

The webinar, scheduled May 23 from 12:00-12:45 pm, is being offered via a partnership between WHA and the Wisconsin Medical Group Management Association (WMGMA). There is no fee to participate in this webinar, but pre-registration is required. Registration is now open at: www.cvent.com/d/z5qq0r.

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

Stroke is the fifth leading cause of death in the United States*, killing nearly 130,000 Americans each year—that’s 1 of every 20 deaths. Recognition of stroke and calling 9-1-1 will determine how quickly someone will receive help and treatment. Getting to a hospital rapidly will more likely lead to a better recovery.

According to the WHA Information Center, in calendar year 2016, there were 9,945 inpatient admissions, 2,817 emergency room visits (treated and released), 924 observation care visits and 10,777 hospital visits that required imaging, lab work or other medical services where primary or secondary treatment was for stroke.

Every four minutes, someone in the United States dies of stroke. Every year, more than 795,000 people in the U.S. have a stroke. About 610,000 of these are first or new strokes; 185,000 are recurrent strokes. Stroke is an important cause of disability and reduces mobility in more than half of stroke survivors age 65 and over. Stroke costs the nation $33 billion annually, including the cost of health care services, medications and lost productivity.

WHA’s CheckPoint program has data related to Wisconsin hospitals’ mortality and readmission rates for stroke. You can access that information here: https://www.wicheckpoint.org/report_topic_Stroke.aspx?tab=2&mode=Star 

*Centers for Disease Control

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

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WHA Advocacy Day 2017: Photos now on Facebook


When over 1,000 hospital supporters converge on Madison to attend WHA’s Advocacy Day, it is truly a sight to behold. Keynote speakers Governor Walker and Amy Walter, an outstanding legislative panel discussion, presentations of the Legislator of the Year and Advocacy All-Star awards as well as 600 attendees going on legislative visits…it all makes for an outstanding event! And all of this was captured in literally hundreds of photographs which you can view at WHA’s Facebook Album at: 
http://bit.ly/WHA2017AdvocacyDay. Be sure to “like” us and share!

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Give Your Physicians the Foundation to Successfully Lead Quality Improvement 
WHA Physician Quality Academy – registration open for fall cohort

Great leaders give their team members the tools and resources needed to be successful. The WHA Physician Quality Academy is your opportunity to give your physicians the foundation they need to be successful in leading quality improvement projects and initiatives in your organization. Give your physicians the training and resources needed today by registering them for the fall cohort of the WHA Physician Quality Academy.

The Academy includes two non-consecutive days of in-person training and access to supporting resources both between and after the live sessions. Participants will learn to design and conduct quality improvement projects utilizing proven improvement models; interpret data correctly; facilitate physician colleague engagement in quality improvement and measurement; and, discuss quality requirements, medical staff functions and their link to quality improvement.

Registration is open for the fall cohort of the Academy, scheduled September 29 and November 3 in Wisconsin Dells. Attendance is limited, so register your physicians as soon as possible at www.cvent.com/d/wvq5nm.

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