November 1, 2013
Volume 57, Issue 44


UWSMPH, MCW Leaders Take Action to Avert Physician Shortage

Wisconsin hospital, health system and physician leaders joined representatives from the state’s two medical schools and residency programs to share strategies that will help address current and predicted shortages in the state’s physician workforce.

Speaking at the Wisconsin Council on Medical Education and Workforce (WCMEW) conference October 24, Robert Golden, MD, dean of the University of Wisconsin School of Medicine and Public Health (UWSMPH) said UWSMPH graduated their largest class ever in 2013, but projections for the supply of physicians here range from "bad to really bad."

"A sentinel report by WHA said 100 new physicians are needed a year to meet demand. The need for physicians is most urgent in primary care," Golden said. "If you look at the distribution of primary care physicians by geography, that’s where you find the problem. On average, you have problems with too many and too few."

Golden said the number of in-state residency slots is a concern, as he made the point that "medical schools produce residents—not doctors, so you must complete a residency before you can set up a practice."

"We have outgrown our medical school capacity by not having enough residency spots," he added.

The Medical College of Wisconsin (MCW) President/CEO John Raymond, MD, agreed with Golden that there are two big problems in Wisconsin—a shortage of physicians and mal-distribution. To help address the shortage, Raymond said MCW has committed to developing a three-year medical school curriculum that reduces student debt load and allows students to gain clinical experiences earlier in the education process.

"We currently graduate 400 medical students each year in Wisconsin, but the need is 500 per year," Raymond said. "We can address the start of the physician pipeline by expanding our medical schools."

Raymond said MCW has focused on expanding their class size by creating medical education and GME opportunities for physicians in settings outside of Madison and Milwaukee. Their multi-community medical school model extends their campus to Green Bay and central Wisconsin by partnering with local academic and health-related organizations. Those partnerships are a gateway to "enormous talent pools" in Wisconsin’s health systems exposing students to community-based practices and to hospitals that are focused on quality improvement.

"I want to expose our students to places where clinical care is embedded in the community," Raymond said. "As we move out into the communities, our medical schools are becoming better."

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DHS Begins Reimbursing at Medicare Rates for Primary Care Services for 2013 and 2014
Providers must complete attestation by December 31 or lose eligibility for entire calendar year 2013 increase

The Department of Health Services (DHS) started reimbursing primary care services at the higher Medicare rate for current claims submissions. The higher rate is required to be paid for certain services under provisions of the Affordable Care Act (ACA), and for physicians that have completed an attestation as required by DHS.

"It is great news that physicians in Wisconsin can now access this higher payment," said Joanne Alig, WHA senior vice president for policy and research. "We encourage our members to make sure their physicians complete the attestation by December 31 so they can be eligible for retroactive payments back to January 1, 2013." Providers who attest on or after January 1, 2014, will only be eligible for the rate increase beginning on the date of attestation going forward.

Under the ACA, states are required to raise their Medicaid fees to Medicare levels for family physicians, internists, and pediatricians for many primary care services. WHA strongly supported this provision in its comment letter to the Centers for Medicare and Medicaid Services (CMS) on the proposed rule related to its implementation. WHA supported the payments being made for all services, including those provided for Medicaid managed care patients, and agreed with CMS on the need to monitor contracts to ensure payments intended to increase access to care are passed on to providers.

The payment is required to be made for both fee-for-service (FFS) and managed care payments. FFS payments will be made on a claim-by-claim basis. DHS is requiring Medicaid HMOs to pay providers the difference between the Medicare rate and their contracted provider rate. Department staff has indicated more information about the payment process and their monitoring of payments through the Medicaid HMOs will be forthcoming.

The payment increase can be significant. The Kaiser Family Foundation has estimated an average increase of 78 percent in physician fees for Wisconsin as a result of this policy—an indication of the low rates of reimbursement in our state Medicaid program. The primary care fee increase applies only for two years—in 2013 and 2014. It is fully federally funded up to the difference between a state’s Medicaid reimbursement amounts in effect on July 1, 2009 and Medicare reimbursement rates for 2013 and 2014 as determined under a formula. The ACA provision was to be effective January 1, 2013; however, the lack of CMS rules until late last year and the complex nature of system changes has caused a delay in implementing the payments. As a result of the delay, DHS is allowing providers who attest by December 31, to be eligible for retroactive payments for the entire calendar year 2013.

The physician attestation process is explained in the September 2013 ForwardHealth Update (2013-44), titled "Policy Clarifications for the Affordable Care Act Primary Care Rate Increase Provider Attestation." at https://www.forwardhealth.wi.gov/kw/pdf/2013-44.pdf.

The reimbursement policy is explained in the October 2013 ForwardHealth Update (No. 2013-54), titled "Reimbursement for Services Provided Under the Affordable Care Act Primary Care Rate Increase," and can be found at: https://www.forwardhealth.wi.gov/kw/pdf/2013-54.pdf.

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Guest Column: Light at the End of the Premium Support Tunnel
By Attorneys Steve Hahn, Paul Seidenstricker, and Dave Snow of Hall, Render, Killian, Heath & Lyman, P.C.

The U.S. Department of Health and Human Services (HHS) has clarified that it does not consider Qualified Health Plans (QHP(s)) purchased on a federal or state exchange established under the Affordable Care Act to be "federal health care programs," even when the individual purchasing such QHPs qualifies for premium tax credits and cost sharing subsidies. This clarification came in a letter dated October 30, 2013 from HHS to Representative Jim McDermott of the State of Washington.

Hospitals in Wisconsin, like hospitals across the country, have been looking for guidance on whether it is permissible to provide premium support payments to individuals who are at risk of losing their coverage due to their inability to pay their QHP insurance premium. This issue has been widely discussed since the Centers for Medicare and Medicaid Services issued its final rule on March 27, 2012, regarding the three month grace period applicable to the termination of an individual’s QHP insurance coverage. Under this final rule QHP insurers can hold claims during the second and third months of the grace period and ultimately deny payment for any held claim if the individual does not pay all outstanding QHP insurance premiums by the end of the grace period.

The concern with a hospital’s payment of an individual’s QHP insurance premiums is that it could be considered an inappropriate beneficiary inducement to acquire health care services under the Federal Anti-Kickback Statute ("AKS"). The AKS prohibits any entity from knowingly and willfully offering or paying remuneration, directly or indirectly, to someone to induce the referral, including a self-referral by a beneficiary, of any item or service for which payment may be made in whole or in part under a "federal health care program."

Because of the premium tax credits/subsidies offered to qualifying low-income individuals who obtain QHP insurance coverage, it was unclear whether HHS would treat QHPs as federal health care programs and therefore subject to the AKS. HHS’ clarification that it does not consider QHPs and other Marketplace-related programs to be federal health care programs is significant and appears to address one of the legal obstacles facing hospitals looking to implement a charity care program designed to provide premium support payments to individuals at risk of losing their coverage due to their inability to pay their QHP insurance premiums.

While it appears that a hospital’s payment of an individual’s QHP insurance premium through its charity care policy will not trigger direct concerns under the AKS, we still recommend that any hospital that intends to implement a premium support program carefully review and consider all of the characteristics of such program to ensure compliance with applicable state and federal law. As HHS’ letter notes, there are other laws, including the False Claims Act, that might, under the right (or better said, wrong) circumstances, impact the appropriateness of a hospital’s premium support program. For example, premium support involving certain Medicaid waiver or pilot programs offered on an exchange could implicate the False Claims Act as referenced in HHS’ letter.

HHS’ correspondence to Representative McDermott is available at: www.hlregulation.com/files/2013/10/The-Honorable-Jim-McDermott.pdf.

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Political Action Campaign at 78 Percent of Goal

Total contributions to the 2013 Wisconsin Hospitals Conduit and State Political Action Funds campaign surpassed the three-quarter mark this week. With two months left in the calendar year, the campaign needs to raise $57,000 by year’s end to meet the $260,000 goal.

So far, 305 individuals have participated in the campaign contributing almost $203,000. The median contribution remains at $500 while the average contribution is $665. This pace is behind 2012 in number of individual participants—down 78 contributors and $30,000 behind the pace of last year’s record-breaking year.

Individual contributors are listed in The Valued Voice by name and affiliated organization on a regular basis. Thank you to the 2013 contributors to date who are listed below. Contributors are listed alphabetically by contribution amount category. The next publication of the contributor list will be in the November 15 edition of The Valued Voice. For more information, contact Jodi Bloch at 608-217-9508 or Jenny Boese at 608-274-1820.

Contributors ranging from $1 to $499
Allen, Patricia Columbia St. Mary's, Inc.
Ambs, Kathleen St. Mary's Janesville Hospital
Anderson, Phil Sacred Heart Hospital
Andritsch, Stacie Wheaton Franciscan Healthcare
Appleby, Jane Aurora Health Care
Bagnall, Andrew St. Nicholas Hospital
Bair, Barbara St. Clare Hospital & Health Services
Ballentine, Anne Wheaton Franciscan Healthcare
Baltzer, David Memorial Medical Center - Neillsville
Bayer, Tom St. Vincent Hospital
Bergmann, Ann Spooner Health System
Bloom, Deborah Sacred Heart Hospital
Boson, Ann Ministry Saint Joseph's Hospital
Bowman, Andrew Sacred Heart Hospital
Breeser, Bryan Aurora Medical Center Summit
Brenholt, Craig St. Joseph's Hospital
Brennan, Karen St. Mary's Hospital
Brenny, Terrence Stoughton Hospital Association
Brenton, Andrew Wisconsin Hospital Association
Burgener, Jean Aspirus Wausau Hospital
Buss, Diane St. Mary's Hospital
Campau, Patricia Columbia St. Mary's, Inc.
Capelli, A.J. Aurora Health Care
Cardinal, Lori Agnesian HealthCare
Casey, Candy Columbia Center
Censky, Bill Holy Family Memorial
Clark, Renee Fort HealthCare
Collins, Sherry Wisconsin Hospital Association
Coniff, Barbara St. Mary's Hospital Medical Center
Connors, Lawrence St. Mary's Hospital Medical Center
Cormier, Laura Bellin Hospital
Culotta, Jennifer St. Clare Hospital & Health Services
Dahl, James Fort HealthCare
Dalebroux, Steve St. Mary's Hospital
Danner, Forrest Aspirus Wausau Hospital
DeMars, Nancy Sacred Heart Hospital
Drengler, Kathryn Aspirus Wausau Hospital
Dux, Larry Froedtert & MCW Community Memorial Hospital campus
Feldhausen, Mary St. Vincent Hospital
Ferrigno, Sandra St. Mary's Hospital
Fielding, Laura Holy Family Memorial
Folstad, John Sacred Heart Hospital
Fox, Stephen Aspirus Wausau Hospital
Fry, William Columbia St. Mary's, Inc.
Furlong, Marian Hudson Hospital & Clinics
Gagnon, Annette HSHS-Eastern Wisconsin Division
Gajeski, Lynn St. Vincent Hospital
Gansemer, Sheila Wheaton Franciscan Healthcare
Garvey, Gale St. Mary's Hospital
Gille, Larry St. Vincent Hospital
Granger, Lorna Aurora Health Care
Gresham, James Wheaton Franciscan Healthcare
Gruber, Richard Mercy Hospital and Trauma Center
Grundstrom, David Flambeau Hospital
Guffey, Kerra Meriter Hospital
Gulan, Maria Aspirus Wausau Hospital
Gullicksrud, Lynn Sacred Heart Hospital
Hafeman, Paula St. Vincent Hospital
Halida, Cheryl St. Joseph's Hospital
Hamilton, Mark
Hansen, Karen Memorial Medical Center - Ashland
Hardy, Shawntera Hudson Hospital & Clinics
Hattem, Marita Aspirus Wausau Hospital
Helgeson, Jason HSHS-Eastern Wisconsin Division
Henricks, William Rogers Memorial Hospital
Hieb, Laura Bellin Hospital
Hockers, Sara Holy Family Memorial
Hockin, Jennifer Aspirus, Inc.
Hofer, John Bay Area Medical Center
Hueller, Julie Wheaton Franciscan Healthcare
Jelle, Laura St. Clare Hospital & Health Services
Jensema, Christine HSHS-Eastern Wisconsin Division
Jensen, Russell St. Mary's Hospital
Johnson, Charles St. Mary's Hospital
Johnson, Kimberly Sacred Heart Hospital
Josue, Sherry St. Mary's Hospital
Karuschak, Michael Amery Regional Medical Center
Keene, Kaaron Memorial Health Center
Kelsey Foley, Kathy Aspirus Wausau Hospital
Kempen, Jacob Aspirus Wausau Hospital
King, Peggy Memorial Health Center
King, Steve St. Mary's Hospital
Klay, Chris St. Joseph's Hospital
Klay, Lois St. Joseph's Hospital
Klein, Tim Holy Family Memorial
Knutzen, Barbara Agnesian HealthCare
Kocourek, Cathie Aurora Medical Center in Two Rivers
Lambrecht, Randy Aurora Health Care
Lange, George Westgate Medical Group, CSMCP
Larson, William St. Joseph's Hospital
Lentz, Darrell Aspirus, Inc.
Leonard, Mary Kay St. Mary's Hospital
Lepien, Troy St. Mary's Hospital
Lucas, Roger Aspirus Wausau Hospital
LuCore, Patricia Sacred Heart Hospital
Luehring, Sally St. Vincent Hospital
Lynch, Sue Mayo Health System - Franciscan Healthcare
Maroney, Lisa
Martin, Nancy Ministry Saint Michael's Hospital
Maurer, Mary Holy Family Memorial
McCarthy, Steven Southwest Health Center
McManmon, Kristin St. Mary's Hospital
McMeans, Scott Holy Family Memorial
Meicher, John St. Mary's Hospital
Natzke, Kristin
Nevers, Rick Aspirus, Inc.
Nguyen, Juliet Sacred Heart Hospital
Nicklaus, Todd Aspirus, Inc.
O'Brien, Laura
O'Hara, Tiffanie Wisconsin Hospital Association
O'Keefe, Robert
Oland, Charisse Rusk County Memorial Hospital and Nursing Home
Olson, Bonnie Sacred Heart Hospital
Ose, Peggy Riverview Hospital Association
Ostrander, Gail HSHS-Eastern Wisconsin Division
Ott, Virginia St. Joseph's Hospital
Palecek, Steve St. Joseph's Hospital
Pavelec-Marti, Cheryl Ministry Saint Michael's Hospital
Peck, Lori Memorial Health Center
Pempek, Kalynn Aspirus Wausau Hospital
Penczykowski, James St. Mary's Hospital
Pinske, Heather St. Mary's Hospital
Reinke, Mary Meriter Hospital
Reising, Chris Aspirus, Inc.
Rocheleau, John Bellin Hospital
Roundy, Ann Columbus Community Hospital
Sanicola, Suzanne Columbia St. Mary's Columbia Hospital
Schaetzl, Ron St. Clare Hospital & Health Services
Schneider, David Langlade Hospital - An Aspirus Partner
Schubring, Randy Mayo Health System - Eau Claire
Scieszinski, Robert Ministry Door County Medical Center
Scinto, Jeanne Aspirus Wausau Hospital
Sheehan, Heather Hayward Area Memorial Hospital and Nursing Home
Sio, Tim Wheaton Franciscan Healthcare - All Saints
Slomczewski, Constance Wheaton Franciscan Healthcare - All Saints
Smith, Brian Aspirus, Inc.
Statz, Darrell Rural Wisconsin Health Cooperative
Stelzer, Jason St. Clare Hospital & Health Services
Strasser, Kathy Aspirus, Inc.
Swanson, Becky Sacred Heart Hospital
Tandberg, Ann St. Joseph's Hospital
Teigen, Seth St. Mary's Hospital
Thornton, Eric St. Mary's Janesville Hospital
Tuttle, Kathryn Memorial Medical Center - Ashland
Vergos, Katherine Ripon Medical Center
Voelker, Thomas Aspirus Wausau Hospital
Walker, Troy St. Clare Hospital & Health Services
Westrick, Paul Columbia St. Mary's Columbia Hospital
Wheeler, Susan St. Nicholas Hospital
White-Jacobs, Mary Beth Black River Memorial Hospital
Whitinger, Margaret Agnesian HealthCare
Wipperfurth, Kay Fort HealthCare
Woleske, Chris Bellin Psychiatric Center
Wymelenberg, Tracy Aurora Health Care
Wysocki, Scott St. Clare Hospital & Health Services
Yaron, Rachel Ministry Saint Clare's Hospital
Contributors ranging from $500 to $999
Anderson, Rhonda Columbia St. Mary's Milwaukee Hospital
Ashenhurst, Karla Ministry Health Care
Bablitch, Steve Aurora Health Care
Behl, Kevin Columbia St. Mary's Milwaukee Hospital
Boecker, Ron Wheaton Franciscan Healthcare
Borgerding, Dana
Bukowski, Cathy Ministry Health Care
Bultema, Janice
Busch, Rebecca Spooner Health System
Carlson, Dan Bay Area Medical Center
Chumbley, Clyde ProHealth Care, Inc.
Deich, Faye Sacred Heart Hospital
Dewitt, Jocelyn
Dicus-Johnson, Coreen Wheaton Franciscan Healthcare
Dietsche, James Bellin Hospital
Dolohanty, Naomi Aurora Health Care
Dube, Troy Chippewa Valley Hospital
Eckels, Timothy Hospital Sisters Health System
Frangesch, Wayne Wheaton Franciscan Healthcare
Freimund, Rooney Bay Area Medical Center
Griffin, Gregory ElderSpan Management
Hartberg, David Gundersen Boscobel Area Hospital and Clinics
Hinner, William Ministry Saint Clare's Hospital
Houlahan, Beth
Hyland, Carol Agnesian HealthCare
Jacobson, Terry St. Mary's Hospital of Superior
Johnson, Kenneth St. Mary's Hospital Medical Center
Joyner, Ken Bay Area Medical Center
Kellar, Richard Aurora West Allis Medical Center
Krueger, Mary Ministry Saint Clare's Hospital
Larson, Margaret Mercy Medical Center
Lewis, Gordon Burnett Medical Center
Logemann, Cari Aspirus, Inc.
Mantei, Mary Jo Bay Area Medical Center
May, Carol Sauk Prairie Memorial Hospital
McCarthy, Bruce Columbia St. Mary's, Inc.
Mueller, Joan Mayo Health System - Franciscan Healthcare
Mugan, James Agnesian HealthCare
Mulder, Doris Beloit Health System
Nelson, James Fort HealthCare
Ouimet, Mary Wheaton Franciscan Healthcare - All Saints
Pollard, Dennis Froedtert & The Medical College
Quinn, George Wisconsin Hospital Association
Richards, Theresa Ministry Saint Joseph's Hospital
Richardson, Todd Aspirus, Inc.
Rickelman, Debbie WHA Information Center
Rocole, Theresa Wheaton Franciscan Healthcare
Rohrbach, Dan Southwest Health Center
Sczygelski, Sidney Aspirus Wausau Hospital
Selberg, Heidi HSHS-Eastern Wisconsin Division
Shabino, Charles Wisconsin Hospital Association
Simaras, James Wheaton Franciscan Healthcare
Smith, Gregory Wheaton Franciscan Healthcare
Sommers, Craig St. Mary's Hospital
Stuart, Philip Tomah Memorial Hospital
Swanson, Kerry St. Mary's Janesville Hospital
Thurmer, DeAnn Waupun Memorial Hospital
Van Meeteren, Bob Reedsburg Area Medical Center
VanCourt, Bernie Bay Area Medical Center
White, Pamela Mayo Health System - Eau Claire
Zenk, Ann Ministry Saint Mary's Hospital
Zorbini, John Aurora Health Care
Contributors ranging from $1,000 to $1,499
Bedwell, Elizabeth Children's Hospital of Wisconsin
Britton, Gregory Beloit Health System
Dexter, Donn Mayo Health System - Eau Claire
Gullingsrud, Tim Hayward Area Memorial Hospital and Nursing Home
Gutzeit, Michael Children's Hospital of Wisconsin
Hart, Shelly Aurora Health Care
Heifetz, Michael SSM Health Care-Wisconsin
Herzog, Sarah Wheaton Franciscan Healthcare
Huettl, Patricia Holy Family Memorial
Hymans, Daniel Memorial Medical Center - Ashland
Kerwin, George Bellin Hospital
Kosanovich, John Watertown Regional Medical Center
Lappin, Michael Aurora Health Care
Lewis, Jonathan St. Mary's Hospital
Martin, Jeff Ministry Saint Michael's Hospital
McKevett, Timothy Beloit Health System
Mohorek, Ronald Ministry Health Care
Natzke, Ryan Marshfield Clinic
Nauman, Michael Children's Hospital of Wisconsin
Nelson, Dave HSHS-Western Wisconsin Division
Rakowski, Mark Children's Hospital of Wisconsin
Reynolds, Sheila Children's Hospital of Wisconsin
Robertstad, John ProHealth Care - Oconomowoc Memorial Hospital
Roller, Rachel Aurora Health Care
Russell, John Columbus Community Hospital
Sanders, Robert Children's Hospital of Wisconsin
Schafer, Michael Spooner Health System
Sohn, Jonathan Wheaton Franciscan Healthcare
Spooner, Allan Columbia St. Mary's Milwaukee Hospital
Standridge, Debra Wheaton Franciscan Healthcare
Wolf, Edward Lakeview Medical Center
Worrick, Gerald Ministry Door County Medical Center
Contributors ranging from $1,500 to $1,999
Alig, Joanne Wisconsin Hospital Association
Anderson, Sandy St. Clare Hospital & Health Services
Bloch, Jodi Wisconsin Hospital Association
Boese, Jennifer Wisconsin Hospital Association
Byrne, Frank St. Mary's Hospital
Canter, Richard Wheaton Franciscan Healthcare
Clapp, Nicole Grant Regional Health Center
Coffman, Joan St. Joseph's Hospital
Court, Kelly Wisconsin Hospital Association
Eichman, Cynthia Ministry Our Lady of Victory Hospital
Francis, Jeff Ministry Health Care
Frank, Jennifer Wisconsin Hospital Association
Geboy, Scott Hall, Render, Killian, Heath & Lyman
Grasmick, Mary Kay Wisconsin Hospital Association
Harding, Edward Bay Area Medical Center
Heywood, Matthew Aspirus, Inc.
Hilt, Monica Ministry Saint Mary's Hospital
Khare, Smriti Children's Hospital of Wisconsin
Lepore, Michael Wheaton Franciscan Healthcare
Levin, Jeremy Rural Wisconsin Health Cooperative
Meyer, Daniel Aurora BayCare Medical Center in Green Bay
Millermaier, Edward Bellin Hospital
Olson, David Froedtert & The Medical College
Potter, Brian Wisconsin Hospital Association
Sanders, Michael Monroe Clinic
Sexton, William Prairie du Chien Memorial Hospital
Stanford, Matthew Wisconsin Hospital Association
Wallace, Michael Fort HealthCare
Warmuth, Judith Wisconsin Hospital Association
Contributors ranging from $2,000 to $2,999
Brenton, Mary E.
Desien, Nicholas Ministry Health Care
Duncan, Robert Children's Hospital of Wisconsin
Gage, Weldon Children's Hospital of Wisconsin
Herzog, Mark Holy Family Memorial
Jacobson, Catherine Froedtert & The Medical College
Kachelski, Joe Wisconsin Statewide Health Information Network
Katen-Bahensky, Donna
Kief, Brian Ministry Saint Joseph's Hospital
Leitch, Laura Wisconsin Hospital Association
Little, Steven Agnesian HealthCare
Mettner, Michelle Children's Hospital of Wisconsin
Neufelder, Daniel Ministry Health Care
Normington, Jeremy Moundview Memorial Hospital & Clinics
O'Brien, Kyle Wisconsin Hospital Association
Oliverio, John Wheaton Franciscan Healthcare
Pandl, Therese HSHS-Eastern Wisconsin Division
Potts, Dennis Aurora St. Luke's Medical Center
Starmann-Harrison, Mary Hospital Sisters Health System
Taylor, Mark Columbia St. Mary's, Inc.
Troy, Peggy Children's Hospital of Wisconsin
Woodward, James Meriter Hospital
Contributors ranging from $3,000 to $4,999
Borgerding, Eric Wisconsin Hospital Association
Kammer, Peter The Kammer Group
Turkal, Nick Aurora Health Care
Contributors $5,000 and above
Brenton, Stephen Wisconsin Hospital Association
Kerwin, George Bellin Health
Size, Tim Rural Wisconsin Health Cooperative
Tyre, Scott Capitol Navigators, Inc

 

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WHA Enrollment Action Council Reviews Health Insurance Exchange Status
Provider reports available from DHS on Medicaid recipients who may be disenrolled January 1

The WHA Enrollment Action Council (EAC) met recently to discuss the latest on the implementation of the federal health insurance exchange website. Co-chaired by Therese Pandl, president/CEO of HSHS in Eastern Wisconsin, and Mark Taylor, president/CEO of Columbia St. Mary’s, Inc., over the past few months the group has been meeting to share information about enrollment activities as well as to provide important feedback to state policymakers on a variety of enrollment issues.

The EAC discussed the status of the federal insurance exchange in Wisconsin, and how to help patients given that the exchange is essentially non-functional. The Obama Administration has indicated that the exchange should be functional by November 30—a message re-iterated by CMS Administrator Marilyn Tavenner and HHS Secretary Kathleen Sebelius in their separate testimonies before Congress this week.

In the meantime, hospitals, community health centers and other community organizations that have been gearing up to assist consumers are left without an efficient and effective way to help them enroll in coverage to date. Options such as applying for coverage and enrolling in a health plan over the phone or via a paper application still rely upon the exchange web tool to complete the enrollment process. Nevertheless, many see the paper application and phone options as a way to get the process started and to, at a minimum, help consumers determine if they are eligible for tax subsidies.

As discussed by EAC members, organizations have been helping consumers in a variety of ways, such as signing up for an e-mail address if they don’t have one; learning about the documentation they will need to apply for coverage; and understanding basic concepts of having health insurance such as paying monthly premiums and having copayments and deductibles. All of this information will be needed should the website become fully functional.

Moreover, for individuals who have income above the level for which they would qualify for a tax subsidy (400 percent of the federal poverty level, or about $94,200 for a family of four), private coverage outside of the exchange is available. Coverage in the individual market outside of the exchange must still meet the same rating requirements as coverage inside the exchange, and a policy cannot be denied due to a pre-existing condition.

The EAC has also discussed other questions raised by providers, such as whether provisions of the federal anti-kickback and tax-exemption laws affect the ability of hospitals and health systems to offer financial assistance to patients by paying health insurance premiums for consumers obtaining coverage through the health insurance exchange. (See related guest column in this issue.)

In other exchange news, the Obama Administration announced a new exemption from individual mandate penalty such that anyone who applies for coverage within the open enrollment period will not face a penalty for not having coverage for the first several months of the year. The duration of the initial open enrollment period through March 31, 2014, implies that individuals have until the end of the initial open enrollment period to enroll in coverage through the exchange while avoiding a penalty. However, without the new exemption announced by HHS, consumers who purchase insurance through the exchange toward the end of the initial open enrollment period could have incurred a penalty when filing their federal income tax returns in 2015.

The state’s Department of Health Services announced that providers can now begin requesting reports to help them assist patients who may be disenrolled from the Medicaid program beginning January 1, 2014. Providers are able to access a report through the Department’s secure web portal indicating the patients for whom the provider had a paid Medicaid claim in the past 14 months. For information on how to access the report, go to www.wha.org/outreachplans.aspx.

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WHA, Hospitals in DC to "Protect Hospital Care"
Urge legislators to protect high value states like Wisconsin, address SGR, fix RAC program

As budget conferees began meetings this week on funding government, over a dozen hospital and health system leaders joined the Wisconsin Hospital Association in Washington, DC to urge Wisconsin’s Congressional Delegation to stop continued payment cuts and to protect high value providers like those in Wisconsin.

"We are entering yet another fiscal crisis where long-term solutions will be scarce and short-term cuts to Medicare reimbursement will be on the menu," said WHA’s Eric Borgerding. "Congress has a short memory, forgetting the billions in cuts Wisconsin hospitals have taken over the past few years to fund quick fixes and temporary patches. It’s critical that our members stay engaged, and clearly they are."

Wisconsin is fortunate to have three individuals—Senators Johnson and Baldwin and House Budget Committee Chair Paul Ryan—on the budget conference committee. Attendees therefore took the opportunity to remind legislators that Wisconsin hospitals/systems are already seeing close to $4 billion in Medicare/Medicaid payment cuts from previously enacted laws even though it is nationally-recognized as one of the highest value health care states in the nation.

Attendees strongly reiterated that continued cuts to hospitals and providers have an impact on local jobs and economies, health care innovations, programs and services. Additionally, cuts disproportionately impact high value states like Wisconsin that have not operated under the "more is better" mentality, but have proactively focused on doing the right thing by providing value—cost efficiency and high quality.

Hospital leaders spoke out strongly against a proposal focused on "site neutral" payments. Under this proposal, payments to the hospital outpatient department would be set at the lower rate of a similar service when provided in the physician office or other care setting.

"The fact remains that Medicare payment systems for different care settings are fundamentally different, and ‘site neutral’ proposals do nothing to address those structural differences, nor do such proposals promote improved quality," said Jenny Boese, WHA vice president, external relations & member advocacy. "Rather, site neutral payments focus only on the end payment rate, which makes them payment ratcheting cloaked in another name."

Hospital and health system leaders expressed concerns that proposals like "site neutral" cuts could pop up again as Congress looks for ways to pay for fixing the physician reimbursement under Medicare, known as the sustainable growth rate (SGR). While hospitals strongly desire a long-term fix to the SGR, using hospital payments to pay for it is unacceptable.

Finally, leaders asked legislators to sign on to important legislation such as the "Medicare Audit Improvement Act," which seeks to improve the recovery audit contractor program (RAC). The RAC program continues to sap health care time and resources that could be more efficiently used to provide care. To date, Reps. Ribble, Duffy and Sensenbrenner have signed onto this legislation.

The group made sure to again express gratitude to Wisconsin’s Delegation for their strong and bipartisan commitment to protecting rural and critical access hospitals.

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Wisconsin Health Care Leaders Collaborate to Create New, Expand GME Opportunities

A record number of students applied to and enrolled in the nation’s medical schools in 2013, according to data released recently by the AAMC (Association of American Medical Colleges). The total number of applicants to medical schools grew by 6.1 percent to 48,014, surpassing the previous record set in 1996 by 1,049 students. First-time applicants, another important indicator of interest in medicine, increased by 5.8 percent to 35,727. The number of students enrolled in their first year of medical school exceeded 20,000 for the first time (20,055), a 2.8 percent increase over 2012.

"The increase in the number of medical students is good news. However, it is imperative that we build an infrastructure in Wisconsin that will facilitate the creation of more residency positions so we can attract new grads and retain our current physicians," according to Chuck Shabino, MD, WHA chief medical advisor.

Interest in graduate medical education (GME) programs is high in Wisconsin. More than 70 hospital and health system leaders and senior decision makers attended a one-day conference October 24 in Neenah sponsored by the Wisconsin Council on Medical Education and Workforce (WCMEW). The conference addressed a number of the key issues involved in starting and sustaining community-based GME opportunities.

Two health care organizations that presented at the conference—Monroe Clinic and Aurora Health Care—are actively engaged in GME, albeit on different scales. However, both found that GME can fit into a hospital’s strategic plan if one of the goals is to retain and attract physicians.

Andy Anderson, MD, senior vice president of academic affairs at Aurora Health Care, said Aurora looked at their current and future physician workforce needs during their strategic planning process. From there, they performed an objective review of their GME program to determine if it would support their future goals. Aurora trains about 150 residents and Fellows each year.

"The residency program has led to a broader conversation in the medical community, specifically among mentors, that their participation in the program has added a new dimension to their practice and reinforces the positive aspects of their professional life," according to Mark Thompson, MD, chief medical officer at Monroe Clinic.

Anderson appreciated WCMEW’s and WHA’s efforts to organize the conference and facilitate networking among those interested in GME.

"By openly acknowledging clinical competition, and thinking about our communities, our patients and our state, we can all come together and train our future workforce together in the right way," Anderson said. "We can all agree on what the physician of the future will look like."

Starting a GME Program
Ken Simons, MD, executive director of the Medical College of Wisconsin Affiliated Hospitals (MCWAH) and associate dean for GME and accreditation at MCW, laid out the fundamentals for what it takes to support GME. MCWAH is a consortium of 12 hospitals that supports their individual residency programs, which alleviates the administrative burden, including accreditation and resident employment issues. MCWAH is also responsible for curriculum.

Tom Grau, MD, program director for the La Crosse-Mayo family medicine residency program and director of medical education and research for Mayo Clinic in La Crosse, directed those who are looking into starting a new GME program to the Accreditation Council for Graduate Medical Education (ACGME). The ACGME is responsible for accrediting post-MD graduate programs in the U.S. Grau provided a detailed review of how to complete an accreditation application to ACGME. He said the ACGME.org website has a wealth of resources related to the application process and it outlines program requirements.

Expenses associated with a GME program can vary, but Kenneth Mount, senior associate dean for finance at UWSMPH reviewed the general categories that are common to most programs. Mount also identified major revenue sources, which included Medicare payments, grants and support from the sponsoring institution.

Infrastructure grants
With the strong support of Governor Scott Walker, the state is investing nearly $23 million into improving access to health care for Wisconsinites in rural and impoverished urban areas through medical training programs and rural medical residency grant incentives. The grants program is being administered through the Wisconsin Department of Health Services (DHS).

Public Health Administrator Karen McKeown, RN, MSN, from the Wisconsin Department of Health Services; Byron Crouse, MD, associate dean for rural and community health at UWSMPH; and George Quinn, WHA senior policy advisor, described the various GME funding sources.

Quinn provided background on the current funding sources and identified the need for additional, targeted funding as well as the need for new funding sources. Medicare is one of the primary funders, now, but the uncertainty of the federal budget environment must be factored in as a cause of concern in the future.

Crouse said the Wisconsin Rural Physician Residency Assistance Program (WRPRAP) provides financial support and technical assistance to residency programs, rural training tracks, rural rotations and rural education development activities. Crouse said WRPRAP will continue to promote rural GME in new and existing settings.

"If you have an idea that you’d like us to consider for funding, please just talk to us," Crouse said.

McKeown said the goal of the DHS GME grant program is to increase access to quality health care by increasing the number of physicians practicing in rural and underserved areas of Wisconsin. Grants are available to support planning and implementation of new collaborative multi-institution programs.

GME case studies and lessons learned
It makes sense to focus on creating new GME opportunities in rural areas since medical residents who train in rural settings are two to three times more likely to practice there, especially those who participate in rural training tracks, according to Kara Traxler, rural GME development and support manager at the Rural Wisconsin Health Cooperative (RWHC).

Traxler and RWHC Executive Director Tim Size indicated that the number of rural training tracks is on the upswing nationally. There are four types of clinical experiences that hospitals can establish: rural rotation site; rural fellowship program; integrated rural training tract residency program or a rural training track.

"Teaching makes you a better doctor. Exposure to med students and resident challenges one’s thinking," according to David Chestnut, MD, director of medical education at Gundersen Health System. "By participating in a residency or physician education program, you enhance the working environment for current physicians, which improves your retention and recruitment activities and it improves the quality of patient care. It is a nice alignment with our hospital’s strategic plan. "

Lee Vogel, MD, campus director of the Fox Valley Family Medicine Residency Program, said one long-standing aspect of their program that is unique is their community advisory board, comprised of health care professionals and community members.

"This Board has served us well when we are considering adding services directed at community need," Vogel said. "We discussed with the Board how residents can be integrated in the community, and they helped us establish an endowment to support the long-term success of the residency program.

Vogel said the community advisory board is also a great tool for advancing legislative strategies to gain support for GME, while building community awareness of its importance to the community.

Next Steps
At the close of the conference, attendees said they were pleased that a statewide meeting on GME had been convened, and indicated that they had learned a good deal both from the presentations and from interactions with others having a stake in GME. All agreed that there should be future conferences.

Suggestions for future meetings included having student and resident participation, providing lessons learned in involving the medical community, showing how using technology can overcome distance barriers, and continuing to focus on funding.

Quinn summarized the meeting by stating, "It was exciting to see the energy and expertise that was shared today. I am confident that we can leverage these resources to continue the positive momentum for GME in Wisconsin."

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Get Latest on Health Insurance Exchange at November 7 WHA Webinar

WHA hospital and corporate members can participate in a November 7 webinar focused on the most current information available on the health insurance exchange.

"A 30-Day Check-Up on the Health Insurance Exchange in Wisconsin" will be offered from 1-2 pm. WHA Senior Vice President of Policy and Research Joanne Alig will provide the most up-to-the-minute information available about the implementation of and access to the exchange in Wisconsin.

There is no cost to participate in this member-only forum, but pre-registration is required. Register online at http://events.SignUp4.com/13HCExchange1107. If you cannot participate in the live webinar, there is an option to request an audio recording.

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WHA Offers Dual Coding in Both ICD-9 and ICD-10 Webinar, November 8

The concept of dual coding, or coding the same patient health record in both ICD-9-CM and ICD-10-CM/PCS, should be considered as one of several steps to prepare for the ICD-10 transition. Dual coding has the ability to provide the information needed to reduce the financial impact of ICD-10.

On November 8, WHA is offering a webinar that will focus on what hospitals and physician practices should know when considering including dual coding as part of the ICD-10 transition plan. Topics will include:

Chief financial officers, ICD-10 transition team leaders and members, coding managers and others considering the inclusion of dual coding in their ICD-10 transition plan should attend. Full information and online registration is available at: http://events.SignUp4.com/13ICD10Coding1108. Encourage your team to gather on November 8 to learn more about the dual coding option.

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Prescribing Practices Reflect State’s High Quality Care in New Dartmouth Report

A new report from the Dartmouth Atlas Project proves Wisconsin physicians are prescribing the most effective medications for their patients, avoiding the use of potentially harmful medications, and are encouraging the use of generics. The report offers evidence that location continues to be a key determinant in the quality and cost of medical care that patients receive.

In their first look at prescription drug use, Dartmouth researchers found that the health status of a region’s Medicare population accounts for less than a third of the variation in total prescription drug use, and that higher spending is not related to higher use of proven drug therapies. The study raises questions about whether regional practice culture explains differences in the quality and quantity of prescription drug use.

The report found dramatic variation in patterns of care, which they said should be more uniform for non-controversial drug therapies that have strong evidence for their use. Wisconsin ranked well in nearly all the categories of care outlined in the report.

Here are a few Wisconsin-specific highlights:

"This report is an excellent example of why Wisconsin is a great place to receive health care. Providers are prescribing medications that are important for good outcomes and they are controlling costs by using generic substitutes and avoiding use of medications that have not been proven to be effective," said Kelly Court, WHA chief quality officer.

The report is available at: www.dartmouthatlas.org.

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Wisconsin’s High Quality, High Value Care Touted in National Magazine
"Site Selection" article hard copy is in WHA Packet this week

Wisconsin’s high-quality high-value health care message continues to "catch fire" with the media. And Wisconsin continues to amass data to support its health care ranking with the release of the latest Dartmouth report on prescription drug use among Medicare patients (see related article in this issue). Wisconsin’s national position as a state that continuously ranks among the best for health care caught the attention of Site Selection magazine, which featured an article submitted to the publication by WHA that ran in their Life Sciences Report, now available at www.siteselection.com/LifeSciences/2013/sep/healthcare.cfm?s=mp and included in this week’s packet.

According to the article: "Many states have yet to restructure their approach to health care, which typically takes at least five years to mature to the point where big improvements can be made. Wisconsin has been improving its health care programs for two decades, and has the results to prove it…These enviable rankings are a result of the many ways Wisconsin health systems have worked to increase quality and reduce cost. When patients have quick access to excellent care and are rapidly assessed, efficiently diagnosed, and well-managed, their care is less expensive, especially over time. They also miss less work because of illness or disability. This type of coordinated, streamlined care is also facilitated by highly integrated medical centers."

"WHA is committed to increasing awareness of and promoting our excellent health care system as an asset to economic development in every one of our communities," said WHA Executive Vice President Eric Borgerding. "Our hospitals and health systems are national leaders in innovation, quality and performance. It’s a good reason for a business to consider locating here, and we intend to spread the word."

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Wisconsin Improves Hospital Emergency Communications Capabilities

A hospital’s ability to communicate—whether internally or externally with other hospitals and health care partners—is essential, especially in the event of an emergency. Fortunately, Wisconsin hospitals have recently seen significant improvements in their communication abilities. These improvements have come in two specific areas: the statewide interoperability radio communication system—Wisconsin Interoperable System for Communications (WISCOM)—is close to full functionality. Second, the hospital and emergency response provider communications tool—Wisconsin Tracking Resources and Communication System (WI-Trac)—is transitioning to a new system that will host a broader scope of functions.

As part of WISCOM, high-frequency radios have been or are being installed at hospitals throughout the state. These radios allow emergency department personnel to communicate with other key emergency responders. WISCOM, which should be fully functional by February, will create efficiencies by having emergency response providers—hospitals as well as such partners as EMS and public health—on the same system. WISCOM’s usefulness is not limited to mass casualty situations. Earlier this month, Vernon Memorial Healthcare in Viroqua experienced a malfunction in their main EMS radio but was able to move its hospital-ambulance communications seamlessly over to its recently installed WISCOM radio.

WI-Trac is a tool that hospitals use to alert and communicate with each other and with their emergency response partners such as EMS and public health in emergency and non-emergency events alike. It is an Internet-based system, first implemented in the mid-2000s, accessed by hospitals across Wisconsin to report bed counts, issue alerts and request resources. Starting in December, WI-Trac will be operated on a new system, which will make possible broader capabilities, including patient tracking, hospital incident command center functionality, mass casualty incident tracking and alerting, and the ability to track health care coalition resources such as equipment, beds, personal protective equipment, medical surgical supplies, ventilators, dialysis centers, and long term care facilities. Training on the new system is currently being conducted across the state.

WISCOM and the new WI-Trac system are helping to strengthen Wisconsin hospitals communication. The Wisconsin Hospital Emergency Preparedness Program (WHEPP), a program administered by DHS in partnership with WHA and other stakeholders to support hospital emergency preparedness planning and response to mass casualty incidents and other emergencies, is responsible for these improvements in hospital communication capabilities. WISCOM and WI-Trac are illustrative of the value of WHEPP and the importance of state and federal investment in hospital preparedness.

If you have questions, contact Andrew Brenton at WHA at abrenton@wha.org, or Carolyn Strubel at DHS at carolyn.strubel@wisconsin.gov.

Article submitted by the Wisconsin Department of Health Services

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Wisconsin Hospitals Community Benefits – Charity Care

Fear of a bill should never prevent a patient from seeking care at a Wisconsin hospital. Wisconsin hospital charity care programs provided $232 million to more than 700 patients each day last year. The stories that follow illustrate the deep commitment and continuing concern that hospitals have to their patients to ensure they receive the care they need regardless of their ability to pay.


Community Care takes care of treatments for an optimistic, strong woman

It has been a long journey for Natalie Nelson. She has been battling Multiple Sclerosis for over 10 years. In 2010, she had to endure back surgery and treatment due to her condition, making her unable to work and with no income.

Natalie, age 51, was diagnosed with Multiple Sclerosis in 2000. But she did not let this misfortunate event bring her down and remained optimistic. She continued working as a teacher’s aide, helping to teach grade school students with disabilities.

Her own disabilities were taking a toll on her mind and body. She began having trouble walking, making her depend on a cane for stability. She also began to have trouble remembering short-term events like what she did the day before. These symptoms are only few compared to the many effects that Multiple Sclerosis has on the body.

Not only did she have to deal with her disability, Natalie also had to worry about how to pay for her back surgery and infusion therapies. She has to pay $666 a month along with a co-pay to receive any coverage from her private insurance. Unable to work, Natalie has no income to pay her insurance or her medical bills. On top of all of this she is going through a rigorous three-year process of applying for disability benefits from the state government. "I had no idea how I was going to pay for these bills," she expressed.

Sue, a financial counselor for Wheaton’s Community Care program, was there to comfort and help her through a time of need. Sue went above and beyond by even visiting Natalie after her treatments. "She treated me with the most respect and she was very kind," Natalie said.

Wheaton Franciscan Healthcare provided her back surgery at no cost to Natalie through Community Care, the System’s charity care program that assists patients with financial need. Wheaton also continues to pay for her infusion therapies.

Despite her hardships over the past 10 years, Natalie still remains kind hearted, optimistic, and strong. "I appreciate the abilities that I still have, not what I don’t have," Natalie humbly said. "Whatever doesn’t kill you makes you stronger."

Wheaton Franciscan Healthcare, Milwaukee


The anticipation of surgery adds to anxiety

Sam has been without a job or health insurance coverage for over a year. To make matters worse, he has serious health problems and his symptoms seem to be worsening. When he visited his physician, he was informed that he was in need of surgery for kidney and lower urinary calculus, which needed to be done the next day.

The financial counselor at Aurora St. Luke’s South Shore was asked to meet with Sam. He is a 43-year-old male, unemployed, uninsured and without financial resources as his unemployment checks had just ended. Sam was so nervous about the surgery and the cost that in his meeting with the counselor, he kept repeating, "I can’t afford this."

The counselor explained Aurora’s Helping Hand Patient Financial Assistance Program and instructed Sam to return with the documents that were needed for the application and approval, which he did. Without knowing the status of his application, Sam underwent surgery the next day. The procedure made it evident that he needed two additional procedures to have a full recovery. Sam called the counselor several times a week checking on the status of his application. Finally, she was able to share the great news with him that he was approved for 85 percent coverage. Sam was thrilled and thanked the counselor profusely for her help and for relieving him of the anxiety he was experiencing.

Aurora St. Luke’s South Shore, Milwaukee


Submit community benefit stories to Mary Kay Grasmick, editor, at mgrasmick@wha.org.

Read more about hospitals connecting with their communities at www.WiServePoint.org.

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