January 22, 2010
Volume 54, Issue 3
WHA HIT Task Force Alarmed by New Federal EHR Rules
WHA’s Health Information Technology (HIT) and State-Level Health Information Exchange Task Force met January 21 for the first time and expressed deep concern about the newly-proposed requirements hospitals must meet to receive electronic health record (EHR) implementation incentive payments—and avoid penalties—created under the 2009 ARRA stimulus act. The Task Force is made up of Wisconsin hospital CEOs, CIOs, physicians, quality improvement experts, attorneys and others.
Task Force members repeatedly expressed frustration that the incentive payments will provide little incentive to modify hospitals’ existing EHR implementation strategies given the overly ambitious timeline and the excessive number of and complexity of requirements proposed by CMS as conditions on receiving the payments.
"Task Force members said that these flawed rules are dramatically decreasing the interest in the HIT incentives and are defeating the intent of rapidly moving forward," according to Task Force Chair Sandy Anderson, CEO, St. Clare Hospital in Baraboo.
"It appears that CMS is not expecting to pay much incentive to hospitals," said Rod Dykehouse, CIO, ProHealth Care in Waukesha. "Rather, penalties in 2015 seem to be CMS’s way to ‘encourage’ hospitals to implement its vision of a robust EHR."
Steve Nockerts, CEO, The Richland Hospital in Richland Center, echoed that assessment. "The incentive payments will not influence our EHR strategies because we want to set this up to succeed."
The ability of rural hospitals to meet the meaningful use requirements and their exclusion from the PPS hospital incentive payment methodology was also concerning to the Task Force. Differing eligibility and payment methodologies for CAHs vs. PPS hospitals as well as high economies of scale for some of the EHR requirements, such as CPOE, will pose significant additional challenges for CAHs to avoid 2015 EHR-related Medicare payment penalties.
Task Force members also expressed significant concern about the certification scheme proposed by the Office of the National Coordinator (ONC) and the ability of vendors to provide the needed services within the CMS timeline.
"The certification rule wiped everything clean, and we are all at risk at this point," said Dykehouse. Under the certification rule, all EHR products currently certified by the Certification Commission for Healthcare Information Technology (CCHIT) would have to be recertified under the new certification rule.
In addition to the newly proposed EHR implementation rules, the Task Force also began to identify HIT-policy priorities for 2010. Regulatory and legislative advocacy on the federal EHR implementation rules and on the developing state-level WIRED for Health Project were discussed, as well as possible member education activities related to new HIT policy.
The next meeting of the Task Force is scheduled March 3. A link to the meaningful use proposed rule can be found here: http://edocket.access.gpo.gov/2010/pdf/E9-31217.pdf. A link to the EHR certification interim final rule can be found athttp://edocket.access.gpo.gov/2010/pdf/E9-31216.pdf.
The Task Force considered multiple issues related to the newly-proposed incentive payment rules including:
For more information, a copy of the Task Force meeting PowerPoint presentation can be found at www.wha.org/healthIT/HITtaskForce1-21-10.pdf.
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Governor Jim Doyle announced a new health care program for low-income adults without dependent children during a January 21 morning press conference in Madison. According to the Governor, the new program, the BadgerCare Plus Basic Plan, offers limited benefits and is designed for people who are on the waiting list for the BadgerCare Plus Core Plan.
The waiting list for the Core Plan is the result of overwhelming interest in that program; 63,000 people are enrolled in the Core Plan causing the Department of Health Services to suspend enrollment in order to comply with federal "budget neutrality" requirements. The Basic Plan will allow persons on the waiting list for the Core Plan to have access to a minimal form of coverage until space becomes available in the Core Plan. The waiting list currently is more than 20,000 people with thousands of applications pending review. An average of 1,500 application requests have been received each week since the waitlist began on October 9, 2009.
In general, a person is eligible for the Basic Plan if he or she: is a Wisconsin resident; is age 19-64; has no dependent minor children under age 19; has self-reported income at or below 200 percent of the federal poverty level; is not eligible for another public health program; does not have access to health insurance through a current employer; and has not been covered by a health insurance policy in the previous 12 months unless there is a good cause reason for losing coverage. Participants will continue to stay on the program as long as they pay the monthly premium of approximately $130 per month and stay on the waitlist. Participants in the Basic Plan would have access to limited benefits including:
The Basic Plan will not cover a number of services that state law requires commercial insurance to cover, including mental health, chiropractic services, home health services, and nursing home services.
While announcing his proposal, the Governor observed, "Uninsured costs are passed on to all of us. The Core Plan is a bridge to employment; the Basic Plan is a bridge to the Core Plan. It isn’t as rich as an employer-based plan, but it will ensure that people can see a physician, get their medications, and meet their needs in an emergency."
Senator Jon Erpenbach and Representative Jon Richards, the chairs of the Senate and Assembly health committees, plan to hold a joint public hearing on the plan and move it through the Legislature as soon as possible. "Private insurance finds a way to say no. Government finds a way to say yes," said Erpenbach.
Richards noted, "A lot of people are signing up at technical colleges, which would indicate that they are looking for a bridge to health care during a transitional time in their life."
But the plan is not without its detractors. State Representative John Nygren (R-Marinette), ranking Republican on the Assembly Insurance Committee, was highly critical of the Basic Plan, including its estimated $130 per month premium, scaled down benefits package and Medicaid reimbursement rates.
"There are private plans already in existence that cost as low as $104 per month with comparable or stronger coverage than that which was laid out by Governor Doyle," Nygren said in a written statement. "Additionally, without government mandates and regulations, private plans could be offered at lower rates…The Governor’s Basic Plan can unfairly function outside of state mandates and regulations placed on private insurers. As well, government reimburses pennies on the dollar for care shifting cost to hospitals and patients."
WHA officials expressed support for the state’s efforts to extend coverage to the uninsured, but are cautious about the Basic Plan while awaiting more details.
"Through the hospital assessment, Wisconsin’s PPS (non Critical Access) hospitals have provided roughly $300 million for the state’s Medicaid program, including the funding necessary to expand BadgerCare Core statewide," said WHA President Steve Brenton. "We applaud the efforts of lawmakers, the Governor and our members to make affordable coverage available. But BadgerCare Basic is something quite different—it’s not a Medicaid waiver program, rather state-run insurance operating under a different set of rules, and rules that could change. The details of the enabling legislation will be very important and given the worsening situation with the Medicaid budget, we should make sure that all options for affordable coverage are explored."
To see the Governor’s announcement and the Department of Health Services’ BadgerCare Plus Basic Plan Concept Paper, go to this link:www.wha.org/badgerconcept1-20-2010.pdf.
New WHA Task Force Reviews Statewide Emergency Code Standardization
Emergency code systems are used in all hospitals to alert staff of existing crisis situations, like a fire in the facility or potential danger—for example, a tornado in the area. For the most part, hospitals have devised their own emergency code systems over time resulting in a lack of standardization across hospitals in Wisconsin. There have been numerous cases documented across the country stating that patient safety is at risk without the standardization of emergency codes. Following on the success of a WHA-led initiative that standardized color-coded patient alerts statewide, WHA has initiated a new project team to consider whether emergency codes should or can be standardized statewide.
The Task Force met in Madison January 18 and determined the scope of the project is as follows:
"Our project goal is to reduce the risk of harm to patients, staff and visitors due to incorrect interpretation of emergency alert codes. Unfortunately, there is no national standard for emergency codes, but many states have implemented or are in the process of implementing a statewide standard," according to Dana Richardson, WHA vice president of quality initiatives. "We want to ensure that we review the emergency codes now in use in Wisconsin hospitals and understand what is occurring in our border states."
The Task Force discussed known variation in Wisconsin hospitals, as well as the option to move to "plain language" (example, hazardous spill and its location) to describe an emergency instead of a "secret code" (Code Orange) known only to hospital employees. The advantages of plain language are that it is less confusing to staff and visitors, the disadvantage is it may cause concern or alarm for patients and their families.
"We know that physicians and hospital staff often work in more than one hospital," said Charles Shabino, MD, WHA senior medical advisor. "If a recommendation is made to standardize emergency codes, it will be essential that all Wisconsin hospitals adopt the voluntary standard."
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This week the State Senate passed Senate Bill (SB) 203 relating to claims for loss of society and companionship in medical malpractice cases. The bill, introduced by Senator Jeff Plale (D-South Milwaukee), provides a parent the right to recover for loss of society and companionship if the parent’s adult child is injured as the result of medical malpractice. The bill also provides the same right to an adult child if the adult child’s parent is injured as a result of medical malpractice.
In a memo to legislators, WHA reminded lawmakers that Wisconsin’s current medical liability system is unique. It is the only such system in the nation that guarantees injured patients are compensated for 100 percent of their economic damages, but necessarily places certain limitations on who can recover when someone else is a patient injured by medical malpractice.
"As Wisconsin strives to maintain an accessible health care system, the very professionals we rely on to provide high quality health care cannot be driven out of business, out of state, or into retirement because of an unstable, prohibitively expensive, or simply unavailable medical malpractice insurance market.
Increasing the number of medical malpractice claims would jeopardize the system," explained Paul Merline, WHA vice president of government relations.
Even without the provisions of SB 203, Wisconsin’s balanced medical liability system faces financial challenges. Last session, $200 million was transferred from the Injured Patients and Families Compensation Fund (IPFCF) to cover state budget shortfalls. Due in large part to this transfer, the IPFCF is now in deficit, which prompted a recent 9.9 percent increase in the assessments charged to providers. Additional increases are likely.
SB 203 now awaits action in the Assembly where a companion bill, AB 291 authored by Rep. Jon Richards (D-Milwaukee), has passed out of committee. Identical versions of the bill need to pass both houses before they can be forwarded on to Governor Doyle for his consideration. WHA is part of a coalition that is opposing the bills.
Also advancing in the Senate was SB 308 authored by Sen. Kathleen Vinehout (D-Alma) that would permit employees who are volunteer emergency responders to be late or absent from work if that lateness or absence is due to responding to an emergency.
Responding to concerns raised by WHA about the possible unintended consequences of unpredictable and unexpected staffing emergencies that could result, Sen. Vinehout offered an amendment that the bill not apply to employees who provide direct patient care in emergency rooms and intensive care units. The amendment, which also was approved, ensures that staff scheduled to be on duty will be there to provide emergency and intensive care services to patients.
An Assembly companion bill, AB 464 authored by Rep. Scott Gunderson (R-Waterford), has passed out of committee with the same amendment, offered by Rep. Andy Jorgensen (D-Fort Atkinson).
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The last time the Commonwealth of Massachusetts elected a Republican to the U.S. Senate was 1972—that was 38 years ago. Now, just 14 months after that state gave Obama a 26 point plurality, one of the most lopsided in the nation, it VOTED Tuesday (January 19) to send Republican Scott Brown to Washington D.C. to fill the late Ted Kennedy’s vacant seat. And voter concerns about the way DEMS are handling the health care issue was a top tier reason behind this eye popping vote. Ted Kennedy....health care...Massachusetts. The ironies abound.
Perhaps another irony is the fact that Massachusetts already has a health reform plan in place (supported by Scott Brown as a State Senator) that looks a lot like the plan the DEMS are trying to cobble together in D.C. Its key ingredients include an expanded Medicaid program, an individual mandate with subsidies for low income workers, insurance reform and a state level insurance exchange called The Commonwealth Connection.
So what’s next? On the one hand, Speaker Pelosi and Majority Leader Reid say that the Massachusetts vote won’t stand in her way to get something done and "it will happen soon." That also seems to be the position of the Administration. On the other hand, moderate Democrats as well as conservative ‘Blue Dogs’ are beginning to say..."not so fast." Virginia Democrat Jim Webb is calling on Reid to "suspend further votes on health care" until Senator Brown is seated. Once seated, the DEMS no longer have the 60 votes needed to thwart a filibuster on the next health care vote.
Perhaps the most recent dynamic souring voters on the debate in D.C. was the flurry of special deals that were needed to garner votes to pass legislation in the Senate. The Louisiana Purchase, The Cornhusker Kickback and the (SE FL) Gator Aid poisoned many. As one pundit noted, "If this bill is so terrific, than why are some Senators signing on only after their states are exempted from its’ provisions?" The recent exemption of labor union negotiated health benefits from the "Cadillac Tax" on expensive health insurance premiums was seen as a cynical and crass ploy to pay back a key constituency. And the fact that union bosses chortled about their special deal pretty much confirmed the obvious. In his comments following the Tuesday election, Senator Webb noted that the vote had become a referendum "on the openness and integrity of our government process." Ouch!
So is it back to the drawing board or will Pelosi and Reid jump off the cliff? We will soon find out. Important and potentially consensus-oriented building blocks are in place to still do something significant in 2010. And additional ideas like meaningful tort reform, interstate insurance deregulation and real payment and insurance reforms could attract moderate Republicans that want to support a bipartisan health reform bill. Perhaps this week’s wakeup call can make that happen.
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Alice B. knows the true value of support from her friends—and her local hospital. A year ago, Alice found herself in a situation she could never imagine. She was having major health issues and her friends were urging her to move back to Lancaster and away from an abusive relationship. She feels it was the stress of her relationship with her boyfriend that caused her health to deteriorate. Her biggest fear was the thought of being homeless, so she continued to stay in the relationship. She remembers the day everything changed—she was in a great deal of pain in her stomach and lower back and she just couldn’t take it anymore. Her friends from two hours away in Lancaster drove to get her and helped her pick up and move back with them. She knew she needed emergency care, so she was taken to Grant Regional’s ER for treatment.
Her pain turned out to be a condition diagnosed as ulcerative colitis, a disease of the intestine, that includes characteristic ulcers, or open sores, in the colon. Since she was staying with friends, no job or health insurance—she had no source to pay her hospital bill. Worried about her condition and her lack of ability to pay for the services she so desperately needed, she explained her situation to the hospital staff.
Alice was relieved to find out that she was eligible for assistance through Grant Regional’s Community Responsibility Program which wrote off her entire ER bill, totaling close to $3,000. Since that time, she has also been diagnosed with fibromyalgia and required some additional testing and treatment. The charges resulting from recent hospital visits totaled close to $2,000 and were also written off, thanks to Grant Regional’s Community Responsibility Program.
Alice feels that this experience marks a new beginning for her. Even now dealing with fibromyalgia and continuing to learn about living with colitis, she knows she is taking better care of herself and is on the right track to improve her overall health and wellbeing. She can’t thank Grant Regional Health Center enough for the wonderful care they provided her—when she needed it the most. Her health conditions prevent her from working full-time, but she is determined to work as much she can and avoid disability. She is now working four hours a day at a local grocery store bakery and is glad to be back in a community where she received such great support from friends and her local hospital.
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The patient was 44 years old, single, with Guillian-Barre Syndrome which forced him to move back home and live with his mother, because he had no insurance and was unable to work for an indefinite period of time due to his illness. He was admitted to Holy Family Memorial and was an inpatient for five days, and then transferred to St. Vincent Hospital for a month. From there he was admitted into Holy Family Memorial Homecare for another month and then to physical therapy for three months. The patient received well over $30,000 in Community Care Assistance for treatment of his illness from onset until he became eligible for medical assistance, which only covered his physical therapy. He remains disabled today.
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