Amidst news of plummeting stock markets and intensifying concerns about the economy, Governor Jim Doyle delivered his much-anticipated State of the State address last Wednesday night, January 23.

The Governor minced no words and gave sobering warnings about tough times ahead if the economic downturn continues.

"Tonight, our nation finds itself at a time of great uncertainty," Doyle said as he opened his speech. "Because of the national economic slowdown, we too will face a very difficult fiscal situation … all signs show that America’s economy is slowing, and all of us will be affected in the weeks and months ahead."

A sharp drop in tax revenue collections in December means the state will not have as much money to spend as authorized in the budget legislation signed on October 20. In fact, the respected, non-partisan Legislative Fiscal Bureau warned this week that Wisconsin would face a deficit of between $300 and $400 million by the end of the current fiscal year on June 30.

"We will have to delay some things we all agree on," Doyle said in his speech. "We will have to make deep cuts and hard sacrifices."

The Governor did not elaborate on where those cuts will come from, and Administration officials appear to be waiting for more concrete revenue data before recommending specific plans.

"Medicaid is a big part of the state budget, so of course we are concerned," said WHA’s Eric Borgerding. "But cuts to Medicaid, including provider reimbursements, will be counterproductive, simply driving costs even higher as health care providers are forced to recoup those cuts through higher prices."

Proposes Insurance Reforms for Small Business

Small businesses (2-50 employees) perpetually struggle to provide health insurance for their employees, with only 44 percent in Wisconsin offering coverage. The slowing economy is exacerbating already high anxiety over health care costs, especially among small businesses.

Against this backdrop, the Governor also unveiled his new plan to make health insurance more affordable for small businesses. Calling it "BadgerChoice," the Governor wants to pool small businesses into one massive (up to 800,000 lives) buying group "to negotiate better rates from insurance companies … and access affordable health insurance without having to pay broker fees or navigate through substantial paperwork."

The most controversial component of Doyle’s plan would phase in "community rating" for small group health insurance. Community rating essentially eliminates underwriting criteria that is used to set individual or group insurance premiums. In essence, everyone pays the same, regardless of health status, wellness, lifestyle or claims history.

Opponents of community rating say it will end up increasing the cost of insurance for employers and individuals who have relatively low health care costs now by simply redistributing costs across the board. Proponents say it will minimize massive fluctuations in premiums and allow employers greater choices among health insurers.

The Governor would also provide $100 million to help subsidize insurance premiums for very small businesses (fewer than 10 employees). He did not elaborate on where the funding will come from, and Assembly Speaker Mike Huebsch was quick to criticize this aspect of Doyle’s plan.

"I don’t think government subsidies in any way reduce the costs of health care. They simply mask what the actual costs are and what’s driving those costs up," Huebsch told those attending a breakfast this week sponsored by WisPolitics.

No action expected this session

The Governor’s health care proposals will be fleshed out and modeled over the coming months under a grant funded by the Robert Wood Johnson Foundation. It is quite possible components of the plan could be introduced in the Governor’s 2009-2011 state budget that will be introduced next February.

"The Governor is continuing to take a targeted approach to health care reform," said WHA’s Eric Borgerding. "Rather than overhauling the entire system, he is focusing on specific populations and using government programs to do it. BadgerCare Plus, which was adopted with bipartisan support in the last budget, is focused at children and low income uninsured adults. BadgerChoice is intended to address insurance costs for small businesses. We are interested in seeing the details as they develop over the summer and fall, but in general support this targeted approach to health care reform – preserving and strengthening the employer-sponsored system while using government programs as the safety net to help vulnerable populations."

It’s an election year and health care is clearly on the minds of the American people. At the WHA Task Force on Access and Coverage meeting in Madison January 24, Wisconsin Manufacturers and Commerce Senior Vice President James Buchen shared the results of several focus groups held in three locations across the state. Not unexpectedly, health care was identified as a top tier political issue, and women and seniors are most likely to cast their ballots based on a candidate’s health care platform.

Buchen said the focus group participants described health care as "confusing and expensive." They also uniformly praised the quality of their health care and strong reservations about "government run" health care. They wanted health care to operate more like other markets where they purchase goods, which is difficult given that employers "shop" for health care, not the employees.

Participants defined universal health care to mean everybody can use it and everybody has an equal level of care. They made it clear, according to Buchen, that "one size fits all health care is not what they want."

Milwaukee Health Care Partnership

The Task Force also learned how one region of the state is tackling the issue of improving health care for underserved populations. The Milwaukee Health Care Partnership, led by Joy Tapper, is backed by five Milwaukee-area health systems. She told the group that it is modeled after programs in other communities across the country that were successful in putting together public and private funding for similar health initiatives aimed at meeting the medical needs of underserved populations.

In addition to the five health systems, members of the Partnership include four federally qualified health centers, Milwaukee County Department of Health, WHA and the Wisconsin Department of Health and Family Services. Tapper said the goals of the Partnership are to secure coverage for all, improve access, enhance care coordination, promote health and wellness among patients, and improve the cost-effectiveness of care.

Tapper said one of the critical success factors is having a clear mission focused on patient and community needs. She said working with the federally qualified health centers (FQHCs) is also important to the success of the Partnership. The FQHCs are important in that they are located in medically underserved areas, participate in the Medicaid program and offer a comprehensive range of services.

The plan is to expand access to specialty care, and to do that, Tapper said it is essential to secure adequate reimbursement, ensure adequate Medicaid HMO specialty panels, and to establish a coordinated community-wide process for specialty referrals and equitable distribution of underinsured and uninsured patients among providers.

Task Force members noted that the Milwaukee Health Care Partnership addresses several of the priorities set in the Association’s strategic plan, which includes improving coverage, access and the overall health of our communities.

Task Force Reviews Health Care Reform Principles

WHA President Steve Brenton said the WHA Board and staff have used the eight principles (www.wha.org/financeAndData/pdf/2006accessprinciples10-19.pdf) developed by the Task Force in late 2006 to evaluate reform proposals. Brenton walked the Task Force members through the principles, observing that while coverage in Wisconsin is good overall, the sustainability of that coverage is a long-term concern.

The group agreed that everyone has a role to play in health care reform. Task Force member David Fish noted that what is lacking are appropriately defined roles that would produce a complementary, sustainable long-term approach to reform.

WHA Information Center Vice President Joe Kachelski presented an overview of Healthy Wisconsin, the Senate Democrats’ health plan. That presentation was followed by a scan of the political landscape surrounding health reform by WHA Executive Vice President Eric Borgerding. Borgerding said the Senate Democrats are still working to tweak Healthy Wisconsin and will introduce a new version yet this session. Assembly Republicans are touting an alternative that would lean toward market-based reform while Governor Doyle pursues a course more down the middle. Borgerding provided analysis of the Assembly Republican’s and Governor’s Doyle’s health care proposals (see related story).

AHA Chair Bill Petasnick, also a member of the Task Force, summarized the work being done to build broad national consensus for Health for Life, the AHA initiative. AHA plans to disseminate Health for Life to a broad national audience. The goal is to spur a national discussion among the public, community, business and health care leaders and elected officials about the future of health and health care in America.

The WHA Task Force on Access and Coverage will reconvene in a couple of months to continue its work in positioning WHA to actively participate in and advance meaningful health care reform in Wisconsin.

The WHA Task Force on Access and Coverage, chaired by Leo Brideau, president/CEO, Columbia St. Mary’s, Milwaukee, is charged with assessing the current Wisconsin environment as it relates to potential initiatives that can improve access and coverage for vulnerable populations. The Task Force is examining proposed state and national initiatives and identifying specific proposals that should be supported consistent with WHA’s strategic plan and reform principles.

In late 2006, the Task Force developed a set of eight principles that will be used to define the fundamental expectations and outcomes WHA will strive to achieve. The principles provide the basis for which WHA will evaluate reform proposals as the Association actively engages in what is sure to be an intense debate. The principles are posted at www.wha.org/financeAndData/pdf/2006accessprinciples10-19.pdf. The WHA Board approved the principles in October, 2006.

"This Task Force provides a great opportunity for our members to begin wrestling with this hugely important topic," said Task Force Chair Leo Brideau. "We have had excellent dialogue among Task Force members, and what I sense to be a real commitment for WHA to continue playing an important and proactive role in supporting initiatives that will improve access and coverage for our vulnerable populations."

It’s a decision that Jennifer Weber, interim president of Calumet Medical Center in Chilton, called "baffling." The Centers for Medicare & Medicaid Services (CMS) does not allow critical access hospitals (CAHs) to participate in the new outpatient quality data-reporting program. Hospitals participating in Medicare’s outpatient prospective payment system (PPS) are required to submit data on seven outpatient quality measures to receive a full payment update in FY 2008. Five of those measures are related to heart attack transfers and two are related to surgical care.

CAHs qualify for cost-based reimbursement from Medicare and thus do not participate in the program’s PPS. But Weber pointed out "the value of doing the reporting is so that consumers can compare one facility to another. We collect that data internally, but making it publicly available would help CAHs make the case that just because we’re smaller doesn’t mean we don’t compare quality-wise to larger hospitals."

"I’m surprised that CMS would allow CAHs to report inpatient measures, but not outpatient measures," Weber said, noting that CAH outpatient volume is much higher than inpatient volume.

In a letter to CMS, the American Hospital Association (AHA) urged the agency to allow CAHs to submit and publicly report outpatient data along with other hospitals in 2008. "While there is no link between payment and the submission of quality data for critical access hospitals, they also would like the opportunity to submit data because of their commitment to public transparency and quality improvement," the AHA said in the letter.

"Wisconsin hospitals know that the value of public reporting goes far beyond meeting CMS payment requirements. Our CAHs have been reporting data to CheckPoint and Hospital Compare since their inception despite the lack of CMS financial incentive under their payment structure. It is difficult to understand why CMS would prohibit the CAHs, for which the outpatient measures are most relevant, from reporting this data on Hospital Compare." said Dana Richardson, vice president, quality, WHA.

Wisconsin hospitals were the first in the country to voluntarily begin publicly report quality and safety data in 2003 with the launch of CheckPoint (www.wicheckpoint.org). Now, nearly all hospitals in Wisconsin report data on CheckPoint, which now includes 49 measures related to the quality and safety of care that they provide to their communities.

(Story from AHA News, January 21, 2008, Matthew Malamud, reporter)

Lawmakers in Madison and in Washington D.C. are facing a variety of commonalities this year:  1) Relatively short legislative calendars (especially in Madison); 2) low expectations for getting much done; and 3) busy, rhetoric-choked campaign seasons that have already begun. It is this last reality that virtually guarantees that there will be a lot of smoke but very little fire over the next few months.

In Madison, there are but a handful of legislative days remaining on the 2008 session calendar. Governor Doyle’s State of the State initiatives are designed to focus on politically popular, big picture themes that set the stage for the November elections and for 2009, when a new state budget cycle presents the next real opportunity to advance an agenda. The fact is, divided government means that very little will pass the Wisconsin Legislature between now and adjournment date (March 13) unless it has overwhelming bipartisan support and/or absolutely has to get done to prevent state government from grinding to a halt. Regarding the latter scenario, some speculate that given the recent news about declining state revenues (see related story), the Legislature will need to meet in a special budget session. If that happens, it could certainly be contentious.

In Washington, D.C., the most significant health care issue that absolutely must get done is "fixing" the formula-driven Medicare physician payment cuts that were temporarily delayed by Congress late last year. While there is universal consensus that this is a "must do," there’s no consensus on how it will get done or how backfilling the cuts with necessary Medicare revenues will be paid for. The position of many in Congress is that higher payments must be balanced by reducing spending elsewhere within the Medicare program. The hospital market basket update is one potential revenue source, as is siphoning dollars from a special Medicare managed care program—an idea vigorously opposed by the Bush Administration.

The Medicare physician payment issue may provide a rare opportunity for a larger Medicare initiative that could address a host of issues (Medicare "pay for performance," regulatory limits on specialty hospitals, a one-year moratorium on RAC implementation, etc.) that will otherwise sit on the back burner until 2009. The fact that the physician payment issue has to move through Congress means that there will be a vehicle that can be loaded up with new spending, special projects and regulatory "fixes." However, Administration threats of vetoing higher spending are very real and served to dismantle a similar vehicle (the "must do" renewal of the S-CHIP program) that was moving through Congress in December.

While there may be an absence of new health care statutes this year, there will be no shortage of highly charged rhetoric, partisan finger pointing and political posturing in either the nation’s Capitol or in Madison this year. That’s because there is so much at stake in November, and health care is viewed as a top tier domestic issue that can actually sway voter sentiment.

Steve Brenton,
President

For two consecutive years, 100 percent of Wisconsin’s hospitals have collected and publicly reported community benefits information. In 2008, WHA will switch survey vendors and begin using Lyon Software’s online community benefits collection and survey software, known as the "Community Benefit Inventory for Social Accountability" software, or CBISA.

WHA will offer training courses to use this new system on February 26 in Wisconsin Dells and on February 27 in Wausau. The seminar is designed to train those who complete the annual WHA community benefit survey on the system. The CBISA Online software will streamline hospitals’ data collection and provide hospitals that now use the CBISA Online software a more efficient means to report data to WHA. If you do not currently use the Lyon CBISA Online Software to collect community benefits, it is highly recommended that you or someone from your hospital attend one of the two programs.

In addition, staff from WHA and from Lyon Software will be available to answer questions and concerns that member hospitals may have about processes related to gathering and reporting this data. While all hospitals completed the survey in 2006 and 2007, many continue to have questions about what can be counted, how to assign dollar values to non-material contributions, and how to integrate the WHA survey into the processes they may already have set up to collect this data. These items will be discussed at these sessions as well.

The sessions will be held from 9 a.m. - 4 p.m. on February 26 at the Kalahari Report in Wisconsin Dells and again on February 27 at The Plaza Hotel in Wausau. The registration fee is $50 per person. Any hospital employee involved in collecting benefit data or completing the WHA survey is strongly encouraged to attend.

The brochure is available at www.wha.org, where you can also register online. For information on program content, contact Mandy Ayers at mayers@wha.org, or call 608-274-1820. For registration information, contact Lisa Geishirt at lgeishirt@wha.org, or 608-274-1820.

Beginning February 1, WHA will distribute its new Education Insider, a monthly e-mail communication highlighting all of the education offerings lined up for the coming four to six weeks for WHA hospital member administrative and clinical staff. On the first of each month, the Education Insider will offer a quick glance at the upcoming on-site sessions, audio conferences and webinars offered by WHA, as well as the webinars and online courses available through its distance learning partner careLearning. Quickly and easily, from your desktop, you can access additional information and easy, online registration for all of WHA’s education offerings. Anyone can request to be added to, or removed from, the Education Insider’s monthly distribution list, simply by contact Lisa Geishirt at lgeishirt@wha.org.

For questions about this new member service, contact Jennifer Frank at jfrank@wha.org or 608-274-1820.

The new federal program where recovery audit contractors, known as RACs, look for overpayments and underpayments in Medicare is the focus of a March 18 webinar sponsored by WHA. The RAC program has been operational in three states as a demonstration and will roll out nationwide over the next year, likely coming to Wisconsin in January 2009. A representative of the Florida Hospital Association will share their experience as a demonstration state, discuss the key differences between the demonstration and permanent program, and discuss how to prepare your facility for the RAC audits during this one-hour program.

Under the program, RACs are able to review the last three years of provider claims for the following types of services: hospital inpatient and outpatient, skilled nursing facility, physician, ambulance and laboratory, as well as durable medical equipment. RACs are paid on a contingency fee basis, receiving a percentage of the improper overpayments and underpayments they collect from providers. They are authorized to perform "automated reviews" (no human review of claims data) and "complex reviews" (human review of claims data) to identify potential payment errors in such areas as duplicate payments, fiscal intermediaries’ mistakes, medical necessity and coding. During fiscal year 2006, the RACs collected $69 million in overpayments and found $3 million in underpayments.

"The experiences of the three demonstration states reveal the importance of the hospital association in educating members on this issue," said WHA President Steve Brenton. "This webinar presented by faculty who experienced it first-hand in Florida is one of the many means WHA will use to make certain our members are well informed as this comes to Wisconsin," he added.

"Preparing for the Recovery Audit Contractor (RAC) Program: An Overview - What Every Hospital Needs to Know" is scheduled from 12 - 1 p.m. March 18, and for one fee, you can educate several hospital staff on this important topic.

The Board of Nursing (BON) spent considerable time on three issues related to advanced nurse practice at their January 24 meeting. The Department of Health and Family Services (DHFS) discussed the collaborative relationship between advanced practice nurse prescribers (APNPs) and physicians. NUR 8, the administrative rule regulating APNPs indicates only that this relationship be documented. Surveyors from DHFS have asked for specific documents, and facilities have objected to this request. The BON declined to describe what specific documents, formats or meetings are necessary for a collaborative relationship, indicating that each APNP/physician must determine what is effective for their practice. The Board reaffirmed that facilities and their practitioners can establish policy relating to this documentation and must be able to demonstrate how the relationship is ‘documented’ on the survey.

DHFS also asked the Board if psychotherapy is within the scope of practice for advanced practice registered nurses. DHFS is revising the administrative rule (HFS 35) and plans to eliminate the current process that provides approval for some providers (including RNs) to offer psychotherapy without a specific license or credential to do so. DHFS did indicate that they understood that this action could result in decreased access to mental health care in Wisconsin.

The third advanced practice issue related to school nurses and their role in supervising and administering medications and treatments to children with complex care needs in the school environment. The Department of Public Instruction has asked that the BON assist them with policy in this area.

Medical Examining Board

Legislative issues, including licensure of dietitians, highlighted the January 23, 2008 meeting of the Medical Examining Board (MEB). SB 394 creates licensure for dietitians in Wisconsin, sets educational requirements for licensure, sets a requirement for continuing education for re-licensure and defines a scope of practice. A representative from the dietitians described the bill to the MEB as necessary to protect the public from individuals calling themselves dietitians without adequate educational preparation.

Member hospitals have told WHA that the length of time it takes the Department of Regulation and Licensing (DRL) to respond to questions, issue licenses and investigate complaints is unacceptable. Currently, new nurse licenses are taking many weeks to process, which is causing delays in hiring and orienting newly graduated nurses. Members have ongoing concerns about the time it takes to license physicians new to the state. Dietitians are one of four groups seeking licensure this session, creating even more concern about turn-around times. The WHA Workforce Council will address this issue at their next meeting.

The MEB also discussed prescribing by first-year residents. The Board requested that staff evaluate the vendors and specific tests used to monitor physicians in the impaired professionals program with the aim of achieving more accurate results that are cost effective.

As a Certified Occupational Therapist, Cory Frederick often works with patients that don’t have the means to purchase medical equipment when they need it. Many times patients don’t see the need coming and don’t have time to prepare for circumstances where they need the assistance of medical equipment.

This is why St. Joseph’s Auxiliary and St. Joseph’s Rehab Department have teamed up to sponsor the "Loan Closet Program." The program was established in 2000 with the purpose of providing low cost and/or free reconditioned durable used medical equipment to people in St. Joseph’s Community Health Services’ market area.

St. Joseph’s Auxiliary provides limited funds to allow the purchase of used durable medical equipment on garage sales, auctions, etc. and to repair the equipment. Many items are simply donated to the Loan Closet from previous patients or families that no longer need them. All donated equipment is cleaned and repaired as needed by St. Joseph’s Rehab Department before it is issued to a new patient. The Masonic Lodge of Hillsboro graciously provides storage of all equipment for the Loan Closet Program.

St. Joseph’s Rehab Department offers the Loan Closet service as a benefit to our community. The need was there and they found a way to fill the need. The Loan Closet Program benefits those who can’t afford to purchase durable medical equipment on their own.

As a sample of the different types of medical equipment that are used, during a three month period, the following items were issued: two manual hospital beds, one tub seat, two commodes, one bed transfer handle, one wheelchair, and two roller walkers. Free will donations are accepted from patients whom receive the medical equipment from the Loan Closet.

The Loan Closet accepts any new or used durable medical equipment as well as cash donations to purchase minor parts to repair the used equipment as needed. For more information or to make a donation to the Loan Closet, please contact Cory Frederick, Occupational Therapist - St. Joseph’s Rehab Services Department by calling 608-489-8260.

Jason Mayer and his seven friends did everything right. They arranged a driver to chauffer them around for Travis Schisel’s bachelor party. However, despite their preparations, on their way home to the Manitowoc area from Appleton, their vehicle collided with a van driven by a drunken driver. All nine people were injured; four, including Mayer and Schisel, were taken to Theda Clark Medical Center.

Six months later, Jason still suffers from a bruised spinal cord and severe nerve damage. He walks with crutches and requires assistance for nearly every daily function, including getting out of bed.

"I used to be able to do anything," said Jason, 28, an accountant from Whitelaw. "But now I cannot. It’s hard – I will not lie. I get frustrated and angry. But, I realize it doesn’t help to do that, and I try to work through it all the best I can."

Jason shared his story at the third annual P.A.R.T.Y. at the P.A.C., April 19 and 20 at the Fox Cities Performing Arts Center in Appleton. Prevent Alcohol and Risk-Related Trauma in Youth, or P.A.R.T.Y., is a reality education program for students, allowing them to see and hear firsthand what can happen as a result of making poor choices. To date, the program, which is offered by the Trauma Center at Theda Clark and funded by the Theda Clark Medical Center Foundation, has been presented to more than 10,000 young people in Neenah, Menasha and surrounding communities.

On April 19 and 20, both the Theda Clark Medical Center and Appleton Medical Center Foundations sponsored a "super-sized" version of the P.A.R.T.Y. program at the Fox Cities P.A.C. Approximately 4,400 ninth-grade students from 22 area public and parochial schools attended one of the half-day events. High schools planning to attend include the Appleton Area School District, Brillion, Freedom, Hilbert, Kaukauna, Menasha, New London, Stockbridge, Valley New School, Wild Rose, Fox Valley Lutheran, Kimberly, Little Chute, Valley Christian High School, Hortonville, St. Mary’s High School, New Holstein, Ripon, Valders, Winneconne, Waupaca, and Shiocton. Nearly 6,000 students have attended P.A.R.T.Y. at the P.A.C. since 2005, when it began.

"All too often area motor vehicle crashes involving teens are a result of teenagers making poor decisions and engaging in risky behavior," said Krystal Schneider, RN, coordinator of the P.A.R.T.Y. program. "If our efforts can prevent just one student from making a bad decision that results in a traumatic injury, we have done our job."

P.A.R.T.Y. at the P.A.C will deliver a powerful message about the perils of risk-taking behavior, the consequences, and the importance of personal responsibility – while empowering young people to make informed, safe choices. The program includes a high-energy opening, a student skit, by the Kaukauna PRIDE group, presentations from trauma and neurosurgeons, and the personal stories from trauma and spinal cord injury survivors.

Jason Mayer wants the ninth graders to know that decisions they make can impact their lives or the lives of others. "They will be getting their drivers licenses soon and being influenced to drink alcohol," he said. "They need to know they will be accountable for their actions because their actions could affect someone else, like me and my friends."

Travis and his fiancé, Tiana Boetcher, finally married March 17, the seventh anniversary of the day they met. Everyone in the wedding party was still involved in the ceremony.

The greatest incidence of trauma injury and death occurs in the 15 to 24 year age groups. P.A.R.T.Y. was developed in 1986 in Canada to educate teens to the perils of risk-taking behavior and the tragic consequences that can occur, such as drinking and driving, noncompliance to seat belt legislation, and dangerous behaviors, like diving into shallow water.

The Trauma Center at Theda Clark began the first P.A.R.T.Y. program in the United States in September 1998.