The H1N1 pandemic tested Wisconsin’s ability to respond to a public health threat at both the state and local levels. Hospital preparedness plans were put into action as health care providers cared for the ill and coordinated closely with state and local health departments to immunize patients and the health care workforce.

On January 22, WHA invited representatives from several Wisconsin health systems, clinics, the Wisconsin Hospital Emergency Preparedness Program (WHEPP), and the State Health Department to review the effectiveness of the statewide response and determine what improvements should occur in the future.

Some of the issues discussed, but not resolved, included the distribution of H1N1 vaccine. Private providers were consistent in how they handled the limited supply of vaccine. They cooperated with the State Health Department to move vaccine where it was needed most. However, the state’s distribution process lacked transparency as public immunization clinics were scheduled before those on the target list—including health care workers—had been immunized. More transparency is needed in the vaccine distribution. How much is there and where is it going? Some counties met their priorities much faster than others. The group felt it is important that once vaccine priorities are set, all counties and all providers adhere to those priorities.

Another concern was the lack of an established relationship between local and state public health departments. It varies from county to county, with providers often caught in the middle because their service territories include multiple municipalities and counties with different interpretations of state health department guidance and priorities.

The group said the WHA regional meetings held last fall served an important role by helping to organize the local and state response, and they provided a forum for delivering consistent, accurate messages early in the process. The regional meetings sent a strong message that WHA and DHS were working together to ensure that providers received the resources they needed to care for their patients and ensure the safety of their workforce.

Going forward, Wisconsin’s State Health Director Seth Foldy, MD, said he is very interested in building on the positive and addressing the concerns raised by providers. He noted that while issues arose, overall Wisconsin saw a high level of cooperation among all those involved in the H1N1 response.

The full minutes from the debriefing session outlining strengths and weaknesses of the H1N1 response are available here. The January 22 session was the first of several forums that will be held to review the response of public health and health care to the H1N1 outbreak. WHA will continue to gather input from providers and work closely with Dr. Foldy and Dennis Tomczyk, director of the WHEPP, to address concerns and foster communication among all organizations. (See related story below.)

If federal health care reform hadn’t had a bumpy enough ride already, last week’s election in Massachusetts sent the legislation straight off the rails. The election removed Senate Democrats’ coveted 60 vote supermajority—the supermajority essential for stopping a Republican filibuster—and left health care reform teetering after eight months of arduous negotiations.

Not even Senate Democratic Majority Leader Harry Reid or House Speaker Nancy Pelosi could figure out how to keep the legislation moving after the unexpected Massachusetts loss, prompting Reid to say there is "no rush" to get health care reform done and Speaker Pelosi to admit she "does not see the votes" at this time. Even President Obama didn’t mention health care reform until 30 minutes into his first State of the Union address—a statement in itself of the political and policy troubles that have accompanied health care reform from the beginning.

In the coming days, watch Congressional Democrats take a step back, strategize all possible options and continue to float various trial balloons, like Pelosi’s most recent "two track" approach of passing easy reforms now and comprehensive ones later. Only time will tell if any of these balloons will fly.

The backdrop for the health care reform story is that important hospital-supported issues now also remain in limbo. Those include WHA-supported provisions that bring value (high-quality, cost efficient care) into the Medicare reimbursement system, an extension of the temporary FMAP increases for Medicaid payments, and a fix to physician payments among others. WHA will continue to advocate for inclusion of these provisions in other appropriate legislative vehicles.

WHA will also closely monitor President Obama’s impending 2011 budget release, which is expected next month. Of particular concern is the potential for provider cuts to be included as a means for deficit reduction. Stay tuned…

This past week the American Hospital Association (AHA) sent all hospital and health system leaders in the nation, regardless of AHA membership, a survey on health information technology (HIT) and a proposed rule on "meaningful use." The meaningful use rule was recently released by the Centers for Medicare & Medicaid Services (CMS) and will be used as the criteria by which CMS awards HIT incentive payments to hospitals and eligible professionals.

The survey—Electronic Health Records (EHR) Survey—is designed to gather information from the hospital field for comment letters AHA will be submitting to CMS. WHA and its HIT Task Force will also use Wisconsin-specific survey results from the AHA survey to formulate its own comment letter to CMS on the proposed rule. Therefore, WHA urges all members to respond to the AHA survey by February 4.

The survey will provide information to demonstrate the potential implications that the proposed regulations would have in implementing the electronic health record incentive programs under the American Recovery and Reinvestment Act. This information will be used to build the case for changes in the definition of "meaningful use" to ensure that hospitals receive EHR incentive payments and avoid proposed financial penalties that would begin in 2015.

Hospital and health systems leaders received instructions on January 21 to complete the survey online. If you misplaced your original email from AHA, please contact AHA Member Relations at (800) 424-4301 for your registration information.

Contact WHA’s Matthew Stanford (mstanford@wha.org) or Jenny Boese (jboese@wha.org) if you have any questions or problems.

Rural hospital leaders continued to meet with legislators to voice their concern that the CAH Medicaid reimbursement cut effective January 1 will negatively impact access to some critical medical services now offered in their communities. This week, hospital leaders in western Wisconsin held a meeting at Vernon Memorial Hospital, Viroqua, with their legislators to discuss the impact of the state’s 2009-2011 budget provision that calls for the Wisconsin Department of Health Services to cut Medicaid payments to CAHs by $18 million, or 10 percent across the board. The group also discussed possible options to the 10 percent cut, including creation of a new assessment for CAHs modeled after the program now in place for PPS hospitals.

"The proposed Medicaid payment cuts will mean a $450,000 loss in real dollar reimbursement to Vernon Memorial Healthcare," according to Garith Steiner, CEO. Steiner said, "While Vernon Memorial will continue to provide the services we have always provided to our patients, these potential cuts will definitely have a negative impact on many of the community benefit dollars we have typically been able to provide schools and community organizations."

The cut permanently changes CAH reimbursement from 100 percent to 90 percent of cost, a reversal of state policy never approved by the Legislature.

The recession has taken a heavy toll on rural Wisconsin hospitals already. Over the past year, charity care has risen 24 percent, bad debt has climbed 14.5 percent, and nearly half of rural Wisconsin hospitals either lost money or barely broke even in 2008. Every person who arrives at a Critical Access Hospital is cared for, regardless of personal or financial circumstances.

Over the past few weeks, more than 30 of these meetings have occurred between CAHs and their elected representatives.

Some may recall that the American Recovery and Reinvestment Act (aka…Economic Stimulus Bill) that passed Congress last year included significant funding to help hospitals and physicians implement electronic health records (EHR). The bill’s provisions promised over $30 billion to providers as "incentive payments" that would help pay for the hardware, software and personnel costs of the expensive but transformative information systems. But now, like many other elements of the highly touted legislation, the regulatory and implementation "fine print" doesn’t add up. In fact, proposed CMS rules may end up sabotaging the original intent of the legislation and be counterproductive for accomplishing an essential and necessary delivery reform goal.

The problem comes down to the definition of "meaningful use" and the specific criteria which "meaningful users" must comply with in order to receive incentive payments over the next few years and avoid Medicare payment penalties in the future. The proposed regulations, issued by CMS a few weeks ago, are overly restrictive and the compliance phase-in timelines too short.

The most glaring example of regulatory inflexibility is the proposed "All-or-Nothing" Standard. This rule states that to be eligible for Medicare incentive payments, hospitals must meet all 23 EHR functionality objectives and must be able to use their EHR to generate data needed to calculate 35 specific quality measures and attest to the accuracy of the data. AHA and WHA analysis and early member feedback suggests that very few hospitals will be able to meet the "all-or-nothing" standard anytime soon and that EHR vendor readiness to assist in compliance will be uneven, at best.

This chart, prepared by AHA, lists 12 of the 23 "meaningful use" objectives and the percentage of surveyed hospitals that meet each objective. The results underscore the "All-or-Nothing" standard’s overreach. No hospital met 12 of the 23 surveyed objectives.

WHA’s new HIT Task Force has already met, discussed and agreed to coordinate a response to CMS regarding the proposed rules. And WHA and AHA intend to work together to survey members to ascertain the status of hospital-specific EHR implementation and document our findings to present our case to CMS and to members of the Wisconsin Congressional Delegation. Look for this to be a major federal advocacy issue in 2010.

Steve Brenton
President

The outbreak of 2009 H1N1 Influenza seriously stressed health care providers nationally and in the state of Wisconsin. Although the response from the health care community was pre-planned and well-executed, health care providers have already identified many "lessons to be learned."

To encourage hospitals to write and share their "After Action Reports," the Wisconsin Hospital Emergency Preparedness Program (WHEPP) is making grants available to hospitals and other selected health care facilities throughout the state that complete and share their "After Action Report" and participate in one of two statewide H1N1 After Action Conferences in May, 2010. A total of $604,000 is available to hospitals for grant awards under this announcement. Hospitals may apply for a maximum of $4,000. To apply for this funding opportunity, the hospital must be compliant with the National Incident Management System (NIMS). The grant application and guidelines are posted here:  www.wha.org/disasterPreparedness/h1n1.aspx. Applications are due February 8, 2010.

Eligible hospitals must complete an After Action Report in the required format. A template After Action Report must be used and will be provided with the Application Approval Letter.

Using the submitted hospital reports and information gathered at the conferences, "Lessons Learned" and "Corrective Actions" documents will be developed. The lessons and corrective actions will then be applied to strengthen state and health care facility plans, develop necessary resources and make these resources available to health care facilities.

Initially it was a tense encounter when Charlene Barnes first stepped into Steven L’s hospital room. As a Vietnam Vet suffering from an array of medical problems, he was a frequent patient of Hudson Hospital & Clinics. He had no health insurance, and his unpaid bills were piling up. In her, Steven saw the hospital’s bill collector. In him, Barnes saw a veteran who needed help.

"I was stubborn and difficult to deal with," said Steven of his 2003 visit. "But eventually I had to face reality: This lady was trying to help me."

Barnes was stubborn, too. "He needed help, and I was going to find a way to work with him."

Barnes and Steven have worked together now for five years, through deeply difficult times in Steven’s life and many visits to the hospital. He now has health insurance and is working to get his finances back on track.

"Charlene stepped into the picture, and she was really the one who helped me," said Steven, who has lived in Hudson since 1979, when he completed his military service. "There is something about her and how she does her job that’s the perfect fit."

For about eight years, Steven had taken care of his mother, Lucille. He and his children were her only family. Sadly, Lucille became very sick with an illness that slowly took her life.

"Lucille was a very sweet woman," said Barnes. "She was a joy."

Steven said his mother’s medical bills were covered. She didn’t need help from Barnes in that regard. But Barnes made sure Lucille was in touch with the right people for medical care and other resources. When Lucille passed away a year ago, Steven said Barnes was the first one at his side.

"I went down to say good-bye to Lucille. And I was concerned about Steven," said Barnes.

Being there for Steven at that moment was overwhelming to him. "That meant so much. She just cares," he said.

More recently, when he had surgery at a VA medical center, Barnes called him to check on him.

"Steven is a very decent man," said Barnes. "He is a good father and he was a good son. Many of us at one time or another need help."

Though Steven said he feels like he’s the hospital’s biggest "problem child," Barnes said that’s hardly the case. "Her willingness to work with me to manage my health care bills and help me get insurance was ‘phenomenal’, he said. But her compassion meant even more."

"Everyone who deals with me feels they have a spotlight on them, that they are the only one," said Barnes. But, in fact, situations like Steven’s are not uncommon. Her patients—those who can’t afford to pay for hospital services, but need them—have more than doubled in the past three years.

"We provide financial assistance to many patients in need," she said. "We have a commitment to customer service and to the humanity we share with every patient."

When Cathie R. of Eau Claire, Wis., was forced to go to the Emergency Department at Luther Midelfort because of a kidney stone, she knew she didn’t have insurance. "I was just starting a new job and the insurance hadn’t kicked in yet," she says. "But I had to go to the Emergency Department. I didn’t have a choice."

Follow-up tests were considered part of a pre-existing condition so Cathie’s new insurance didn’t cover them. Despite making payments, her debt increased. That’s when a patient financial planner at Luther Midelfort suggested Cathie fill out the paperwork for the Financial Assistance Program.

When bad timing strikes, the Luther Midelfort Financial Assistance Program is invaluable.

Based upon the knowledge that most medical expenses are the result of unexpected accidents or illnesses and are difficult to budget for, the Financial Assistance Program provides face-to-face financial counseling, explanations of payment options and the billing process, and assistance with completing the proper paperwork for financial assistance from Luther Midelfort or other assistance programs.

Carla Holstein, a lead Patient Financial Planner at Luther Midelfort, says, "Patient Financial Planners contact and meet with patients to discuss their bills, and they offer options that will work best for them to resolve their balances. The Financial Assistance Program is one of those options and has made a huge impact in many patients’ lives."

The factors affecting eligibility for Luther Midelfort Financial Assistance include:

• Income – In general, if income is below two times the federal poverty guidelines, patients are more likely to receive assistance
• Evaluation of savings, checking and investment assets
• Assessment of property other than a home
• Evaluation of monthly expenses including living expenses, medical expenses and other expenses
• Any special circumstances

A committee reviews the facts and circumstances surrounding each application and provides a decision within 30 days.

"When I received the letter that said I was eligible for assistance, it felt like a two-ton weight being lifted off my shoulders," Cathie says. "Luther Midelfort forgave half of my bill, and I finished paying the rest," she recalls.

In 2008, 1,403 people throughout the Luther Midelfort system benefitted from the Financial Assistance Program.

"Having to ask for help is a real humbling experience," Cathie says. "However, everyone I worked with was extremely kind, and I was treated with dignity and respect. I hope the program continues. I’m certainly grateful for it."

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