Legislative leadership changed hands in the Senate this week for both parties. After losing his third district congressional bid, Sen. Dale Schultz (R-Richland Center) surprised political insiders by challenging Senate Majority Leader Scott Fitzgerald (R-Juneau). Fitzgerald took over the role after Mary Panzer’s primary loss in September. Senate Republicans caucused on November 9, and after a secret ballot, Dale Schultz emerged as the new Majority Leader. Extending an olive branch, Sen. Schultz named Sen. Fitzgerald as chair of the powerful budget-writing Joint Finance Committee. Sen. Mary Lazich (R-New Berlin) was elected Assistant Majority Leader and Vice Chair of Joint Finance. Insiders speculate the shift in Senate GOP leadership signals that Senate Republicans are committed to building a consensus within their house for their own agenda.

The Senate Democrats elected a new minority leader with the appointment of Judy Robson (D-Beloit) to the post. She beat out Sens. Bob Jauch (D-Poplar) and Tim Carpenter (D-Milwaukee) in the secret ballot. In addition to working on trying to regain seats for the Democrats, Robson stressed the need to work on health care reform as a top priority for her caucus. Sen. Robson replaces Jon Erpenbach (D-Middleton) who resigned from the position. Sen. Robson is also a leading advocate for banning unavoidable overtime and mandating staffing ratios in hospitals.

In the Assembly, Rep. John Gard (R-Peshtigo) was unanimously reelected Assembly Speaker by his Republican colleagues. Mike Huebsch (R-West Salem) was elected majority leader replacing Rep. Steve "Mickey" Foti who retired from the legislature. The Democrats re-elected Rep. Jim Kreuser (D-Kenosha), minority leader and Jon Richards (D-Milwaukee), assistant minority leader.

In addition to being named WHA’s 2003 Advocate of the Year, new Senate Majority Leader Schultz has a long history of championing rural hospital issues. At a recent forum, Schultz made one thing clear — he understands how the government contributes to the increasing cost of health insurance premiums. "The federal and state governments are not paying the full costs of their programs, meaning there is a tremendous cost shift," Schultz said. "If you are a small business you really feel this pain, because it is a hidden tax."

WHA looks forward to continuing a good working relationship with the leadership in both houses and parties.

Since taking over the responsibility for collecting and disseminating Wisconsin hospital and ambulatory surgery data at the beginning of this year, WHA Information Center has made great strides.

We set out to greatly improve the efficiency of the state-run data collection and editing process with our new Web-based collection system. The results of our recent customer survey show convincingly that we have succeeded. Key policymakers and other health care leaders widely recognize that privatized hospital data collection has been an overwhelming success thus far.

Our quarterly data cycles (from the close of the quarter to release of data sets) have been about three months shorter than BHI’s historical average cycle times. In each of our first two data cycles, we have released data sets approximately 4.5 months after the close of the quarter. We expect to release data from the second quarter of 2004 on schedule next week.

We recognize that none of this would have been possible without the efforts of those who submit the data. Wisconsin hospitals have shown tremendous cooperation and dedication to the idea of privatization.

As we look ahead to 2005, we are preparing to implement our new WIpop system and phase II of hospital data privatization. WIpop will allow us to expand data collection to include hospital outpatient services and revenue-code detail, as required by law.

We provided detailed technical specifications for the new data collection system to all facilities in July of this year, and we recently completed a series of five WIpop training sessions for nearly 300 hospital data submitters and their IT vendors.

We will be following up with each facility to confirm their progress and offer our assistance with their preparations for the new data submission requirements, which are effective with January 1, 2005 dates of service. The first live data submissions will be accepted as of April 1, 2005.

We are scheduled to produce the first data sets from the new system in mid-August 2005. We expect to make a new data analysis tool available at that time to help hospitals maximize the value of the much more detailed data that will become available.

Data privatization has been a resounding success, thanks in large part to the commitment of Wisconsin hospitals to make it work. Next year looks even better.

Our phone and fax numbers will remain the same.
Phone: 608-274-1820 / Fax: 608-274-8554

Please update your records for Wisconsin Hospital Association, WHA Financial Solutions, Inc. and WHA Information Center, LLC.

Visit www.wha.org/about/whamap.pdf for directions and a map to our new location.

On November 9, 2004, Department of Health and Family Services (DHFS) officials announced an urgent recall of automated external defibrillator (AED) devices manufactured by Access CardioSystems, Inc. While the company has officially recalled only products with certain affected serial numbers, Access CardioSystems says the investigation is on-going and it is instructing customers to discontinue use of all of its automated external defibrillators. The following products have been recalled to date:

Product Description             Catalog Number         Affected Serial Numbers
AccessAED, AccessALS     9100-0100                 075690-077140
AccessAED, Access ALS    9100-0100                 075180-084760

In a recall letter to its customers, Access CardioSystems says that some of the devices may experience "a catastrophic failure of the shock delivery circuit." When the problem occurs, it is not possible to deliver additional defibrillation shocks. The company’s investigation indicates to date that this failure mode is restricted to a specific batch of one device component.

Access CardioSystems has also become aware of "a situation involving certain of its AEDs in which the On/Off button of the device may become inoperative after the device turns on unexpectedly." According to the company, if this problem occurs, the device may not defibrillate.

DHFS distributed the AED devices to emergency medical service providers throughout the state. Any organization using the affected products should immediately contact Access CardioSystems Recall Coordinator at 978-405-1057 for more information.

Although not all of Access CardioSystems AEDs are affected by the recall, the company has decided to immediately discontinue manufacturing and marketing all models of its AEDs. The company says it will also no longer support its AEDs that are currently being used throughout the country.

In recent years, portable, automated electronic defibrillators have become more common in a variety of settings including schools, airports, businesses and YMCAs. Several different companies manufacture automated electronic defibrillators. This recall affects only those products produced by Access CardioSystems, Inc. "Although these particular defective defibrillators pose a serious problem, defibrillator devices have saved the lives of thousands of people nationwide," said Meg Taylor, Director of the Bureau of Local Health Support and Emergency Medical Services for the state Division of Public Health.

A just-released Institute of Medicine (IOM) report Quality through Collaboration: The Future of Rural Health, provides validation of WHA’s CheckPoint^SM initiative and a roadmap for the evolution of quality initiatives in rural America.

The new report is a byproduct of the landmark 2001 IOM Crossing the Quality Chasm: A New Health System for the 21st Century. That report documented serious shortcomings in America’s health care system and called for fundamental reform through the focus on six aims for quality improvement—health care should be safe, effective, patient-centered, timely, efficient and equitable.

The new report concludes, "In many respects, rural communities have been on the periphery of discussions of national health care quality." It goes on to suggest a five-prong strategy to address the quality challenges in rural communities. [The Rural Wisconsin Health Cooperative (RWHC) has done a special 8½-page analysis of the IOM rural report. That analysis can be accessed at www.rwhc.com, click on "What’s New."]

Importantly, one of the major recommendations of the new IOM report is that the federal Department of Health and Human Services should establish a rural quality initiative "to coordinate and accelerate efforts to measure and improve quality of personal and population health care programs in rural areas." The recommendation suggests that such a proposed initiative should use evidence-based measures that are benchmarkable for rural communities and that public reporting be part of the equation.

In Wisconsin, CheckPoint in its current state and its future evolution can be such a reporting "initiative." All but two small and rural hospitals are participating in CheckPoint, which currently provides evidence-based information on five error prevention goals and 14 clinical interventions. And the promised evolution of CheckPoint is framed by WHA’s commitment that the program remains statewide in its focus and relevant to the national agenda…principles that align well with the IOM recommendations.

To date, the embrace by Wisconsin hospitals of public reporting of patient quality measures and error prevention goals has been universal. And the fact that rural hospitals are part of this initiative means that at least in Wisconsin, rural communities have not been "on the periphery" of the national health care quality agenda. They’ve been full participants!

Wisconsin fingerprints are all over this new report. Rural Wisconsin Health Cooperative Executive Director Tim Size was an active participant in fashioning the findings and recommendations. And RWHC has been a national leader in advocating for quality initiatives that are relevant for rural hospitals and rural communities. Now Wisconsin is well positioned to lead in fulfilling goals that are at the center of this new IOM agenda.

Steve Brenton
President

Along with the rest of the nation, the Wisconsin Hospital Association has been monitoring the implementation of mandatory nurse ratios in the state of California. At the WHA 2004 Annual Convention, Dan Gross, CEO of Sharp Memorial Hospital in San Diego enumerated the serious ongoing problems created by the legislation. In a state where nurses are in short supply, surgical delays or cancellations and emergency diversions have become common.

It appears that Gov. Arnold Schwartzenegger of California has now taken steps to ease those problems. On November 4, the California Department of Health Services (DHS) proposed modifications to the state’s nurse ratio rules. The proposed changes would:

• Maintain the 1:6 patient ratio in Med-Surg units (delaying the proposed January 1, 2005 implementation of the 1:5 patient ratio) for a period of three years.
• Clarify the ‘at all times’ language. Currently, whenever a nurse temporarily steps away for a break or to use the restroom, his/her patients must be reassigned to another nurse. Under the proposed change, as long as the assigned nurse remains on the patient-care unit, patients will not have to be reassigned.
• Allow flexibility for emergency rooms in complying with the ratios when faced with an unexpected influx of patients.

When the changes were announced, DHS indicated that before changes are made, data must be collected to assess the impact of the current ratios. DHS also said that ER changes are being recommended to reduce the frequency with which patients are diverted because of nurse staffing limitations.

These proposed changes must be approved by the state Office of Administrative Law within 10 days. California Nurses Association has already launched a vigorous campaign to derail the rule changes while the California Healthcare Association has applauded DHS’s changes as essential to preserving patients’ access to health care.

An annual Health Confidence Survey, conducted in October 2003 by the Employee Benefit Research Institute, assessed consumer’s attitudes regarding health care costs. The survey reported that 44 percent of respondents were "not too" or "not at all" satisfied with the cost of their health insurance in 2003. This compared to 37 percent dissatisfaction in 2001. The survey also reported that 37 percent of consumers had "little" or "no" confidence in their ability to afford health care without financial hardship, compared with 31 percent in 2002.

With 83 percent of consumers participating in employment-based health care plans (according to the Kaiser Family Foundation) and the level of dissatisfaction regarding the cost of health care, many employers are exploring long-term solutions. Employers who continue to manage and seek greater value in benefit expenditures have changed their strategy from reactive to proactive - seeking other solutions rather than absorb increased health care premiums.

Read the entire article in Solutions Spotlight, included in this week’s packet, and contact Jon Braddock at jbraddock@wha.org or Fred Bounds at fred.bounds@kunkel-bounds.com to learn more about health care cost solutions.

The Centers for Medicare and Medicaid Services (CMS) has released the final calendar year 2005 Medicare Outpatient Prospective Payment System (PPS) rule with comment period, which is scheduled for publication in the November 15 Federal Register. A display copy of the rule is available online at www.cms.hhs.gov/providers/hopps/2005fc/1427fc.asp.

Major provisions of the rule include:

• Incorporation of the inpatient wage index from the final Inpatient PPS Rule, including redefined wage areas, an occupational mix adjustment, hospital reclassifications, and the temporary relief provided for hospitals harmed by the redefinition of wage areas.
  
• The 2005 conversion factor is $56.983, compared to $54.561 in 2004. This is the result of a 3.3 percent market basket update, a slight decrease for budget neutrality, and a 1.2 percent increase due to a lower "carve-out" for pass-through payments in 2005.
  
• CMS has changed the outlier methodology to target payments for complex, expensive procedures. Currently, outlier payments are provided if the cost for a service exceeds 2.6 times the Ambulatory Payment Classification (APC) rate. For 2005, CMS requires that costs must exceed 1.75 times the APC payment rate and exceed a $1,175 fixed dollar threshold. Both the multiple and the fixed dollar threshold were increased from the proposed rule. The policy change will eliminate outlier payments for low cost services and provide higher outlier payments for relatively expensive procedures.

• CMS has simplified payment for observation services by eliminating the requirement that hospitals document use of specific diagnostic tests. The rule also modifies the guidelines for counting patients’ time spent in observation care.
  
• Significant payment changes for many drugs, biological products, and radiopharmaceuticals due to revisions required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Move slowly and use great care when using quality data in marketing and advertising efforts was the advice given during a panel discussion on the ethics of using quality data in advertising and marketing claims. The three members of a guest panel spoke to more than 60 health care marketing professionals gathered for a Wisconsin Forum on Healthcare Strategy seminar on November 11 in Pewaukee.

Ford Titus, president and CEO of ProHealth Care, pointed out that one danger of using quality data is that is vacillates too much to be able to use it in advertising and marketing claims.

"My attitude is we all look good on some rating system. If you take the bait in advertising your quality, you live and die by the data," he cautioned. "Quality data can’t be used to create a competitive distinction in the market; it is too immature at this point."

Mark Kaufman, MD, senior vice president and chief medical officer at Dean Health Plan, said without a doubt, public reporting energizes and catalyzes the health care community to improve, and he considers himself a "true believer in public reporting."

"The data has to be transparent, meaning the health care community must be able to drill down and use it to drive improvement; otherwise, it just creates turbulence," Kaufman noted.

These are exciting times we live and practice in, because Wisconsin is a state known as a national leader in the measurement and public reporting of safety, quality, service and very likely, hospital prices, according to WHA President Steve Brenton. "We will lead the nation by the example we set in these areas," he added.

"We have just begun, but it is a promise and a commitment to our communities that we will be accountable, and the Wisconsin Hospital Association has been a catalyst in the health care community to ensure that we fulfill this promise," Brenton said.

Brenton shared a document with the group that was adopted earlier this year by the WHA Board that lays out a set of principles that health care providers should follow to ensure that their advertising and marketing claims are truthful, complete, and sensitive to the information needs of the public. The advertising and marketing principles can be seen at www.wha.org under News Center.

For those who may be tempted to use hospital rankings set by outside organizations, Brenton, like Titus, urged his audience to take great caution, as the methodologies used to determine those rankings are often proprietary.

"Hospitals must be careful about using scores on quality measures and publishing rankings, such as ‘Top 100 or Best of the Best,’" Brenton urged. "In trying to create a competitive advantage with the current measures, a health care organization can create unrealistic expectations for patients and their families. We need to report measures that help clinicians improve the quality of the care and that help consumers learn about health care."

One of the major challenges to meeting the demand for more nurses hinges on increasing capacity in the nursing programs. This will not be accomplished unless more faculty is available to these programs. With the average age of a nurse faculty member nearing 60, and few nurses in the faculty pipeline and little interest among nurses in teaching roles, there clearly will not be enough nursing faculty to educate an adequate supply of nurses that will be needed in Wisconsin in the future.

The role hospitals can plan in addressing the nursing faculty shortage was a topic of discussion at the November 11 meeting of the WHA Workforce Council. Lea Acord, RN, dean of the Marquette University College of Nursing and board member of the American Association of Collegiate Schools of Nursing, along with Linda McIntyre, RN, unit manager at Myrtle Werth Medical Center suggested that dialog between the schools and the hospitals is necessary to create solutions that will lead to increased enrollments in nurse educator programs.

WHA Workforce Council Chair Robert Fale said that every hospital represented at the meeting probably already contributes staff time and space to nursing programs. Both speakers agreed and added that a more positive image of the role of nurse educator is needed to attract more nurses to this career. This must start earlier, perhaps when nurses are students themselves.

Other business included a review of WHA’s workforce advocacy agenda and an overview of the recent elections by Eric Borgerding and Jodi Bloch. Judy Warmuth offered an update of her workforce development activities, and she presented the Department of Workforce Development statistical projections for 2002-2012 and the 2004 Nursing Workforce Report. Both of those presentations are suitable for external audiences and will be available on the WHA Web site soon.

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