As the dust still settles on the 2008 elections, the WHA Public Policy Council looked forward into the next legislative session to examine just how the results from those elections will impact hospital and health care issues and the direction of health care policy in Wisconsin when they met in Madison on November 17.

Diane Postler-Slattery, chief operating officer at Aspirus Wausau Hospital, presided over her first Council meeting as incoming chair. Postler-Slattery takes over for outgoing chair David Olson, chief executive officer at Bay Area Medical Center in Marinette, who completes his tenure this year.

Among the highlights of the meeting was the Council’s special guest, Assembly Speaker-elect Mike Sheridan (D-Janesville). Sheridan, who was just elected Assembly Speaker last week, discussed his background as president of the local United Auto Workers Union and how his experience will help him lead the Assembly Democratic majority as they work to shape Wisconsin’s public policy and tackle the state’s daunting budgetary challenges.

Sheridan described his leadership style as inclusive, indicating that everyone around the state needs fair representation. When it comes to different thoughts on solving problems, "Let’s find common ground," he said. "We can find the things that we agree on and get to work."

Sheridan said he has been glad to keep an open dialogue with WHA on the hospital assessment as discussions continue on how to best structure the assessment to improve hospital Medicaid payments, reduce the price-escalating effects of cost-shifting, and finally draw down more of Wisconsin’s fair share of federal Medicaid dollars.

Commenting on health care reform, Sheridan said he has always felt that any major reform initiatives are more of a federal issue. But if there isn’t a federal solution, "I want to make sure that all those with an interest have a seat at the table."

Sheridan said his top priority for next session will be jobs and the economy. "We need to protect those jobs that we have and create incentives to bring new jobs into the state," he said.

Update: 2008 election results, Medicaid, hospital assessment

Following Sheridan’s remarks, WHA Executive Vice President Eric Borgerding along with WHA staff provided a comprehensive overview and in-depth analysis of what can be expected from the new Democratic majority in Wisconsin, the expanded Democratic majority in Washington and President-elect Obama.

Borgerding said the policy forecast for the 2009-11 Legislative Session is shaped almost entirely by the revenue shortfalls confronting the state now as the slowing economy and declining tax revenues continue to lead to increased budget shortfalls for Wisconsin. These shortfalls amount to a $400-500 million deficit for the remainder of this biennium (ending June 30, 2009) and point to upwards of a $5 billion shortfall the state must deal with for the 2009-11 biennium.

These realities make general purpose revenue (GPR) for hospital Medicaid increases impossible, Borgerding said, and make a deliberately crafted hospital assessment a viable solution for both the state and Wisconsin hospitals. But he warned that tinkering with the assessment could have the direct opposite effect of driving health care costs up.

WHA Senior Vice President George Quinn also provided Council members with the latest on the hospital assessment. Quinn said that ongoing talks with the Doyle administration have been both positive and productive. He said discussions have continued to focus on WHA Board principles on the assessment including safeguarding the revenue, delivering the promised payment increases, and the amount and timing of the assessment. Quinn reiterated that critical to a viable assessment proposal is minimizing the negative impact on hospitals.

Besides Medicaid payment increases, Borgerding mentioned health care reform and coverage expansion; the union agenda; health care quality, safety and transparency; medical malpractice, and regulation and hospitals’ tax-exempt status as issues that could be debated in the next legislative session.

Borgerding highlighted some of WHA’s comprehensive and issue-focused strategies and activities that lead up to and will be continuing past this fall’s election, including legislator and candidate visits, race and issue polling, issue advocacy and radio ads, and editorial board visits.

Borgerding said all of these, along with WHA’s ongoing, proactive effort to inform lawmakers of all the ways Wisconsin hospitals are leading the way in many key policy areas, are designed to strategically position WHA and our members with legislative decision makers as they craft Wisconsin’s health care policy in the next session.

On the federal level, Borgerding said increasing majorities in both the U.S. House of Representatives and Senate will impact hospital issues such as health care reform and labor policy in the years to come. Especially critical is the increasingly likely passage of the Employee Free Choice Act (EFCA), also known as "Card Check" legislation (see below).

Council members were briefed on President-elect Obama’s health care plan by Joe Kachelski, vice president of the WHA Information Center. Kachelski reminded members that Obama’s plan has been neither drafted nor introduced so any discussion is based only on general statements and position papers. He said that since many specific details are not covered in the plan, only broad general themes can be recognized.

In addressing whether or not anything will actually happen with Obama’s plan or any other federal health care reform initiative, Kachelski said one of the key questions is how other national crises will impact federal legislative priorities.

Union workforce agenda

WHA Vice President of Workforce Development Judy Warmuth presented Council members with the latest information on the union workforce agenda on the federal level. She said the number one priority for unions is the Employee Free Choice Act (EFCA), under which employees lose their right to a secret union election. EFCA would effectively eliminate the federally-supervised private election option under the National Labor Relations Review Board (NLRB).

Warmuth said under EFCA, when a union submits signed authorization cards from 50 percent plus one members of a potential bargaining unit, the NLRB would be required to certify the unit, and the employer would be required to begin bargaining within 10 days.

Warmuth said among the other items included on the national labor agenda are definition of a supervisor, no manual lifting, employer neutrality (on unions), employment verification, staffing ratios and mandatory overtime.

BadgerCare Plus

Bill Bazan, WHA vice president for Metro Milwaukee updated Council members with the latest developments on BadgerCare Plus for Childless Adults, who Bazan said are the most chronically uninsured people in Wisconsin.

Because of the large and growing budget deficit, Bazan speculated that implementation may be phased in. Timing for transitioning enrollees to the new program could depend on the availability of state budget resources.

Behavioral health issues

Bazan, Quinn and WHA Associate Legal Counsel Matthew Stanford briefed Council members on growing provider concerns over behavioral health issues as well as several recent developments aimed at addressing this brewing crisis.

Quinn said the WHA is putting together a Behavioral Health Task Force charged with identifying the barriers to accessing behavioral health services in Wisconsin and developing a set of recommended goals and actions for improvement. The Task Force will also develop a set of key principles to guide the recommendations. Quinn encouraged Council members to forward names of individuals from their organizations who might be interested in participating on the Task Force.

Bazan indicated that especially with elderly patients, the relationship between hospitals and nursing homes is critical regarding mental health behavioral issues as determinations are made into where these patients can receive the most timely and appropriate care. He also provided Council members with information on the Wisconsin Star program, a pilot project proposed to help care providers who often feel especially burdened when trying to provide quality care to older adults with many simultaneous health problems.

Stanford provided a summary of the new federal mental health parity provisions. While the new regulations do not mandate mental health coverage, if mental health is covered by a plan, the coverage must meet several requirements. Among those requirements are: identical out-of-pocket expenses and limitations on treatment to other benefit coverage, prohibitions on separate cost-sharing and treatment limitations, and no separate restrictions on access to out-of-network providers. Stanford said the parity provisions do not become effective until October 2009 and that a specific analysis of the affect of those provisions on Wisconsin is in development.

The next meeting of the Public Policy Council is scheduled for March 26.

With our nation’s economic troubles, fewer patients are seeking hospital care while at the same time a growing proportion of patients need help paying for care, according to a new report from the American Hospital Association (AHA). The report also noted that hospitals, which employ five million people nationwide, could be facing uncertain times as their financial health falters and the ability to borrow funds for improving facilities and updating technology is squeezed.

According to the report, many hospitals are beginning to see the effects of the economic downturn with more than 30 percent of survey respondents reporting a moderate to significant decline in patients seeking elective procedures, and nearly 40 percent of respondents reporting a drop in admissions overall. The majority of hospitals surveyed also noted an increase in the proportion of patients unable to pay for care. Uncompensated care was up 8 percent from July to September versus the same period last year, according to the report.

Hospitals have seen the immediate impact of the economic downturn in other ways. According to the report, total margins fell to negative 1.6 percent in the 3rd quarter of 2008 versus positive 6.1 percent during the same period last year. Like many institutions, hospitals rely on investment income as one of the ways to help make ends meet, especially since government payers do not cover the costs of care. However, recent turmoil in the stock market has turned investment gains to losses, further worsening hospitals’ financial condition.

At the same time, Medicaid expenditures—the largest and fastest growing portion of many state budgets—increase even faster during economic downturns as enrollment grows and state tax revenues drop. State and federal budget difficulties raise worries about potential cuts to Medicare and Medicaid, which cover half of the patient care provided by the nation’s hospitals. Financial stress is forcing hospitals to make or consider making cutbacks to weather the economic storm including cutting administrative costs (60 percent), reducing staff (53 percent) and reducing services (27), among the hospitals surveyed.

All of these pressures are leading to a decline in hospitals’ financial health, which could ultimately affect local economies.

WHA is currently in the process of collecting state specific data to help quantify the impact of the troubled economy specifically on Wisconsin hospitals. Emails went out early this week to hospital CEOs and CFOs with the online survey information. Responses are due by December 5. Early indications from WHA voluntary data submission sources and conversations with many member hospitals indicate the AHA report findings are very consistent with what is occurring at the state level.

The Wisconsin Research and Education Network (WREN) has named WHA Senior Medical Advisor Chuck Shabino, MD to their Advisory Committee. The Advisory Committee will help determine strategic direction for the organization.

WREN is a statewide practice-based research network of more than 100 physicians who practice in 40 clinics in 24 Wisconsin communities within 17 different health care organizations. WREN members conduct high-quality translational research projects in "real-world" family practices across Wisconsin.

Shabino said he was pleased to be asked to serve on the Advisory Committee.

"WREN opens the opportunity for community-based clinical practice research in our state. The attractiveness is that research at the clinic level can address questions such as how we can provide more efficient and effective care in our communities, unlike research that typically occurs in academic medical centers and large hospitals," according to Shabino. "This research translates directly into improved care for patients in physician offices and clinics across Wisconsin."

The first meeting of the Advisory Committee coincided with the WREN Annual Forum on November 7 in Wisconsin Dells. WHA’s Dana Richardson, vice president, quality initiatives, presented the results of two collaborative learning projects led by WHA aimed at improving patient care. Both projects received grant support from the Wisconsin Office of Rural Health.

The projects focused on improving surgical care in 2007 and stroke care in 2008. Richardson provided an overview of the rationale for improvement, the collaborative learning format, achievements, and lessons learned from the two projects. The surgical care improvement project included 21rural hospitals, while 19 rural hospitals participated in the stroke improvement project. Richardson said the Wisconsin Office of Rural Health has again funded a rural hospital stroke improvement project for 2009. Information about this project will be available in December 2008.

Important amendments to the Family and Medical Leave Act ("FMLA") regulations will go into effect January 16, 2009. The U.S. Department of Labor published its Final Rule amending the FMLA regulations on November 17, 2008, leaving a short timeframe for compliance with the changed regulations. WHA is hosting a webinar to educate members about the changes and to help members comply by the effective date. Attorneys Robin Sheridan and Carrie Turner of Hall, Render, Killian, Heath & Lyman will explain the amendments and offer tips for compliance during an hour long webinar scheduled for December 10. Watch the WHA Web site for more information about the webinar.

The following are some of the changes included in the Final Rule:

• Incorporating military family leave entitlements into the FMLA regulations, following the FMLA procedures wherever possible.
• Addressing when Professional Employer Organizations ("PEOs") are joint employers.
• Providing a new definition for when an employee has worked the requisite 12 months in order to be eligible for FMLA leave.
• Clarifying the definitions for "continuing treatment," "chronic condition," and "serious health condition."
• Providing leave to care for a covered service member with a serious injury or illness.

Will Wisconsin hospitals look back to 2006 and 2007 as the "good old days," at least as it relates to financial performance? And the same might be asked of the nation’s hospitals. The current economic downturn and balky credit markets have created symptoms not seen by Wisconsin hospitals in well over a decade, if ever. A growing pile of anecdotal evidence suggests that hospital inpatient and outpatient activity is slumping while bad debt, charity care and Medicaid business skyrockets. Hospital investment losses are significant and portend negative "total" margins for many, if not most, organizations.

In addition to economic-related factors, Wisconsin employers, as a group, are getting serious about managing their health care costs. Proactive wellness programs mean healthier employees utilizing health care services less. And consumer-driven benefit designs and higher co-payments and deductibles are at least partially responsible for growing hospital and clinic accounts receivables. These trends will not change.

Conventional wisdom has it that hospitals and clinics are generally sheltered from recessions due to population demographics and widespread and pluralistic benefit coverage. This week’s Modern Healthcare notes that during the 2001 recession, "community hospitals never stopped hiring more workers and posted (profits)." But that’s not happening this year. We are already hearing of expense reductions that will have a statewide impact on staffing and capital spending. And Moody’s recently downgraded the national health care sector’s future performance from stable to negative. Consider the impact that will have on future financings.

If we really needed another reason to support Governor Doyle’s hospital assessment initiative, we have it in the form of the new fiscal reality. The State of Wisconsin’s budget dilemma is even worse than is the current private sector’s situation. Preserving current programs that cover our most vulnerable patients will be difficult next year. Additional coverage expansions are hard to envision in the context of the next biennial budget. And, of course, there is NO new money for hospitals, other than through the assessment—an approach that is already in place in our neighboring states. It is the one glimmer of sunlight in a very dark environment.

The Doyle Administration has publicly touted the assessment as an early "must do." WHA staff has participated in discussions to fine tune the assessment/payment plan which is increasingly likely to be in play early next year—running apart from the budget process. Our goal is to align the initiative with WHA Board approved principles that frame our support for the plan. We are cautiously optimistic that when unveiled, the initiative will be an improvement over the approach we supported last year.

Steve Brenton
President

This afternoon session goes beyond the basics and includes an in-depth review of the OPPS Final Rule for 2009, along with review of the latest CMS program memorandums.

2009 Chargemaster Updates – December 10

This full-day seminar will focus on updating your chargemaster for the 2009 reporting requirements and new chargemaster opportunities to keep you "in the know" for the CPT and HCPCS coding revisions, concentrating on those new codes impacting the chargemaster.

The day after Thanksgiving, Julia Means, parish nurse, received a call from a woman who was a recipient of a Columbia St. Mary’s Thanksgiving Basket.

The woman was a single mother in her mid-thirties who had three children. She worked several part-time jobs, but often found herself out of money toward the end of the month. She told Julia that she knew she would be out of money and unable to buy food for a traditional Thanksgiving meal, but she couldn’t stop herself from making a shopping list anyway. As the week of Thanksgiving approached, she put the list aside when she realized that she had no hope of filling it. She was in fact thankful that she had any food at all on hand for the day.

When she found out that Columbia St. Mary’s was providing her with food, she said she had a glimmer of hope. She told Julia that she was completely unprepared for what she was given. She admits that she started to cry when she saw the number of boxes of food, some of them gift-wrapped, others including presents for her children. She gratefully took the boxes home and started to put the food away. Just on a whim, she pulled out the list that she had prepared earlier in the month. She thought it was more than just coincidence that Columbia St. Mary’s had given her everything on her list—and in the brands that she would usually buy. She was still crying when she called Julia to express her great thanks to Columbia St. Mary’s for such generosity.

Helping to ensure the needy have Thanksgiving Day dinner is a holiday tradition at Door County Memorial Hospital/Ministry Health Care (DCMH/MHC). DCMH/MHC employees donated more than $2,500 for family-style Thanksgiving Day dinners in November. Their contribution to Feed and Clothe My People, a program based in Sturgeon Bay, benefited 80 families in the area.

The annual effort to support the poor began in the late 1990s after a DCMH/MHC North Shore Medical Clinic staff member suggested something be done by the employees themselves to help those less fortunate on Thanksgiving Day.

"I took the idea to the Mission and Values Committee, and the rest is history," said Brenda Leist, a member of the committee, who coordinates the Thanksgiving Day dinner project.

Leist said that employee giving has steadily increased over the years, which she attributes to the need in Door County as well as a healthy competitive spirit among the hospital team. In 2006, for example, about $1,800 was raised for 59 family dinners. "Everyone wants to step up to the plate and have a successful project and beat last year," said Leist. "And there is a need in the county for this support."

After the money is raised, Eric VanAlstine, the hospital’s director of hospitality services, orders food from Econo Foods, Sturgeon Bay. A complete dinner—from a 12-pound turkey, vegetables, stuffing and cranberries to dinner rolls, pumpkin pie, milk and apple juice—is made available to each family.

Then, six hospital employees pack nonperishable items in grocery bags. They deliver the goods to Feed and Clothe My People, where the families pick it up the day before Thanksgiving.

Feed and Clothe My People is a community sharing program based on the philosophy of "neighbor helping neighbor." Without the hospital employees’ contributions, many people would be unable to enjoy a traditional Thanksgiving Day dinner, according to Stella Huff, coordinator of Feed and Clothe My People.

"If the hospital didn’t do the collection, the families wouldn’t have the resources to spend on Thanksgiving," Huff said. An area Rotary Club coordinates donations of Thanksgiving Day meals to Feed and Clothe My People as well, Huff said.

The Thanksgiving Day project is one of many projects undertaken by the Mission and Values Committee, which was established to express the DCMH/MHC values, according to Sandy McKuen, the hospital’s vice president of human resources.

"We think of justice when we think of the poor. While it is true that we strive for justice for the most vulnerable, we must also live our other values fully with the poor," McKuen said. "We provide service to the poor through these projects specifically targeted to their needs."

In addition to the Thanksgiving Day dinner project, the committee organizes a silent auction for Katie’s Fund (available to the poor and underserved needing fuel, food, drugs and clothes), a Toys for Tots drop box, area food drives and more.

Among the many people served a free meal at Holy Family Memorial during Thanksgiving 2007, several homeless families attended the gathering. They were provided with a hot meal at Holy Family Memorial hospital cafeteria and a meal to go for each of the parents and the children. A volunteer said, "It is amazing to watch the number of people who are willing to donate time and service, and we are the ones who get the joy out of it!" 36 people volunteered to serve others who were in need or came to be with other people so they would not be alone.

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