A veritable Who’s Who of health care participated in a WHA organized and hosted meeting this week to discuss the various issues presented by the Department of Justice’s (DOJ) decision to criminally charge a Madison nurse for a medical error. The WHA board room was filled to capacity as some 45 people attended the meeting representing a wide range of interests, including hospitals, clinics, nurses, pharmacists, labor unions, physical therapists, employers and other purchasers, chiropractors, nursing homes, health plans, nurse midwives, and patient safety organizations.

Criminal defense attorney Stephen Hurley of Hurley, Burish, & Stanton, who defended the Madison nurse who was criminally charged by DOJ, outlined the brief 15-year history of criminal negligence in Wisconsin, explaining, "The change in the criminal law’s aim has primarily been political – to be ‘tough on crime.’ There is a ‘market’ of public approval for more criminal laws and no effective consideration of countervailing costs to society. With no judicial check on this expansion, a wholesale transfer of power from elected legislative officials to prosecutors has occurred."

Hurley emphasized that the important and troubling issues presented by DOJ’s pursuit of criminal charges for a medical error were not resolved with the resolution of the Madison nurse’s case. Pointing to a prior case involving the law of homicide by negligent operation of a motor vehicle, Hurley said that the courts have found that a change in charging policy to accurately reflect a prosecutor’s new understanding of the elements of a crime is a valid exercise of discretion. He said that the criminal charge becomes a roadmap for future prosecutions by local district attorneys around the state.

WHA Senior Medical Director Charles Shabino and Scott Geboy, Hall, Render, Killian, Heath & Lyman, then discussed the impact the criminal charge could have on health care providers’ peer review and other quality improvement activities. Dr. Shabino emphasized that quality improvement begins and ends at the bedside and walked through the old "punitive" or "bad apple" review system that has given way to the more thorough and effective "Quality Improvement" system. Geboy stressed that if the criminal case signals a return to a punitive system, quality improvement efforts would be hindered. Geboy underscored that health care providers’ quality improvement efforts depend upon professionals willingly participating in the review and evaluation of the care provided and that fear of prosecution will hurt those efforts.

Burton Wagner, general counsel for the Wisconsin Nurses Association, and Laura Leitch, WHA general counsel, walked through several preliminary options for addressing the issues. The comments and questions that followed revealed the thoughtful discussion that is occurring within the health care community on these important issues. WHA is convening a smaller group to prepare a legislative proposal that will address the issues.

WHA Senior Vice President Eric Borgerding noted, "It’s clear that the health care community recognizes that we are at a critical turning point. The wrong decisions will hurt our efforts to address the increasingly dire health care worker shortage in our state and our efforts to provide higher quality more efficient health care. WHA is hopeful that this impressive group representing diverse interests will be united behind and will work hard for a solution – our workforce and our patients depend on it."

As a new Senator, I will need to initially focus on understanding the state budget process and learn more about the committee I chair and the committees I am on. Personally, my first goal is to try to be a facilitator for comprehensive health care reform, which may not come around until spring or fall, after the state budget process ends. That will give me time to find out where my new colleagues are on this issue and allow me to gather input from my constituents by holding community forums on the issue of health care. Wisconsin’s unique characteristics as a state would need to be considered as we determine what a future health plan would look like that provides care for all children and some adults, and at the same time relieve the burden on providers and employers. We cannot continue to shortchange the employers who are paying a hidden tax, or the providers who are caring for patients who are dependent upon medical assistance. We also want to make sure that our rural providers aren’t shortchanged in our well-intentioned desire to provide affordable health care.

2. Just this week the Governor’s Healthy Wisconsin Board recommended increasing the cigarette tax by $1 and to devote that to state health programs, including increases for provider Medicaid reimbursements. Tobacco related diseases cost Wisconsin’s Medicaid program $442 million annually. WHA has supported a cigarette tax increase in the past and continues to do so today. What is your view on this issue? Would you support increasing the tobacco tax if a significant portion of the proceeds were used to increase MA payments to hospitals and reduce the "Hidden Health Care Tax" on employers?

Yes, under those conditions I could see that. You hear from smokers that even they will support a $1 increase if some of the money goes to sponsor smoking cessation programs, and the fact that if the price goes up, they would probably quit, not have the expense, and improve the health of all people in the state, including smokers.

3. As chair of one committee and a member of another that will look at various health care issues, what do you think are the biggest issues facing our health care system today? What do you want to see achieved in any health care reform plan? What do you see as the role of hospitals in health care reform?

The biggest issue is getting a handle on costs so we can make health care more affordable and, therefore, more accessible to Wisconsin families. We need more participants in the health care system, such as the hospitals, physicians, insurance companies, consumers and employers, to continue to search for ways to reduce costs and streamline processes. We need to continue to implement best practices to basically drive the hidden tax out of the system. There is no one in this system that is looking to make a profit off sick people’s paperwork, so it is in our best interest to make the system user-friendly as people seek care. Health care providers can continue to make a reasonable living, and those of us who are consumers can access and afford the system. Let’s start with that challenge. We have to make sure that all Wisconsin families, especially children, have access to quality health care and are not turned away because of what is in, or not in, their wallets. What is achievable is pooling Wisconsin families together with businesses that will help spread the risk and perhaps spread the burden of the plans that are out there. One fact that makes me optimistic is that I believe we will start to see large cooperatives. The goal is to defragment the current system so it stops working against people who are at risk or who have pre-existing conditions. We also need to look out for our providers who provide a disproportionate share of care to those who use the medical assistance program. We can’t continue to put them at a competitive disadvantage to those who serve far fewer Medicaid patients.

The hospital role, as I have come to understand it from the CEOs in the Chippewa Valley, is to ensure that hospitals in Wisconsin are able to provide the best medical care and not be shortchanged by a system that will harm them in terms of their acceptance of medical assistance patients. Hospitals needs to advocate on behalf of themselves on the role they play and what they require to receive as a fair return on investment so they can continue to provide health care border to border.

4. Recently a nurse was criminally charged by the state Dept. of Justice for an unintentional medication error that resulted, sadly, in a death. The unprecedented criminal charges have sent shockwaves through the health care community and will have very serious implications for Wisconsin. What are your feelings about this unprecedented action? Would you support legislation to protect our health care workforce from fear of exposure to criminal charges and prison time for unintentional errors?

I would take a long look at it. A line must be drawn—when does a medical error become criminal? I want to make sure that the line is a distinct as possible so unintentional medical errors go through a clear process. Providers need to have a clear process for dealing with workers who make a one-time error and for those who make errors repeatedly. We must have a system in place that will not tolerate substandard behavior. Health care is not an assembly line – there are lives at stake. If the line that defines criminal behavior is clear, that is the kind of reform that I back because it protects both the patient and the health care worker.

5. Wisconsin’s Medicaid and BadgerCare programs pay hospitals about 49 cents for every $1 dollar it costs hospitals to care for these patients. In 2005, this resulted in $550 million of unpaid costs that were shifted to the private sector. Known as the "Hidden Health Care Tax," this level of cost-shifting due to under-funded government programs contributes to rising health insurance premiums. The situation is much the same for Wisconsin’s nursing homes, many of which are owned/subsidized by hospitals. Do you believe providers should be able to more adequately recover their costs for providing care to these patients?

My feeling is that this is a problem that will get worse based on demographics in Wisconsin, and it requires attention. Certainly what is working against us is a perpetual cycle of moving from one budget crisis to the next. There are no quick fixes, but we should not allow ourselves to shirk our responsibility to see what we can do at the state level to help provide better reimbursement and continue to press at the federal level for long-neglected improved reimbursement at all levels in our health care system.

6. Access to dental health is a growing problem in Wisconsin. From Milwaukee to Chippewa Falls, hospitals see this problem up close when individuals who cannot find a dentist utilize the emergency room for their dental health needs. This year WHA worked with the Legislature in support of a rule change allowing dental hygienists to be certified as a Medicaid provider and bill for the services they are already providing (ex: in schools). We believe this was one innovative way to begin addressing the problem. What else do you think can help with this access crisis?

It still puzzles me. It is a real problem, and I have heard from people on both sides of this issue, both those who provide dental care and those who suffer from the lack of it. I come into this first term uncertain on where we can go on this. I am still open to ideas that people may have that put patients first but also is fair to those who provide dental care. We will end up with a two-tier dental care system if we don’t. We can’t have a two-tier system of health care and dental care for the poor, and we must take steps to ensure that does not happen.

Governor Jim Doyle’s Healthy Wisconsin Council voted on December 19 to recommend a $1-per-pack increase in the state’s cigarette tax to help fund new and existing state health care programs.

The Council recommended expanding Medicaid eligibility to uninsured childless adults with incomes below 200 percent of the federal poverty level. The benefits would be less generous than those offered through standard Medical Assistance or BadgerCare, and would include some co-payments and premium contributions from enrollees.

The Council also voted to recommend the creation of a Reinsurance Authority, a quasi-governmental entity, that would be charged with the responsibility to develop, implement and administer a reinsurance program for the small group (2-50 employees) health insurance market and for employers, including sole proprietors, who participate in co-op health insurance programs.

The Authority would also be charged with developing and administering a $100 million subsidy program, targeted at an estimated 100,000 participants in co-op insurance programs and employer groups of 2-10 low-income employees. The goal of the subsidy program is to reduce premiums for the eligible groups by 25 percent.

The creation of the Authority did raise some questions among the Council members. Many of them, including Mary Starmann-Harrison, WHA’s 2006 Board Chair, asked if an Authority was needed as a vehicle to deliver a subsidy to eligible employer groups. Council members also recognized that reinsurance by itself would not produce any substantial savings for the non-subsidized segment of the small group market. Insurers would merely be assigning claims costs that exceed a certain threshold to a "pool" that they all would be required to fund and build into their premium rates.

Taken as a whole, however, WHA welcomed the Council’s actions. "Increasing the tobacco tax will prevent thousands of teens from taking up smoking, provide a strong incentive for many thousands more to quit, save millions in preventable health care costs, much of which are now borne by Wisconsin taxpayers, and provide needed revenue for state health care priorities," said WHA President Steve Brenton.

Brenton added that WHA is open to the notion of expanding Medicaid and BadgerCare eligibility to cover the truly uninsured. "But we also feel strongly that the state must do a better job of paying for the programs it already has. As adopted, the Council’s recommendations are a welcome first step in that direction," Brenton said.

According to WHA, in 2005 hospitals were forced to shift $550 million in unpaid Medicaid and BadgerCare costs (not charges) to others with health insurance – a situation dubbed the "Hidden Health Care Tax" by leading business organizations. Many of those unpaid costs are the result of smoking-caused illnesses.

In 2005, the Legislative Fiscal Bureau estimated that increasing the tobacco tax by $1.00 would have generated more than $300 million in FY07. According to WHA, if that money were used to support the Medicaid and BadgerCare programs, it would generate an additional $406 million in federal matching dollars for a total of more than $706 million in FY07.

At WHA’s Board meeting last week, new Assembly speaker Mike Huebsch (R-West Salem) claimed that health care is the "number one" priority issue that will face the Wisconsin Legislature in 2007. Two days earlier, new Senate Majority Leader Judy Robson (D-Beloit) told members of the Competitive Wisconsin board of directors in Milwaukee that health care is the "top priority" issue for her caucus as they prepare to lead the Senate next year.

Notably, the common focus of last week’s comments was on curbing health care costs— not on expanding access and coverage to currently uninsured individuals and families. That fact is profoundly important as we anticipate the new legislative session. There is a high level of bipartisan interest in "doing something" about reining in the high cost of health insurance.

In 2003, University of Wisconsin system leaders convened a multi-stakeholder task force to tackle the health care cost issue. The group’s eventual report, "The Health Care Cost Crisis in Wisconsin: An Economic Development Prognosis" was released at the Wisconsin Economic Summit IV in October of 2003. It is now time to dust off this remarkable document and examine conclusions that remain timely and on target as we head into 2007.

One section of the report exclusively discussed health care "cost drivers" and identified those drivers, listed in descending order of perceived importance:

1) Misalignment of incentives (lack of payment for chronic disease management)

2) Consumer insulation from costs

3) Cost shifting losses from government programs

4) Population lifestyle and Wisconsin demographics

5) Health care worker shortages

6) Absence of best practices and incentives to implement those practices

7) Clinical practice variation

8) Inappropriate utilization of health care services

Three years later, each of these cost drivers (with the potential short term exception of labor shortages) remains relevant in the context of the coming health care reform discussion. The UW-sponsored report concluded that a "new and improved" 21st century health care system must be characterized by:

1. Transparency of information
2. Rewarding of value
3. Engagement of consumers

Importantly, each of these identified cost drivers and reform characteristics aligns with WHA’s recently approved principles that will be used to determine the Association’s position on the variety of legislative initiatives.

Steve Brenton
President

Following two years of preparation, the Strong Rural Communities Initiative (SRCI) was able to secure nearly one million dollars in 2006 from four separate funding sources to begin to improve health indicators for selected rural Wisconsin communities. In Wisconsin County Health Rankings 2004, a report by the Wisconsin Public Health & Health Policy Institute at the University of Wisconsin-Madison, 56 percent of metro counties in Wisconsin are in the top (best) quartile for Health Outcomes compared to only 9 percent of non-metro counties; 32 percent of non-metro counties are in the bottom (worst) quartile compared to 12 percent of metro counties.

SRCI is designed to implement the key recommendation in the Institute of Medicine’s 2004 Report Quality through collaboration: the future of rural health care, the only IOM report to date that focuses on rural health. It recommends that rural communities orient their strategies from a "patient- and provider-centric" approach to one that also addresses the problems and needs of rural communities and populations, and… that rural communities, because of their smaller scale and other unique characteristics, offer an excellent setting for undertaking rapid-cycle change. SRCI believes that rural businesses and their employees constitute a major subset of the community who in partnership with public health and the medical community, can significantly accelerate their community’s overall acceptance/demand for prevention services.

SRCI’s six local community projects address the three overarching goals of the Healthy Wisconsin 2010 by addressing disparities in prevention opportunities by rural communities; promoting and protecting health for all by reaching populations at the workplace as well as the community; and transforming the public health system by involving multiple sectors of the community in population-based and community-centered programming.

WHA Senior Vice President George Quinn said, "One important element that has traditionally been missing from community health improvement programs has been the involvement of employers. The Strong Rural Communities Initiative corrects that missing piece by making sure that its funded projects have active employer partnerships."

Tim Size, executive director of the Rural Wisconsin Health Cooperative, believes the initiative will successfully bring about positive change in the rural health care delivery system. "We can’t afford not to go up stream to prevent illness and injury. The Strong Rural Communities Initiative believes that collaboration among medical, business and public health sectors must become the norm and that it is natural for rural communities to lead in this area. The fact that we have received four grants this year totaling nearly a million dollars is a welcomed affirmation of what we have set out to do," Size said.

The SRCI is sponsored by the Rural Health Development Council (RHDC). RHDC works to link rural health and community development, is appointed by the Governor, confirmed by the Senate, and staffed by the Wisconsin Office of Rural Health (WORH). Consequent to strategic planning sessions in early 2004, SRCI was designed to support Healthiest Wisconsin 2010 by implementing sustainable rural models for medical, public health, and business collaboration to enhance preventive health services in rural Wisconsin. Through a statewide competitive process, RHDC chose six local community projects from among 22 proposals.

SRCI combines six local projects, two medical schools and a statewide policy council with the potential to improve the health of 1.7 million rural Wisconsin residents. SRCI with the Center for Healthy Communities as an academic partner at the Medical College of Wisconsin (MCW) has acquired funding for three years, 2006-2009 from the Healthier Wisconsin Partnership Program for community partners in Langlade, Manitowoc and Waupaca Counties.

With the Wisconsin Office of Rural Health as an academic partner at the University of Wisconsin School of Medicine and Public Health (UWSMPH), funding has been acquired for community partners in Jackson, Sauk and Sawyer Counties for three years, 2006-2009. First year funding was allocated from the Wisconsin Rural Hospital Flexibility Program by the WORH and funding from the Wisconsin Partnership Fund for a Healthy Future was obtained for the second and third years.

The Strong Rural Communities Initiative is believed to be the first community-based initiative to receive funding from both of Wisconsin’s Blue Cross conversion foundations. UWSMPH and the MCW have a strong history of sharing information and working in a parallel and supportive manner.

Six Local Community Initiatives

The six local community initiatives and their hospital partners are: Building a Healthier Langlade County Coalition (Langlade Memorial Hospital, Antigo); Healthiest Manitowoc County 2010 (Holy Family Memorial in Manitowoc, and Aurora Medical Center in Two Rivers); Working on Wellness (WOW) in Waupaca County (Riverside Medical Center, Waupaca); ProACTIVE Wellness Initiative-Jackson County, (Black River Memorial Hospital); FIT: Fitness-Improvement-Teamwork Program (Sauk Prairie Memorial Hospital and Clinics); More ENERGY/More ENERGY at Work (Hayward Area Memorial Hospital).

The WHA Foundation has raised more than $50,000 to date in 2006, and the Foundation Board extends its appreciation to each organization and individual who has made a contribution to this effort.

The funds raised through the Foundation’s annual fundraising campaign will be used to fund the WHA Foundation Scholarship Program at the state’s 16 technical colleges, the Nurse Leadership Succession Project, the Global Vision Community Partnership Award, a Health Literacy Summit in 2007, and other statewide initiatives that support hospitals throughout Wisconsin.

To make a contribution, or for more information on the WHA Foundation’s annual fundraising campaign, contact Jennifer Frank at 608-274-1820 or jfrank@wha.org. Additionally, you can access contribution form online at www.wha.org.

Thank You to Those Who Have Made a Campaign Contribution:

Campaign Contributions to Date

Champion Donors – gifts of $5,000 or more:

Aspirus Health Foundation, Wausau
Columbia St. Mary’s, Milwaukee
UW Hospital & Clinics, Madison
WHA Financial Solutions, Madison

Contributions from Organizations:

Agnesian HealthCare, Fond du Lac
Amery Regional Medical Center, Amery
Black River Memorial Hospital, Black River Falls
Divine Savior Healthcare, Portage
Flambeau Hospital, Park Falls
Hayward Area Memorial Hospital, Hayward
Memorial Medical Center, Ashland
SSM Health Care of Wisconsin, Madison
St. Nicholas Hospital, Sheboygan
St. Vincent Hospital, Green Bay
Wisconsin Hospital Association

Contributions from Individuals:

Loren Anderson, Aurora Health Care – Southern Region
Jenny Boese, Wisconsin Hospital Association
Eric Borgerding, Wisconsin Hospital Association
Steve Brenton, Wisconsin Hospital Association
Jennifer Frank, Wisconsin Hospital Association
Mary Kay Grasmick, Wisconsin Hospital Association
Dan Hymans, Memorial Medical Center, Ashland
Joe Kachelski, WHA Information Center
Ron Paczkowski, Franciscan Skemp, La Crosse
Tom Plantenberg, Froedtert Hospital Foundation, Milwaukee
Brian Potter, Wisconsin Hospital Association
Joe Neidenbach, St. Vincent Hospital, Green Bay
Terri Richards, Saint Joseph’s Hospital, Marshfield
Kevin Stranberg, Memorial Medical Center, Ashland
Judy Warmuth, Wisconsin Hospital Association

Last week Lakeview Medical Center in Rice Lake hosted Senator Bob Jauch (D-Poplar), and this week they hosted Rep. Mary Hubler (D-Rice Lake).

Rep. Hubler visited with Lakeview Medical Board Chair Sue Zahrbock as well as hospital administration on December 18.

Rep. Hubler continues to be very supportive of the hospital and to advocate in support of increased Medicaid reimbursements rates. She sees this issue as a priority for rural Wisconsin.

On December 14, the Joint Finance Committee discussed and approved the Department of Administration’s recommendations on the spending of Federal Income Augmentation funds. In the plan, $4.2M was set aside to help improve oral health access for the uninsured and Medicaid patient. After several motions from various members, the following was approved:

• $350,000 for Scenic Bluffs Dental Clinic in Cashton
• $140,000 for the Madre Angela Dental Clinic in Milwaukee
• $1,000,000 to Marquette University School of Dentistry
• $341,000 for the Brown County Oral Health Partnership
• $75,000 for each of the following clinics
• Family Health La Clinica, Wautoma
• Lakeshore Technical College, Sheboygan
• Tri-County Dental Clinic, Fox Valley
• Oneida and Vilas Counties tribal clinics
• Rural Health Dental Clinic, Menomonie

Approximately $1.8 million was approved for one-time competitive grants to be awarded to counties, organizations, and oral health care facilities to expand dental access to low income individuals. These grants and the parameters of the grants will be administered by the Department of Health and Family Services.

Awards will range between $25,000 and $500,000 to expand or create successful local programs. All grant recipients must show that the programs will continue to provide dental services once the grant funding is spent.

WHA, along with Columbia-St. Mary’s Health System and the Madre Angela Dental Clinic, were active in encouraging quick action by the Joint Finance Committee.

According to the American Obesity Association, implementing prevention programs for children is important to controlling the obesity epidemic. A multidisciplinary team of health care professionals coordinated by Wheaton Franciscan Healthcare – All Saints’ Department of Clinical Dietetics recognized a lack of prevention programs in the Racine community and developed the Active Lifestyle Challenge to empower children and their families to achieve healthier lifestyles.

"Our focus is on positive lifestyle changes for the entire family, not just the overweight child enrolled in the program," said Bridget Klawitter, PhD, All Saints’ director of clinical nutrition and diabetes services. "That is why we ask at least one caregiver to attend each session with the child so the entire family can be involved in making healthier choices."

Currently, the 8-week educational and training program targets two groups of children, ages 5 to 10 and 11 to 15. Children are prescreened to determine existing health conditions, current food intake, level of current activity, and attitudes of self and body. They then meet every Saturday morning for two hours to learn how a healthy diet and regular exercise can help them establish positive health habits, improve school performance and prevent diseases of adulthood.

"Even if a significantly overweight child does not have a serious health problem, he or she is at risk emotionally due to teasing and low self-esteem; their future health is also in danger," explained Dr. Klawitter. "While children tend to have fewer serious obesity-related health problems than adults, there are still significant risks, physically and emotionally, as time goes on and weight issues are not addressed."

To date, 40 children have graduated from the Active Lifestyle Challenge and become members in the All Saints Kids Klub, a free monthly support group to promote year-round healthy eating habits and physical activity. To build on the lessons learned during the program, Klub members participate in a variety of health promotion activities, including picnics, family swim outings and nature walks.

What would happen following a crash involving an anhydrous-loaded tanker truck, a school bus and several other vehicles?

That was just the scenario created for the disaster/code yellow drill enacted on September 7. Along with drill-organizer Lakeview Medical Center (LMC), other community participants included the Rice Lake Fire Department; LMC, Birchwood, Cumberland, Barron, and Chetek ambulances; and Barron County Emergency Management.

87 LMC staff members, 20 Rice Lake High School students and 17 second-year nursing and paramedic students from WITC worked to make the drill not only possible, but as realistic as possible.

The crash was simulated at the intersection of Pioneer and South streets at 12:30 p.m. A white gas cloud was reportedly leaking from under the tanker, with wind blowing it toward the WITC and UW-Barron County campuses. Barron County quickly dispatched the LMC Ambulance and Rice Lake Fire Department, and advised the LMC Emergency Desk charge nurse of the potential for a mass casualty situation involving a chemical, and trauma-related injuries. LMC then activated its Incident Command System.

The drill met all Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards – such as an influx of patients, community involvement and independent evaluators – for disaster drills. Outside evaluators Judy Jones of Luther Midelfort Mayo Health System’s Emergency Department and Dallas Crowe, Bloomer Medical Center’s safety director, observed the drill and had positive feedback.

According to LMC Ambulance Coordinator Russ Dennis, the drill went very smoothly and was a positive indication of the teamwork that would transpire during a real disaster. He added that everyone involved should be commended on their hard work and added effort to make the drill a successful tool.

A great deal of preparation took place behind the scenes at LMC prior to this drill. Additional education and training led to vast improvement between last year’s and this year’s drill, according to Dennis. Departments such as lab, housekeeping, radiology and emergency took the initiative to hold mini-drills throughout the year, and the focus of much internal communication was on disaster preparedness. The same preparation is planned between now and the next drill, scheduled for spring of 2007.

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