The Wisconsin Hospital Association (WHA) reiterated its opposition to a proposal in Governor Doyle’s budget that would remove $175 million from the Injured Patients and Families Compensation Fund (IPFCF). An audit released on March 22 by the Legislative Audit Bureau (LAB) cautions that the estimated $685 million in liabilities against the $737.4 million fund are difficult to predict and could be much higher.

WHA Senior Vice President George Quinn, a member of the IPFCF Board of Governors, said the Board this week went on record opposing any attempt to use the Fund’s money for any use beyond the original legislative intent developed in 1975. Further, the Board said the trust fund monies are held in an irrevocable trust to be used only for purposes of medical liability claims beyond the primary insurance limits. The resolution passed on a unanimous vote with only one abstention.

Physicians, hospitals, and other health care providers are required by state law to pay fees into the Fund, which is used to compensate patients injured by medical negligence. No tax monies are in the Fund. This is the third time since 2003 there has been a proposal in the state budget to take money from the Fund to pay for other state programs.

"While it might be tempting to look at the Fund and think there is a lot of money that could be freed up to pay for other state programs, the first and sole priority of the Fund is to ensure that monies are always available to cover the medical bills and living expenses of those who are injured," Quinn said.

WHA President Steve Brenton said the Association and its members would urge the Legislature and the Joint Finance Committee to reject any proposals to withdraw monies from the fund. "We have a bad habit in Wisconsin of taking money that is collected for one purpose and spending it for something else," Brenton said. "While we understand the budget challenges facing Wisconsin, we must remain steadfast in our commitment to collect and use funds for their stated purpose."

Brenton noted that provider premium rate increases to the Fund have increased by 30 percent since 2005. "The removal of $175 million from the Fund will undoubtedly lead to a substantial premium increase for physicians and hospitals in 2008," Brenton said. "This new raid, if successful, could essentially amount to yet another ‘hospital tax’ to fund the state budget."

As the Legislature’s budget-writing committee travels across Wisconsin to take testimony on the state budget, hospitals are making sure their voices are heard on the hospital tax. This week Columbus Community Hospital CEO Ed Harding testified before the Joint Finance Committee at its hearing in Arlington.

"Many of us in health care concur with the Governor’s goals of providing health care coverage to all children in the state as well as expanding coverage for adults," Harding told committee members. "However, the proposed hospital tax is a flawed mechanism for achieving these goals, and unnecessary."

Columbus Community Hospital is a Critical Access Hospital (CAH) and as such, Harding spoke specifically to the impact a tax would have on these critically important facilities.

"I believe this [hospital tax] will not meet certain federal requirements and will therefore negatively impact rural, CAH-designated hospitals in this state…experience in other states shows that hospital taxes create losers and winners. Other states have seen their rural hospital community in the column of ‘losers’." Harding said. "Wisconsin rural hospital communities deserve better treatment than this."

Harding also told the committee that any dollar Wisconsin put towards Medicaid, such as the proposed tobacco tax increase, would draw down additional federal matching dollars; therefore, a hospital tax is not necessary to do so. Additionally, Harding expressed his concerns over the destabilization of the Medicaid budget under the Administration’s proposal.

"The tax actually destabilizes the Medicaid program by removing general purpose revenue from the state’s share of Medicaid funding and replacing it with hospital tax revenue," he said. "This means that any additional Medicaid funding will likely require further increases in the hospital tax, thus negating any theoretical ‘gains’ derived in the first year or two of the tax."

In fact, an analysis done by the Legislature’s nonpartisan Legislative Fiscal Bureau shows the Administration’s budget removes $900 million in existing Medicaid funding dollars from the Medicaid budget to be used for other state spending. The Governor then uses about one-third of the hospital tax and all of the proposed cigarette tax to backfill the hole.

"Our state’s nursing homes are already showing us the debilitating effects of such tax proposals," said Harding. "Each year this tax rises, and each year more and more nursing homes become unviable. This isn’t just an economic problem. There are real consequences for families unable to access care for their loved ones."

"Instead, I concur with the unanimous recommendations of Governor Doyle’s Healthy Wisconsin Council," continued Harding in closing. "This diverse group, which included health care consumers, labor organizations, health care providers and insurers, recommended increasing the tobacco tax by $1 and using those funds for the Governor’s proposed health coverage expansions and Medicaid provider rate increases."

Statewide groups such as the Wisconsin Manufacturers & Commerce (WMC) and the Pharmacy Society of Wisconsin have also weighed in on the negative impact of the proposed hospital tax.

In their written testimony to the Joint Finance Committee, WMC said:

"The 1 percent assessment on hospital revenues is a bad solution to a very real problem—the hidden health care tax. While the "sick tax" would generate additional state and local revenue for Medicaid reimbursement, a Wisconsin Hospital Association analysis estimates a net loss of at least $132 million for Wisconsin hospitals. Rather than raise a tax on hospital patients, the state should increase Medicaid reimbursement rates from existing GPR revenues."

On behalf of the Pharmacy Society of Wisconsin, President Susan Sutter cited their concerns in a written statement:

"The PSW Board expressed concern about placing taxes on health care providers—as with the proposed 1 percent hospital gross revenue tax—as a method to generate additional revenues. Taxing health care providers, in order to better pay them for their services, is highly questionable as a sustainable health care financing model," Sutter said.

The Joint Finance Committee will travel to Chippewa Falls on March 27, Prairie du Chien on April 4, Rhinelander on April 11, and Green Bay on April 12 for additional hearings, and Wisconsin hospitals will be there!

If you would like to or are already planning to testify at one of these hearings, please contact Jenny Boese at 608-268-1816 or jboese@wha.org.

On March 16-17, 105 physician leaders from 40 different hospitals throughout the state attended the Wisconsin Hospital Association’s second annual "Physician Leadership Development Conference" held at The American Club in Kohler. In its second year, the event again drew a much higher than expected attendance of both physicians and hospital "hosts."

Presented by American College of Physician Executives (ACPE) faculty, the conference was designed to assist new and potential physician leaders make the leap from their traditional clinical training to adopt new leadership approaches to decision-making and problem solving.

David Nash, MD, internationally recognized for his work in outcomes management, medical staff development and quality-of-care improvement, focused Friday’s full-day session on measuring and improving the quality of medical care. Sarah Fontenot, RN, JD, spent a half-day the topic of health law, along with EMTALA, peer review and Stark II.

"WHA is committed to helping our members identify and develop physician leadership as a core Association program priority," said Steve Brenton, WHA president. The idea for a conference of this type to be held in-state as a way to offer nationally-recognized leadership education without the high travel and lodging costs of many of the out-of-state programs, came in 2005 from members of WHA’s Council on Medical & Professional Affairs, many of whom are physician and nursing leaders in their own organizations.

Attendee feedback from the 2006 session, coupled with feedback from the Council, assisted WHA staff in developing the curriculum for this year’s physician leadership education. Attendee evaluations also showed strong interest in WHA continuing this conference as an annual event, exposing these new physician leaders to additional important health care topics. Watch for information about a 2008 event later this year.

The Center for Medicare and Medicaid Services (CMS) issued additional guidance on the implementation of section 6032 of the Deficit Reduction Act. DRA 6032 requires providers who receive at least $5 million annually in Medicaid payments to establish and disseminate written policies for their employees, contractors, and agents related to state and federal false claims laws.

The CMS guidance, released on March 22, includes a "Frequently Asked Questions" with 71 items and a description of the federal False Claim Act. The new guidance and other information concerning DRA 6032 can be viewed on the WHA website at www.wha.org under Legal and Regulatory.

DOA Secretary Morgan’s announcement last week that the agency has retained a consultant to wrestle with issues raised by WHA in a recent analysis of the Doyle Administration’s Hospital Tax Plan is validation that the Association’s comprehensive analysis, based on federal law and regulation, was on point. The Secretary is basically calling for a "Mulligan." Here’s a bet that the new hospital payment plan will bear little resemblance to the first plan.

But WHA’s opposition to the hospital tax goes well beyond the fact that the promised millions of dollars in higher hospital payments as described in the original plan cannot happen given the state’s current Upper Payment Limit and given existing federal law and regulation that frames allowable Disproportionate Share Hospital (DSH) payments.

Consider these troublesome aspects of the current plan that have absolutely nothing to do with real or imagined hospital payments:

1. The Hospital Tax would be due July 1, 2007. Higher Medicaid payments would begin to flow to hospitals only after the new state plan amendment is approved by CMS. If the plan amendment is delayed, denied or modified, the tax is collected and continues—with no guarantee of new payments to hospitals.
2. A high-ranking Administration spokesman last week said that he anticipated rapid "approval" by CMS of the plan amendment. But the much-vaunted (by Administration) Illinois Hospital Tax plan actually passed the Illinois legislature in May of 2005 and didn’t win CMS approval until late November 2006. And as of today, unlike Illinois, Wisconsin does not have an approvable plan—as revealed in the recent WHA analysis. That’s why DOA just hired a consultant to try to fix their mess.
3. Speaking of Illinois, just 18 percent of that state’s hospital tax is taken by the State and used for programs other than higher hospital payments. The Doyle Administration Hospital Tax claims 30 percent in just the first year. And that percentage might be much higher depending on CMS’ ultimate treatment of the plan amendment.
4. The proposal creates a "trust fund" fueled by a one-time raid on the Injured Patients and Families Compensation Fund, new tobacco tax funds and the hospital tax. By the end of the biennium, the fund’s ongoing expenses exceed ongoing revenue. The stage is set for a higher hospital tax (or greater percentage claim on current tax) as early as 2009.

The point here is that despite the recent focus on the potential legitimacy of hospital payments, it’s not just about the numbers. There are other nettlesome aspects of the Doyle Hospital Tax Plan that deserve the spotlight. And the above list is by no means a complete accounting.

Finally, it’s important to remember that the WHA Board position on the tax is framed by three broad principles: 1) A provider tax is an awful precedent, as demonstrated by the current tax on nursing homes; 2) There is an alternative to fund health care expansions and provider payment increases (tobacco tax revenues); and 3) The Plan itself is a hugely flawed initiative. It is the sum total of these three facts that make this initiative such an odious approach to funding necessary health care priorities.

Steve Brenton,
President

WHA provided testimony this week before the Assembly Public Health Committee in support of Assembly Bill 90, legislation authored by Rep. Mursau (R-Crivitz) and co-sponsored in the Senate by Sen. Lassa (D-Stevens Point). AB 90 creates a loan program for students of Wisconsin’s two medical schools. Under the bill the loans are provided up front to these students and then forgiven at a certain rate over the next six years if that recipient serves in a Wisconsin Health Profession Shortage Area (HPSA) after graduation.

"In 2004, the Wisconsin Hospital Association published, ‘Who will Care for our Patients,’ a review of the current and future physician supply for Wisconsin," testified WHA Vice President of Workforce Judy Warmuth. "That document points out that a current maldistribution of physicians exists in Wisconsin, and a future shortage and maldistribution of physicians will happen without significant changes to the current system of educating and recruiting students."

Warmuth went on to say that less than 40 percent of the physicians who graduate from the two Wisconsin medical schools actually stay and practice in Wisconsin.

"While there are a number of solutions to the future shortage, one of the simplest is to keep the physicians that we educate here," said Warmuth. "This program places physicians in the geographic areas of greatest need. By requiring practice in a health professional shortage area for repayment, the program will assist us in recruiting physicians to locations in Wisconsin that already demonstrate a shortage or need."

Warmuth’s testimony also pointed out several other positive aspects to AB 90:

• The loan program would be administrated by the Higher Education Aids Board (HEAB) and would parallel similar loan programs for professionals in the state. This proposal is attractive in that it does not require a new administrative structure to address the physician workforce shortage
  
• No single strategy will solve the physician workforce issues facing Wisconsin, but this bill addresses the problem in a positive way, encouraging students early in their medical education to plan to stay in Wisconsin and practice in an underserved area.

The Wisconsin Department of Health and Family Services has issued a new variance concerning the authentication of physician orders. According to DHFS, the purpose of the new variance is to explain DHFS’ current position on authentication of physician orders in hospitals and to align the state requirements with federal Medicare regulations.

The variance of HFS 124.12(5)(b)11 is the following:

Medical Staff Bylaws and rules shall include . . . a statement specifying categories of personnel duly authorized to accept and implement medical staff orders. All orders shall be recorded, dated, timed, and authenticated. All verbal and telephone orders shall be dated, timed, and authenticated in writing by a practitioner who is authorized to write orders by hospital policy within 48 hours of receipt.

DHFS explains that the variance incorporates the Medicare definition of "practitioner who is authorized to write order by hospital policy" to include physician assistants and, in Wisconsin, advanced practice nurse prescribers. DHFS states "In Wisconsin, the only registered nurses who may write hospital orders are advanced practice nurse prescribers. The Department of Regulation and Licensing’s interpretation of the authority of APNPs is that such individuals may issue an order for medications verbally or in writing directly to the hospital pharmacy. The APNP may not give the order verbally to an RN, LPN, ward clerk, or administrative assistant to either call the order in to the pharmacy or write the order in the medical record for conveyance to the pharmacy."

The Wisconsin Society for Healthcare Risk Management is hosting a conference on the "Criminalization of Medical Errors" on April 27 in Madison at the Crowne Plaza Hotel. The 2006 criminal prosecution of a registered nurse shocked the Wisconsin health care community and has had an impact nationwide on patient safety initiatives. Criminal charges for a medication error that tragically resulted in the death of a patient during labor have left us with questions regarding the future for all providers of health care services. Hospital risk managers and other members of the hospital administrative team have worked extremely hard to develop and foster a culture of safety.

This conference will help participants understand how this case will affect the future of actual event and near miss incident reporting, disclosure of unanticipated outcomes, and other patient safety initiatives.

Wisconsin Hospital Association Attorney Laura Leitch will provide a legislative update on the Wisconsin RN criminal case, along with Gina Dennik-Champion, executive director of the Wisconsin Nurses Association. Defense Attorney Steve Hurley will discuss national trends and the specifics of the criminal prosecution/defense of a Wisconsin RN for a medication error. Attorney Jack Zweig, Wisconsin Department of Regulation and Licensing, and Attorney Mark Frankel from Godfrey & Kahn will also present.

At this seminar, participants will:

• Learn the differences between "ordinary" and "criminal" negligence
• Learn the history and nationwide trends related to criminalization of negligence
• Hear the facts of the recent criminal case brought by the State of Wisconsin Attorney General’s Office against a Madison registered nurse
• Identify the potential impact criminal prosecution of a medical error may have on the patient safety movement and learn potential strategies to mitigate the effects in your own organization.

To register, download the brochure at www.wshrm.org. The cost is $60 for members, and $85 for non-members registered before March 28. The price goes up slightly after that date. For more information contact Deb Ankowicz at dankowicz@uwhealth.org or Matt Wahoske at mwahoske@fincorsolutions.com.

Therapists and staff in Rehabilitation Services at Good Samaritan Health Center, Merrill spend much of their time providing one-to-one patient-focused care to people from all walks of life.

This effort usually involves an individualized focus, but every year this group of health professionals goes a step further to band together for the benefit of the Merrill community.

The Rehabilitation Services Department is putting the finishing touches on its annual service project, this year featuring a cookbook sale to benefit the Merrill Food Pantry.

This group of physical, occupational, industrial and cardiac rehabilitation professional uses National Rehabilitation month to jump-start a project to benefit the community. This year’s project resulted in the sale of nearly 300 cookbooks and generated $1,200 for the Food Pantry.

"This project was especially fun because a number of us love to cook," said Kathy Anderson, physical therapist assistant and cookbook project leader. "To be able to share a treasure of great recipes and have the end result provide much needed support to the food pantry is rewarding for all of us."

The development of the cookbook also spurred an additional fund raising source as Rehabilitation Services staff assembled "recipe kits" from the pages of "Celebrate Rehab Services" that were put up for bid in the hospital cafeteria. Anderson was quick to also give credit to her cookbook committee of Michelle Odegard, Kristen Woller, Deb Zuelsdorff and Lana Seefeldt for their efforts to make the project a success.

"This kind of effort is the lifeblood of the Merrill Food Pantry," said Dale and Jackie Kuck, co-directors of the food pantry. "We are able to support about 3,000 people in Lincoln County each year, and if we didn’t have this type of support we would not be able to do it."

The Merrill Food Pantry uses CAP services as its screening agency. Families in need receive a form from the agency that they bring to the food pantry to receive items based on the size of their families.

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