This year’s WHA Advocacy Day attendees had the unique opportunity to witness the results of their advocacy efforts firsthand as the Rural Healthcare Access Act (AB 770 / SB 553) was scheduled for floor votes in both the Senate and Assembly on the same day as nearly 650 hospital supporters descended on Madison to make their voices heard.

They made the most of their opportunity. Meeting with legislators in their offices, in committee hearing rooms, in capitol hallways, and even outside the Senate and Assembly chambers, attendees helped lock in strong bi-partisan support in both houses of the Legislature.

AB 770, which will strengthen rural health through a new assessment on critical access hospitals (CAHs), passed the Assembly on a 60-38 vote (one absent) as 49 Democrats were joined by 10 Republicans and one Independent in voting to approve the measure. The bill was then taken up as the identical version of SB 553 and approved with no further discussion by the Senate on a 22-11 vote as all 18 Democrats were joined by four Republicans in voting yes.

To see how your Representative voted, log on to: www.legis.state.wi.us/2009/data/votes/av0431.pdf. The Senate vote can be found at: www.legis.state.wi.us/2009/data/votes/sv0229.pdf.

AB 770 became necessary to address the 10 percent across-the-board Medicaid cut to CAHs from the Department of Health Services (DHS) as part of their efforts to tackle a more than $630 million current budget shortfall. In addition to restoring the cut, the proposal will preserve and capture more federal Medicaid matching funds that otherwise would be lost, improve CAH Medicaid payments and dedicate funding for rural physician residencies and loan forgiveness for rural health care professionals.

The wide bi-partisan vote margins culminated months of effort from rural hospital members, legislative supporters and their staff, WHA and the Rural Wisconsin Health Cooperative (RWHC). DHS provided technical assistance.

Critical to these efforts were legislator meetings at rural hospitals where hospital leaders discussed the mounting challenges that rural hospitals are facing, especially from recession-related skyrocketing charity care and bad debt. The unprecedented economic strain is forcing cost-reducing measures that are jeopardizing access to rural health care services.

WHA member efforts also helped quickly and efficiently shepherd AB 770 through the legislative committee process. From introduction to final legislative approval, and in a time span of less than seven weeks, AB 770 / SB 553 had hearings in and received approval from two standing committees, was approved by the Joint Committee on Finance and received positive votes from the full Senate and Assembly.

Other organizations supporting the measure include: University of Wisconsin-Madison School of Medicine and Public Health; Wisconsin Primary Healthcare Association; Wisconsin Nurses Association; and the Wisconsin Academy of Family Physicians and Wisconsin Manufacturers and Commerce.

Governor Doyle is scheduled to sign AB 770 on Monday, April 19 at Columbus Community Hospital.

This has been a very busy week with both houses taking up many bills as they move toward the last scheduled session days. On April 15, four bills relating to the workforce and of interest to WHA members were approved by the Assembly: reporting requirements for physicians (AB 877), licensure for anesthesiologist assistants (AB 671), and changes to the practice of midwifery (AB 675). Monitoring dispensing of prescription drugs (AB 227) was approved as amended by the Senate.

In the Senate, a bill that prevents discrimination against an employee who declines to attend an employer-sponsored meeting or to participate in communication with the employer around specific topics including religion, politics and union activity (SB 585) was approved by the Senate. Bonding authority for a new dental school in Marshfield also passed the Senate (SB 656).

With the exception of the "monitoring of dispensing" bill, all of these bills will need to pass in the other house in the very near future to become law.

It was a day to remember for the 650 hospital supporters that converged on Madison April 13 to attend WHA’s Advocacy Day at Monona Terrace. Hospital volunteers and members of Partners of WHA joined hospital executives in hearing from Wisconsin’s gubernatorial candidates, journalist Juan Williams, Governor Jim Doyle, and WHA members and staff. While all speakers presented on different topics, there was a common theme: Wisconsin is a national health care leader, and hospitals are the fabric that forms the health care safety net.

Recognizing the large crowd and thanking them for being strong advocates for the health and well-being of their communities, WHA Chair David Olson, executive vice president, Columbia St. Mary’s, Inc. and president, Columbia St. Mary’s Hospital Ozaukee, observed, "Our voice matters and our voice will be heard." Olson emphasized the importance of the legislative visits scheduled in the afternoon, a point that keynote speaker Juan Williams stressed as well.

Williams, a news analyst with Fox News and National Public Radio, commended attendees for taking time to meet with their legislators. He urged them to press on even though legislators may seem like they are not always attentive to their issues, "be persistent and get their attention."

Health reform has created a significant moment in health care history, according to Williams.

"What a privileged position you hold in terms of this history," he said. "You are shaping the future of health care in America. It has been a long struggle for better or worse. But that puts you in a precarious and precious position…that of having a hand in shaping what is to come."

Wisconsin is uniquely qualified to weigh into the discussion surrounding the implementation of the recently-passed health reform bill, Williams noted.

"You are a model for the entire country in so many ways," Williams said. "You’ve done it (reform) with limited controversy compared to the national debate that has been going on in this county, and you have achieved almost 100 percent coverage."

Demographic shifts have occurred in the United States that are rapidly changing the political, social and economic landscape. The Census Bureau reports that a quarter of the people living in the United States are under the age of 18, half are under 34. More than 50 percent of college students are women, one out of three members of Congress are women, and the last two Secretary’s of State have been women—Hillary Clinton and Condoleezza Rice. In addition, seniors over the age of 65 make up 15 percent of the population. By 2025 they will comprise a quarter of the population. The biggest lobby group in the United States is the AARP.

All of this leads to what Williams described as a "barbell society" weighted on one side with young people and the other with seniors that have goals that may be at odds with the younger generation. Senior citizens’ greatest concerns are social security, prescription drug costs, and access to first-class medical facilities.

"Hospitals are engines of economic activity in our communities because people want those first-class hospitals in their communities," Williams said.

Williams commented on how impressed he is with the fact that hospital volunteers from across Wisconsin traveled to Madison to meet with their legislators, and he offered them advice and encouragement.

"As you visit with your legislators this afternoon, keep in mind that you have to be informed because they don’t know what you know. You have to be the hand that shapes the things to come. It would be foolish to think that they know what to do," Williams said. "That is why this Association is important. They are making your case. It is shaping something that will later be under tremendous pressure, and the ‘center’ has to hold as people talk about cost, the deficits, and finding a way to take care of kids."

"Understand that you are not simply leading your life. You are not simply going about the work of a self-interest group," he added. "You are not just shouting at each other on TV. You are doing the work. Don’t be intimidated, don’t back down, stand up. People are looking for those that get the job done, and hospitals get the job done."

Unable to appear at WHA’s Advocacy Day April 13, gubernatorial candidate and Milwaukee Mayor Tom Barrett met with the WHA Board at their regular meeting April 14 in Madison. Barrett said his key priorities are education, health care, and creating new jobs. He said the state faces a $2.3 billion structural deficit, which he believes places hospitals as Medicaid providers in a very difficult situation.

When asked how he would deal with the state budget deficits, Barrett said he would first "do no harm." He said to truly address the deficit, changes are necessary in education, the prison system, and in health care programs. While he did not have time to detail the changes he might propose, he said he is familiar with the Medicaid, HIRSP and BadgerCare programs and he committed to work through the issues with providers.

Barrett said the role of the Governor is to be a master salesperson for the state. "People are looking for hope," he said. "Most people believe in their families and communities, and they want to work through this."

Brenton Outlines Likely Impact of National Health Reform on Wisconsin

WHA President Steve Brenton described the federal health care reform package for WHA Board members. Brenton said there are five central themes: coverage; how that coverage will be financed; insurance reform; "real" reform; and efforts at addressing adequate workforce and access.

Achieving the projected coverage of an additional 32 million individuals by 2014 is done in part through large Medicare cuts to health care providers—including hospitals—as well as a significant increase in taxes, penalties, and fees.

"While the full impact of health reform can’t be described yet, we know the cuts begin later this year and will cost Wisconsin hospitals at least $2.6 billion over the next decade," according to Brenton.

Hospitals will see cuts in disproportionate-share (DSH) payments, reductions in the market basket updates, and penalties associated with readmissions and health care associated infections.

WHA Priorities: A Blueprint for the Future

WHA staff began a detailed analysis of the health reform package shortly after final passage with the goal of creating a blueprint that aligns with the implementation timeline. Brenton said WHA’s key priorities are to maintain and accelerate the commitment to value and performance improvement; determine how the state’s Medicaid program can be sustained until significant changes are implemented in 2014, and to communicate to members the new regulations related to community benefits transparency.

Legislative Activity in High Gear: CAH Assessment Passes Legislature and will be signed into law Monday, April 19

In the waning days of this legislative session, activity in the Capitol is at a frenzied pace as witnessed by the hundreds of hospital supporters that visited their legislators April 13 while attending Advocacy Day.

WHA Executive Vice President Eric Borgerding reported that both houses of the Legislature passed the Critical Hospital Assessment on Tuesday, April 13, just as 650 hospital supporters converged on Madison for WHA’s annual Advocacy Day (see article above).

The bill (AB 770) will be signed into law by Governor Doyle on April 19 at Columbus Community Hospital.

Borgerding said WHA continues to closely monitor several other major issues:

BadgerCare Basic (AB 697 / SB 484) – Basic is Governor Doyle’s bare bones, low-cost health plan proposal for those on the waiting list for BadgerCare Core. Basic was recently approved by the Assembly Health Committee on a party-line vote. Several WHA-backed amendments to Basic previously adopted by the Senate were also adopted by the Committee. The amendments will help assure the intent of Basic as a safety-net health care program for low-income individuals who have no other options. The amendments will also allow the public and the Legislature to monitor the performance of Basic and assure that it functions as intended. An additional amendment offered by Rep. Jennifer Shilling (D-La Crosse) and Rep. Penny Bernard-Schaber (D-Appleton) and adopted by the Committee sunsets the program at the end of 2013.

The additional amendment means that should Basic be approved by the full Assembly, it will need to go back to the Senate for their consideration of the sunset provision before it can be forwarded to the Governor for his signature in late April. Gov. Doyle’s initial target start date for Basic was April 1.

Banning Mandatory Overtime (AB 152 / SB 108) – WHA continues to monitor these bills and provide information to legislators. Mandatory overtime is a rarity in Wisconsin’s community hospitals; however, it is a common practice in state-owned health care facilities. According to the State’s own analysis of the bills, mandatory overtime is a common staffing practice in government-run health care facilities. Because of this, enacting either of the bills into law would cost taxpayers roughly $5 million and require the state to hire dozens of new employees.

Transparency (WI Act 146) – Signed into law in early March 2010, Wis. Act 146 requires hospitals and other health care providers to disclose certain information about billed charges and quality. Hospitals will be able to comply with requirements in the new law, which becomes effective January 1, 2011, through PricePoint and CheckPoint.

WHA worked closely with the bills’ authors to secure amendments in the proposal that acknowledged Wisconsin hospitals’ nationally-recognized proactive transparency efforts and their unique position to leverage existing infrastructure.

Medicaid – Cuts in Medicaid totaling $300 million continue to be on the table. Borgerding said if Congress extends the Federal Medical Assistance Percentages (FMAP) through June 2011 it should help Wisconsin minimize further Medicaid reductions. It is estimated that Wisconsin will receive an additional $300 million through the temporary extension—dollars that should be for Medicaid, as intended.

The newly-formed WHA Medicaid Advisory Group has now met twice with staff from the Wisconsin Department of Health Services (DHS), including Medicaid Director Jason Helgerson. The purpose of these meetings is to build on the working relationship that has developed between Wisconsin hospitals and DHS as the State and hospital community have tackled important Medicaid payment and coverage issues. The meetings promote transparency in the rate setting process and allow a platform for more hospital feedback into the many Medicaid processes and policies carried out by DHS.

At the last meeting, the group discussed the hospital assessment program and the impact federal health care reform might have on Wisconsin. Borgerding said at the April 28 meeting, the advisory group will further discuss policy decisions for the fiscal year 2011 rates, review the DRG weight-setting process, review a new cost-based UPL analysis, and further discuss Medicaid rate reform version 2.0.

In other business, the Board approved the following persons to serve on the Association’s 2010 Nominating and Bylaws Committee:

Mike Schafer, President/Administrator, Spooner Health System (chair)
Tom Bayer, COO, St .Vincent Hospital, Green Bay
Steve Brenton, WHA President
Greg Britton, President/CEO, Beloit Health System
Faye Deich, RN, MS, COO, Sacred Heart Hospital, Eau Claire
Bob Fale, President, Agnesian HealthCare, Fond du Lac
Daniel Hymans, President, Memorial Medical Center, Ashland
Terri Richards, Executive Vice President, Saint Joseph’s Hospital, Marshfield
Bill Sexton, CEO, Prairie du Chien Memorial Hospital
Ford Titus, CEO, ProHealthCare, Waukesha

The Committee will present its report and recommendations to the membership at the Annual House of Delegates meeting on Thursday, September 16 in Madison.

In what was his final address at WHA’s annual Advocacy Day, Governor Jim Doyle began by thanking WHA and its member hospitals for the partnership that has been provided to him over the past seven years. He asked for their continued backing during the eight remaining months of his final term.

The Governor noted that Wisconsin is number one in health care quality and second only to Massachusetts—that has a health insurance mandate—in coverage. Doyle said his goal in expanding coverage in Wisconsin was to address the "hidden tax" that results when the cost of uncompensated care is shifted to insurers and private payers. Doyle thanked hospitals for their assistance in formulating a solution—a solution made possible by the hospital assessment.

"The assessment has proven to be incredibly helpful to hospitals. It supports BadgerCare Plus and it has been a way to deploy hundreds of millions of additional federal dollars to Wisconsin by shoring up rates and expanding coverage to people," Doyle said. He acknowledged that while it was not easy, all partners "stayed in the room, shared a common vision, and did it the right way by working together."

The Governor outlined two opportunities that he believes may be possible under the newly-passed federal health reform: a statewide system to share medical records and a health insurance exchange that connects the uninsured with coverage options.

Doyle said he believes Wisconsin can be the first state in the nation to have a fully-integrated electronic medical record system. Wisconsin is in a good position to attain that goal given that Wisconsin health providers have already made heavy investments in EMR. Three of the leading electronic medical records vendors are in Wisconsin—Epic Systems, GE Healthcare, and Marshfield Clinic.

Doyle concluded his final Advocacy Day address by recalling the historic and ongoing mission of Wisconsin’s hospitals.

"If you look where all your hospitals started from-- your beginnings from a municipal or religious organization—our hospitals started with a basic mission not of making money, but of making sure people had health care," Doyle concluded. "That is the history of Wisconsin health care…hospitals devoted to making sure people received high-quality health care."

WHA President Steve Brenton presented the Governor with an award for his leadership in supporting coverage improvements that have placed Wisconsin near the top of state rankings for low rates of uninsured.

"No state has been more creative, more relentless or more successful in finding ways to add indigent individuals and families to Medicaid programs," Brenton said. "This is deservedly a legacy issue for Governor Doyle," he added.

Republican gubernatorial candidates Mark Neumann and Scott Walker outlined their priorities for the 650 likely voters gathered for WHA Advocacy Day. Both emphasized that job creation and tort reform are key in reducing health care costs. Democrat candidate Tom Barrett was unable to attend the forum due to a prior commitment.

Walker, the current Milwaukee County Executive, noted in his remarks that the regulatory burden imposed on hospitals and businesses in Wisconsin should be "limited and science-based." Walker stressed that the regulatory environment in a state affects the private sector’s ability to grow their businesses and create jobs. Walker said he adheres to three simple principles, "Don’t spend more money than you have. Smaller government is better than large. People create jobs not government." A self-described fiscal conservative, Walker said as Milwaukee’s County Executive he balanced the budget and still provided core services.

"We can’t cut ourselves to prosperity," Walker said. "I want to balance the budget and increase the overall economy."

Access to quality health care in Wisconsin is excellent, according to Walker; however, the challenge for small and mid-sized employers is offering affordable coverage to their employees. He said the state could play a role in helping these employers form a larger pool to spread risk and access more favorable health insurance rates.

Neumann, a teacher by training and a home builder by trade, said Wisconsin’s ability to compete with other states for business is predicated on a strong education system. If elected Wisconsin’s next Governor, Neumann said he would push for economic development and establish Wisconsin as a place "to do business."

He believes Wisconsin’s economic woes could be addressed by cutting taxes, which allows people to keep more of their money. "You would either spend it and create jobs or save it, and it would become the capital we need to grow our businesses," according to Neumann.

As for the large growth in enrollment in and costs associated with the Medicaid program, Neumann sees job creation—and health benefits attached to those jobs—as the cornerstone for making health care accessible to all.

The WHA 2010 Advocacy All-Star award was presented at this year’s Advocacy Day to Columbus Community Hospital for their stellar commitment to advocating on behalf of their hospital, patients and community. The award is given each year to one hospital that best represents a dedication to grassroots advocacy.

"Columbus Community Hospital is really a special place and I’m blessed to have so many talented people. We’ve got a board of directors and a foundation board of directors that provides great guidance and support throughout the year. Our employees and medical staff are incredible with special emphasis on our management team," said Columbus CEO Ed Harding in accepting this year’s award. "And last, certainly not least, our wonderful volunteers…they’re always present; they’re always active when it comes to legislative issues. They represent us well and we could not exist without them."

In the past year, Columbus hosted their legislators no less than four times, testified at legislative hearings, consistently communicated with their legislators, promoted WHA’s grassroots program (HEAT), and worked collaboratively with WHA on priority issues like the Rural Healthcare Access Act. Harding also served as chair of the task force that developed this legislation.

"Columbus Community Hospital is extremely proud to have worked alongside WHA, one of the state’s premier advocacy organizations, to advance several health care legislative initiatives this past year," said Harding. "I wanted to end by emphasizing our legislators because, really, you don’t get an advocacy award if you don’t have interaction with your legislators and the way our great government works."

"In my case, our Senator, Mark Miller, who first came to our hospital to learn about the 10 percent [Medicaid] cut [to critical access hospitals] and then decided to sponsor the bill that will ultimately be acted on today—that requires a relationship," Harding closed. "And there are 350 traveling to the Capitol today. It’s so important that you do that, not so much for [legislators] to hear from you when you need them, but to make sure you’re there for them as well. Like any healthy relationship, it can’t just be one way."

Columbus was recognized because they "did everything right," said WHA Vice President of External Relations & Member Advocacy Jenny Boese. "From hosting their legislators to testifying at legislative hearings in Madison, their efforts on behalf of their patients and community are an example for everyone to follow."

Capping off the day, nearly 400 people descended on the State Capitol to meet with legislators and staff. The meetings are the most important component of Advocacy Day and the number of those participating is growing every year, a trend that pleases the Wisconsin Hospital Association.

"The job of educating legislators is never done," WHA Executive Vice President Eric Borgerding told the crowd during a pre-meetings issue briefing. "Hospitals are on the front lines of health care and they support their communities in many ways. As the state’s economy has faltered, hospitals are the community’s health care safety net. We are always there for those in need. Sometimes that is taken for granted… your legislators need to hear your story."

Borgerding called hospitals "the cornerstones of our communities." In 2008 Wisconsin hospitals contributed $22 billion to Wisconsin’s economy, provided 100,000 good jobs, and treated for more than one million patients who could not pay for their care. Wisconsin’s hospitals are also national leaders in health care quality and value, a distinction legislators need to better understand and that advocates stressed in their meetings.

Record-Setting Number of Advocates Visit Legislators

But there were also key pieces of legislation to be discussed. Legislation creating a new Critical Access Hospital Assessment was slated for a vote in both houses that very day. The legislation was developed by rural hospitals as a mechanism to increase federal Medicaid funding and preserve access to health care in Wisconsin’s rural communities (see story on page one).

Advocates were also encouraged to reiterate their continuing and strong opposition to legislation that will ban the use of mandatory overtime.

The harried activity at the State Capitol seemed to energize the nearly 400 people who took time to meet with their legislators. It’s no wonder the meetings are the most important and quickly becoming the most popular aspect of Advocacy Day: With both Houses in session, several of the legislative meetings took place just outside the Senate and Assembly Chambers. For some, it was their first chance to sit in the galleries and watch legislators participate in floor debate. Some legislators even interrupted the floor debate to formally recognize visiting hospital advocates.

"We couldn’t have scripted a better day or experience for everyone who came to Madison today," Borgerding said. "Hospital advocates are informed, engaged and ready to stand up for their communities. It was a great experience for everyone and we accomplished good things today—together."

On Thursday night, April 15, the Senate and House passed and President Obama quickly signed into law legislation delaying Medicare physician payment cuts. The delay pushes the 21 percent scheduled cuts off, yet again, until May 31, 2010.

The physician payment cuts had already taken effect April 1, but the Centers for Medicare and Medicaid Services had instructed contractors to hold claims until April 15. Separate legislation still pending in Congress would delay these cuts even longer, until September 30, but that legislation remains to be reconciled by the House and Senate.

"This temporary address of a looming payment cut underscores the need for a permanent ‘fix’ that Congress continues to push off into the future," said WHA President Steve Brenton. "It is unfortunate that Wisconsin physicians continue to have this longstanding problem hanging over their heads with little chance for address anytime soon."

Also included in law signed by the President is language supported by the American Hospital Association and the Wisconsin Hospital Association that corrects the overly-broad definition of "hospital-based" physician included under the American Recovery & Reinvestment Act’s (ARRA) electronic health record (EHR) incentive program. The fix will allow physicians practicing in hospital-owned outpatient clinics to become eligible to qualify for the EHR incentives under ARRA.

"While this fixes a significant mistake in the ARRA EHR incentive program that would have excluded many Wisconsin physicians, CMS’s proposed rule implementing the incentive program still remains flawed," said Matthew Stanford, associate counsel, WHA. "Without substantive changes by CMS in its final implementation rule, it is likely that the intent of ARRA to facilitate rapid, widespread adoption of EHR technology will not be realized."