In this latest meeting, DHS provided an overview of the Medicaid base budget for hospitals. DHS explained the various funding sources, and how their budget worksheets allocate the funding between fee for service inpatient and outpatient payments and HMO capitation payments. They also provided analysis on how the fiscal year 2009 payments compared to the budget, and presented projected payments for fiscal years 2010 and 2011.

DHS staff went into detail on the importance and the mechanics behind the Medicare upper payment limit (UPL) calculation. CMS requires each state to certify that Medicaid payments to hospitals do not exceed what Medicare would have paid for the same services. This calculation has a significant bearing on rate setting and the hospital assessment program, because it limits the amount of payment increases available to hospitals. The group also discussed potential DHS payment policy issues that are in play as we move into the 2011 fiscal year.

The group discussed the hospital assessment program, and DHS presented a mid-year global look at where access payments are for the 2010 fiscal year. The total amount of funding for access payments made using the assessment revenue is set in statute and will be distributed in full. Because of a higher than estimated Medicaid caseload, DHS has distributed this increased funding to hospitals faster than originally anticipated. In order to prevent the State from overspending the assessment revenue, DHS projects that the final HMO access payment (for June) will not be made. Like last year, DHS will reconcile the access payments made to hospitals through both the fee for service payment system and HMOs ensuring that all money due hospitals are paid.

Finally, DHS staff discussed health care reform on the national level and how it might impact Wisconsin. "Many of the coverage expansion elements won’t occur until 2014, but there is a lot of work to do before then," said Helgerson. Helgerson emphasized that DHS will work with its stakeholders as it navigates the Act’s opportunities and requirements.

In the next 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. The next meeting is scheduled April 28.

Materials from the meetings and other information about the Medicaid Advisory Group can be found on the WHA Web site at www.wha.org/financeAndData/MAG.aspx.

WHA’s 2010 Advocacy Day on April 13 is less than two weeks away and registrations have already topped 500 for the fifth year in a row. Some 300 of those individuals will then take what they have learned on important hospital issues and meet that afternoon with their legislators. If you haven’t registered your hospital contingent yet, please do so today.

Join hospital administrators, nurse leaders, employees, trustees and volunteers from across Wisconsin in Madison for this premier grassroots event. In addition to morning keynote Juan Williams, NPR senior correspondent/FoxNews contributor, and confirmed luncheon keynote Governor Jim Doyle, Advocacy Day will also provide attendees with a gubernatorial candidate forum. All major candidates have been invited with both Scott Walker and Mark Neumann confirming their participation.

The day closes with the most important element—visiting with legislators in the State Capitol. Brief legislative visits are scheduled for you and transportation to the Capitol is available if needed.

WHA strongly encourages you to attend Advocacy Day and make an impact on behalf of your hospitals, patients and communities. This event is free of charge but registration is required. Advocacy Day takes place at the Monona Terrace in Madison on April 13. A complete program and online registration are available at www.wha.org.

For registration questions, contact Lisa Littel at llittel@wha.org  or at 608-274-1820. For all other questions, contact Jenny Boese at 608-268-1816 or jboese@wha.org .

BadgerCare Basic (Basic) cleared another legislative hurdle this week when it was approved by the Assembly Health Committee on a party-line vote. Basic is Governor Doyle’s bare bones, low-cost health plan proposal for those on the waiting list for BadgerCare Core (see more detail in 2/12/10 issue of The Valued Voice).

Several WHA-backed amendments to Basic previously adopted by the Senate were also adopted by the Committee. The amendments, which will help assure the intent of Basic as a safety-net health care program for low-income individuals who have no other options include:

• Verifying monthly that individuals with coverage under Basic meet eligibility criteria.

• Requiring a quarterly report to the Joint Committee on Finance that includes information on claims paid, premiums collected, a description of any changes to benefits or premiums, demographic information on applicants and enrollees, and a description of the Department’s process for verifying eligibility.

• Ensuring that Basic applicants receive information about other coverage options they may qualify for and that may provide superior coverage:

  • The Health Insurance Risk-Sharing Plan (HIRSP)

  • Availability of dependant coverage under his or her parent’s health care plan if the applicant is under age 27

  • The right to purchase continuation coverage under certain situations as provided by COBRA and any state or federal premium tax credits or other premium subsidies that might be available for that coverage.

• Preserving access to services by requiring payments to providers be no less than payments under Medicaid (however, deductibles will apply that are not required under Medicaid).

• Requiring an audit of program performance by the Legislative Audit Bureau.

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 later this month. Gov. Doyle’s initial target start date for Basic was April 1.

This week the Office of the National Coordinator for Health Information Technology (ONC) announced that a new pool of $25 million would become available to Regional Extension Centers (RECs), like the Wisconsin Health Information Technology Extension Center (WHITEC), to assist Critical Access and rural hospitals implement and meaningfully use electronic health record systems.

Earlier this year WHITEC received a $9 million grant from ONC under the American Recovery & Reinvestment Act to provide health information technology technical assistance to priority primary care doctors in Wisconsin. The additional dollars will be awarded to RECs so they can provide services and technical assistance to Critical Access Hospitals and rural hospitals with fewer than 50 beds.

The Patient Protection and Affordable Care Act of 2010 includes a set of sweeping changes applicable to charitable hospitals exempt under Section 503(c)(3) of the Internal Revenue Code. The Act (a) imposes new eligibility requirements for 501(c)(3) hospitals, coupled with an excise tax for failures to meet certain of those requirements; (b) requires mandatory IRS review of the hospitals’ entitlement to exemption; (c) sets forth new reporting requirements on the hospitals involving community health needs assessments and audited financial statements; and (d) imposes further reporting requirements on the Secretary of the Treasury regarding charity care levels. Most of the changes in the Act are scheduled to go into effect for tax years beginning after March 23, 2010, the date of enactment.

Eligibility Requirements. Charitable hospitals will now need to comply with four new requirements in order to maintain their exemption under 501(c)(3). These requirements are set forth in a new Code Section 501(r). In multi-hospital systems, each hospital must meet these requirements in order to retain that hospital’s exempt status.

Community Health Needs Assessment. Hospitals must conduct a community health needs assessment at least once every three years.

These assessments must include input from persons representing the broad interests of the community served by the hospital, including those with special knowledge or expertise in public health, and the hospital must then make the needs assessment "widely available to the public." A hospital can satisfy this requirement if it has conducted the assessment during the tax year at issue or in either of the two immediately preceding tax years. Hospitals must adopt an implementation strategy to meet the community health needs identified through their assessments. Hospitals that fail to meet these requirements in any given year will be subject to an excise tax in the amount of $50,000.

Financial Assistance Policy. Tax-exempt hospitals will now be required to establish written policies on financial assistance and emergency medical care. The financial assistance policy must include eligibility criteria, the basis for calculating charges, the method for applying for financial assistance, and (unless the hospital has a separate billing and collections policy) the actions the organization may take in the event of nonpayment, including collection actions and reporting to credit agencies. The financial assistance policy must also specify how the policy is publicized in the community, such as via the hospital website. The emergency medical care policy must require the organization to provide, without discrimination, care for certain emergency medical conditions regardless of an individual’s eligibility under the financial assistance policy described above.

Limitation on Charges. To maintain exemption, hospitals will now be required to limit the amounts charged for emergency or other medically-necessary care provided to individuals eligible for assistance under the financial assistance policy described above. Hospitals may not charge more than "the amount generally billed" to hospital patients who have commercial insurance coverage. In addition, the organization may not bill assistance-eligible individuals using gross charges.

Billing and Collection Requirements. To maintain exemption under Section 501(c)(3), hospitals must refrain from "extraordinary collection efforts" such as collection actions unless the organization has made reasonable efforts to determine whether the individual is eligible for assistance under the organization’s financial assistance policy.

Mandatory Review of Exemption. The Act requires the Secretary of the Treasury to review the community benefit activities of each exempt hospital at least once every three years.

New Reporting Requirements. As noted previously, the Act imposes new reporting requirements on exempt hospitals and on the Secretary of the Treasury. Exempt hospitals will be required to report as follows:

Community Health Needs Assessments. Each hospital will be required to report on how it is addressing the needs identified in the community health needs assessments, provide a description of any needs that are not being addressed, and explain why those needs are not being addressed. This information will be included in the hospital’s annual information return filed with the IRS (Form 990).

Audited Financial Statements. Exempt hospitals will be required to provide copies of audited financial statements for the organization or consolidated financial statements for organizations that prepare financials on a consolidated basis.

The Secretary of the Treasury will be required to report as follows:

Charity Care. On an annual basis, the Secretary of the Treasury, in consultation with the Secretary of Health and Human Services, will be required to report to Congress on levels of charity care, bad debt expenses, unreimbursed costs for services provided with respect to means-tested government programs, and unreimbursed costs for services provided with respect to non-means tested government programs. The preceding reports must be provided with respect to private tax-exempt, taxable, and government-owned hospitals. In addition, for private tax-exempt hospitals only, the Secretary will be required to report on costs incurred for community benefit activities.

Trends. In addition to the annual reports set forth above, the Secretary of the Treasury will be required to report back to Congress in five years regarding trends it has observed in the various levels of charity care included in those annual reports.

Effective Dates. Requirements relating to community health needs assessments will become effective for taxable years beginning after March 23, 2012, while other requirements are effective for taxable years beginning after March 23, 2010.

The Act’s provisions affecting 501(c)(3) status represent the latest chapter—if not the culmination—of a long series of tax exemption reform efforts in Congress spearheaded principally by Senator Charles Grassley and Congressman Max Baucus. For example, legislation was introduced in the House of Representatives back in 2006 (H.R. 6420, the Tax Exempt Hospitals Responsibility Act of 2006) that would have required hospitals to provide mandated amounts of charity care and to publicize charity care policies. In July 2007, Senator Grassley released a discussion draft of proposed non-profit hospital reforms that included requirements for written charity care policies; publication of charity care eligibility criteria; minimum actual annual amounts of charity care (at the greater of five percent of hospital’s annual patient operating expenses or revenues); community needs assessments every three years; community wellness/outreach services for vulnerable populations; caps on charges to the medically indigent; board governance restrictions; standards for billing and collection practices; and reporting and transparency requirements.

The new health care reform legislation contains many features from previous exemption reform proposals, but still falls short of mandating specific levels of charity care. IRS will now be digesting extensive community benefit information contained in hospital filings using the newly-revised Form 990. Senator Grassley and his like-minded colleagues in Washington undoubtedly will be watching for the results of that analysis, and if they remain unsatisfied, we may not have heard the last word on exemption reform.

The AHA now has an interactive online tool (www.aha.org/aha/issues/Tax-Exempt-Status/schedH/default.html) to help member hospitals prepare to complete Schedule H, the new Internal Revenue Service (IRS) form for tax-exempt hospitals. Developed with Ernst & Young and Hogan and Hartson, the educational tool presents questions in the order and format required by the IRS and offers explanations, guidance and links to the IRS instructions for each question. The tool also offers sample narrative responses.

It is the latest in a series of AHA resources to help hospitals prepare for the new reporting requirements. These include Telling the Hospital Story – Going Beyond Schedule H (www.caringforcommunities.org/caringforcommunities/content/09goingbeyondschH.pdf), which provides guidance and tools to help hospitals augment the limited information on Schedule H to ensure the full scope of community benefit is captured and communicated.

Due to the importance of Schedule H, hospitals are encouraged to create an internal team to prepare for and complete the form. The team should encompass staff from throughout the organization including legal, finance, community benefit/community relations and communications departments. Hospitals should not rely on Schedule H alone to inform their communities of the value they bring, rather use these tools to ensure an accurate Schedule H is submitted to the IRS and then go beyond the form to clearly articulate the full reach and impact of your community benefit outreach.

The WHA Workforce Council met March 23 in Madison and had the opportunity to make suggestions and recommendations on issues related to health occupations to leaders of the Wisconsin Technical College System (WTCS).

Annette Severson, associate vice president of the office of instruction, and Kathy Loppnow, education director of health and human services at WTCS reviewed the System’s graduate follow up report. Graduates from health occupation programs report a median wage of almost $32,000 and a 93 percent employment rate. Sixty one percent of graduates work within the Technical District from which they graduated.

Council members urged the WTCS to maintain nurse program capacity in anticipation of retirements and hours reductions in the near future. They also asked for assurance that districts would encourage graduates of surgical technology programs to obtain certification, especially if the current bill requiring that certification passes into law this session. The speakers were asked for assistance from the WTCS to prepare individuals working as radiographers for licensure exams and for assistance equipping new graduate nurses and nurse practitioners with operating room skills. Both requests will be taken back to the local districts.

The WTCS asked how hospitals are currently using and how they plan to use the skills of physical therapy assistants in the future. Graduates from this program, especially in the Milwaukee area, are not finding jobs as easily as in the past. Council members reported that acuity levels of hospitalized patients most often require a physical therapist level of care. Most do not see an increase in PTA hiring. Since this workgroup is relatively young, they also do not see turnover among current employees.

It has been two years since WTCS representatives had attended a Workforce Council meeting to discuss capacity, needs and program planning with the Council. Both speakers expressed thanks to the Council members for the open conversation and asked to return on a regular basis to assure that hospital employment needs are heard by the WTCS.

Judy Warmuth, WHA vice president, workforce, reviewed the nursing workforce situation in Wisconsin. In 2008 nearly 3,200 new nurses took the licensure exam in Wisconsin, a two-fold increase from 2000. Wisconsin has 37 schools that prepare new nurses. Of those, three have been placed on probation and six are currently being monitored by the Wisconsin Board of Nursing because of low license exam pass rates for their graduates. After discussing the impact on hospitals of nurse graduates that do not pass the exam, the Council recommended that the Board of Nursing make licensure exam pass rates public. They believe that students and parents want and need this information as they are making decisions about which program to attend.

The group also discussed employee flu vaccination rates and possible new rules from the Department of Health Services regarding immunization. They expressed a preference for no new regulation but agreed that attaining significant employee immunization rates consumes a considerable amount of time and resources.

There has been much legislative activity related to health care workforce this session. In her report, Warmuth listed bills that had been passed (licensure of radiographers, immunity for emergency workers who are late or absent from work, independence for the Physical Therapy Board, and new functions for podiatrists) and bills that could still pass in the two weeks left in the legislative session (admitting privileges and Fund coverage for nurse midwives, restrictions on employee meetings, licensure for anesthesiologist assistants, mandatory certification for surgical technologists, monitoring of physician prescribing, dietitian licensure, APNP additions to scope of practice, addition to FMLA for school events, and the ban on mandatory overtime).

Wisconsin launched a new, Web-based online Donor Registry this week that will, for the first time, allow Wisconsin citizens to legally authorize organ, tissue and eye donation with a click of a button.

"This new Registry means that anyone over the age of 15½ with a driver’s license or state ID can grant legal authorization in advance to donate their organs, tissue and corneas when they die,’’ said Martha Mallon, president of Donate Life Wisconsin and organ and tissue donor promotion director with the Wisconsin Department of Health Services. "Experiences with online registries in other states show that even more Wisconsin residents will register because they support donation."

Beginning today, a person who applies for or renews their license or state ID will make a decision to be registered as a donor. This decision legally authorizes organ, tissue and eye donation upon death.

"In Wisconsin, people renew their license only once every eight years," said Mallon. "That’s why it is important that everyone who wishes to become a donor, including those who already have an orange dot on their driver’s license, sign up on the online Registry."

Donation professionals will have immediate access to a person’s donation decision, share that information with the donor’s family and work with them to honor that choice. If people change their minds they may remove their names at any time.

Hospitals will celebrate National Hospital Week May 9-15 with the theme "Celebrating Health, Hope and Healing." The annual celebration began in 1921 and has grown to become the nation’s largest health care event, with activities ranging from health fairs to hospital tours and employee recognition programs. The AHA, which sponsors the week, offers an online guide to help hospitals plan and publicize the event in their communities. The guide is available at: http://nationalhospitalweek.com/hospitalweek/hw2010_planning_guide.pdf.

The Hospital Sisters Health System (HSHS) announced that Andrew J. Bagnall has been named president and chief executive officer of St. Nicholas Hospital, Sheboygan. Bagnall began his new role at St. Nicholas Hospital March 15.

Bagnall was previously the chief executive officer of Select Specialty Hospital in Davenport, Iowa. He earned his masters in health administration from St. Ambrose University, Davenport, Iowa, and is a Fellow of the American College of Healthcare Executives. Bagnall has served as a board member of the Iowa Medical Group Management Association and a member of several committees for the Iowa Hospital Association. He is a member of the Davenport Kiwanis Club, served on the South Tama County Community School District Board of Education, and has served on many other community boards and committees.

Educated and involved nurse executives and nurse leaders are critical to creating an environment within hospitals where all direct caregivers are committed to improving the quality of patient care. The Aligning Forces grant recognizes this critical role and has strategies focused on helping nurse leaders encourage and enhance caregiver involvement.

Each quarter, a Wisconsin nurse leader provides an article on the topic of staff nurse engagement. This allows the sharing of best practices and highlights projects and efforts occurring in Wisconsin hospitals. An example from the most recent issue can be found of page three of www.w-one.org//uploads/horizons2-10.pdf.

Nurse leaders can participate in webinars from their own desk. These programs, scheduled over lunch hours, are an easy way to learn and share information. The next session will be held

May 11 and will feature Tim Gengler, chief nursing officer, Aspirus Wausau Hospital and Ruth Risley-Gray, chief nursing officer, Langlade Memorial Hospital, talking about their own experiences with engaging staff nurses. They will discuss what has worked and what needed revision in a large and small hospital environment.

Offered as a pre-conference of the W-ONE spring conference, this program will be presented on April 21 by Barbara Farrell, director of quality and innovation, American Organization of Nurse Executives (AONE). She is responsible for AONE’s Transforming Care at the Bedside (TCAB) project. TCAB is an innovative model that calls for nurses to lead unit and hospital-wide team efforts to improve the quality and safety of patient care. It focuses on nurses’ creativity, teamwork and focus on patients.

To date, TCAB has involved 68 hospitals in rapid cycle change to improve care, increase the amount of time spent with patients and increase nurse satisfactions. Farrell will report on the success of TCAB, and specifically, will share what has been learned about involving staff nursing in this change. More information about the conference can be found at: www.wha.org/education/other.aspx

Publishing a list of credit courses in Wisconsin nursing programs is the next planned strategy aimed at nurse leaders. Suggestions and recommendations would be welcome. Contact Judy Warmuth, vice president, workforce, Wisconsin Hospital Association, at jwarmuth@wha.org  with your ideas and thoughts.