The third meeting of the WHA Medicaid Advisory Group (MAG) with staff from the Wisconsin Department of Health Services (DHS), held on April 28, included a discussion of a number of important issues that will affect hospital Medicaid rates beginning July 1, 2010. Medicaid Director Jason Helgerson and his staff and consultants provided Upper Payment Limit development information that the Centers for Medicare and Medicaid Services could consider if DHS submits a new methodology for approval. DHS staff also discussed the new DRG weights that they estimate will be "flat" from rate year 2010 to 2011. The MAG provided input on a number of issues DHS will need to resolve prior to presenting the 2011 rates, including: adjusted trim points, appeals of unaudited cost reports, CAH settlements, payment of laboratory services, the Essential Access City Hospital (EACH) supplement, and distribution of Disproportionate Share Hospital (DSH) supplement as a lump sum.

Helgerson provided an update on the Medicaid program’s efforts to reduce Medicaid program expenditures by $633 million as required by the Legislature in the last budget, an effort dubbed "Rate Reform 1.0." Helgerson said they are on track with their goal, but are continually looking for more efficiencies and enhancements for the Medicaid program. Rate Reform 1.0 affected hospitals by limiting payment for an emergency room visit to one 24-hour period, implementing the Medicare present on admission payment policy, requiring prior authorization for certain imaging (MRI, CT, PET scans), and reducing CAH reimbursement rates by 10 percent. Helgerson explained that the CAH assessment will replace the CAH rate reduction beginning July 1 and walked through CAH assessment implementation issues.

DHS staff provided year to date data on a hospital-by-hospital basis for the PPS hospital assessment. Finally, created in response to a MAG member suggestion, a DHS consultant demonstrated a planned authorization and deductible online look-up system for the new BadgerCare Basic program that DHS plans to implement July 1. The Legislature passed the BadgerCare Basic authorizing legislation late in the session; Governor Doyle is expected to sign the bill soon.

At the conclusion of the meeting, MAG Chair Jim Woodward, CEO of Meriter Hospital, thanked Jason Helgerson and his team for their work on this new rate setting process.

"The members appreciate the transparency and the dialogue," said Woodward.

On April 21, Reps. Ron Kind (WI), Bruce Braley (IA), Betty McCollum (MN) and Jay Inslee (WA) announced the official Congressional formation of The Quality Care Coalition. This Coalition will provide Members of Congress a forum to transform the health care system to reward value in care and make evidence-based, quality care the standard regardless of location in the United States. It will also focus efforts on the issue of geographic disparity in Medicare payments.

During health care negotiations, a group of more than 30 Members of Congress, representing areas disadvantaged under current the Medicare payment system, came together to advance transformative Medicare reimbursement methodologies, such as paying for value over volume. The end result of those negotiations was several beginning steps toward recognizing the issue of value – high quality, cost-efficient care—in Medicare reimbursements.

Later this fall, Health & Human Services Secretary Kathleen Sebelius will host a National Summit on Geographic Variation, Cost, Access and Value in Health Care. This is one of the outcomes from the Quality Care Coalition’s negotiations. Other outcomes include several studies and movement forward on addressing the issue of geographic variation.

"A value-based reimbursement system benefits all states and all regions," Wisconsin Representative Ron Kind said in announcing the Quality Care Coalition. "We’ve taken significant strides to change the way we pay for health care in this country, but there is more work to be done in promoting quality and value in our Medicare system…. [I] look forward to working with my colleagues to make sure implementation of the health care reform bill achieves the objectives we fought so hard to include."

WHA members attending the AHA Annual Washington Meeting earlier this week trekked to Capitol Hill and told Wisconsin lawmakers that the outcome of three short-term issues of critical importance to hospitals and physicians will go a long way in determining the early success or failure of health reform implementation.

FMAP Extension – Congressional approval of a 12-month extension of higher federal matching dollars for state Medicaid programs will determine whether or not Wisconsin’s current Medicaid program can survive until the next biennium. Lawmakers were asked to support pending legislation that will prevent Wisconsin’s program, and others across the nation, from sinking into a sea of red ink that might require drastic actions later this year.

Meaningful Use – Wisconsin House and Senate members were thanked for their support for revamping proposed meaningful use regulations that could otherwise doom efforts to provide financial support and incentives for the necessary but expensive implementation of EHR and other clinical-based HIT in Wisconsin hospitals and clinics. Meeting attendees repeated earlier warnings that the proposed rules as written are inflexible and impossible for most organizations to comply with, noting that the vast majority of Wisconsin hospitals and clinics face punitive fines in just three years absent substantial revisions.

IPPS Rules – Attendees also expressed outrage over newly-proposed Medicare payment rules that would actually reduce inpatient payments for PPS hospitals by 0.35 percent beginning October 1. The rule proposes a "behavioral adjustment" in order to recoup overpayments resulting from so-called DRG upcoding—a proposition vigorously denounced by hospital representatives. Noting that Wisconsin hospitals have ponied up $2.6 billion over the next decade to help finance coverage improvements found in the reform legislation, hospital leaders described the new cuts as "staggering and unwarranted," and called the CMS claim that hospitals are caring for less sick Medicare patients "preposterous."

The initial feedback from Wisconsin Congressional Delegation members and staff was uniformly positive. WHA will coordinate additional advocacy strategies and communications over the next few weeks.

Steve Brenton
President

P.S. Even without the new inpatient payment reductions Medicare margins are expected to plunge to -32.5 percent by 2019 according to modeling recently undertaken for WHA by the Hospital Association of New York State’s information center, using 2009 Medicare cost report files.

The 2010 Wisconsin Rural Health Conference scheduled June 23-25 at the Kalahari Resort in Wisconsin Dells is a great way for hospital executives, leadership staff and trustees to take advantage of great education close to home, at a fraction of the travel and registration costs of out-of-state events. Register before May 15 and take advantage of the early bird discount. Make your hotel reservations soon, too, and ask for the Rural Health Conference group rate.

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 Wisconsin State Health Plan identifies the primary risks associated with unprotected sexual behaviors as unintended pregnancies and sexually transmitted diseases. These health conditions significantly affect the health of the public as well as the social and economic well-being of individuals, families and communities. Hospitals reach out to at-risk mothers to help them have safe, healthy pregnancies and a successful transition to parenthood. Education classes supported by hospitals focus on maternal and child health issues and help connect women to the social, emotional, and health resources they need to ensure good outcomes for mother and baby.

Addressing the health care needs of a growing Hispanic population

From 1999 to 2004, Monroe County’s Hispanic population grew more than 200 percent and Trempealeau County saw an increase of more than 350 percent. Prenatal care, labor and delivery, and postpartum care can offer challenges especially for those with language or cultural differences. Gundersen Lutheran New Life Family Center is providing linguistically and culturally sensitive childbirth education for Hispanic families whether patients of Gundersen Lutheran or not. This includes prenatal risk assessment that looks at concerns such as nutrition, medical history and social support. Midwives, nurses and Spanish-language interpreters also work with families to address labor, pain relief, breast feeding, SIDS prevention and other concerns.

Becoming a parent and being a parent are two entirely different experiences. Recognizing this, Aurora BayCare Medical Center offers a variety of parenting-related community education classes to support breastfeeding moms, nervous new fathers on the importance of being fully engaged in the lives of their new babies, and a class called 1,2,3 Magic.

1,2,3 Magic is based on an award-winning program originated by Dr. Thomas Phelan and designed to teach practical, easy-to-use discipline techniques without yelling, spanking or arguing.

Each of the two, 2-1/2 hour classes is dedicated to helping parents build strong, positive relationships with their children and to overcome the stress that can sometimes take the fun out of parenting. Annually, the classes are offered multiple times a year and more than 100 parents participate.

In spring 2008, Aurora West Allis Medical Center hosted a new program called "Baby Basics and Beyond" to help meet the challenges faced by new parents and grandparents. This community event for young families was centered on the topic of home and child safety.

Together with over 20 health-related community partners, Aurora caregivers were able to provide those in attendance with valuable information and easy access to health and safety resources. By leveraging the expertise of skilled caregivers such as Dr. George Idarraga, an Aurora pediatrician, and Dr. Elizabeth Deckers, an Aurora obstetrician & gynecologist, new young parents and grandparents were able to strengthen their knowledge of child safety and development. A session entitled "Dads In Training" introduced young new and expectant fathers to the joys and challenges of parenting their infants, supporting their baby’s mother and their child.

Partners included Babies R Us, the West Allis Health Department, and the School-Age Parent Program – a partnership of West Allis/West Milwaukee Schools and the hospital that ensures pregnant teens finish school and acquire the skills they need to provide for their families and be responsible parents.

This fall, the "Baby Basics and Beyond" program will be replicated at Aurora Sinai Medical Center to help meet the needs of new parents and grandparents elsewhere in the greater Milwaukee community.

The Western Racine County Health Department, part of Aurora Memorial Hospital of Burlington hosts the local Women, Infant and Children clinic at their location free of charge and offers other vital services when clients come to the clinic. The program serves low-income pregnant, postpartum and breastfeeding women and infants and children up to five who are at nutrition risk.

According to Cheryl Mazmanian, director, Western Racine County Health Department, the clinic is open three days a month and demand continues to increase. In 2008, the health department served over 1,900 clients through the program and numbers through June 2009 are on pace to exceed last year’s total.

"This is a high risk group that is difficult to reach, they often lack telephones and transportation,’’ she said. "In addition to providing services through the Women, Infant and Children program, we also wrap other services around their visit, including immunizations.’’

By offering immunization and other necessary services during the clinic, Mazmanian said families can pick up information on parenting skills, additional support programs, and ensure that their child’s immunization schedule is kept current.

Mile Bluff Medical Center in Mauston recognized the opportunity to help area parents learn to answer some of the questions that come along with having young children and teenagers. Paul Gasser, marriage and family therapist, put together a "Keeping Parenting Fun" workshop to provide simple solutions for dealing with difficult issues that arise while rearing children.

The program was first offered at Mile Bluff’s Lake Delton location. After word got out about how helpful the sessions were, a number of Juneau County parents requested that the program be brought to Mauston as well. Participants appreciated all of the practical ideas they were given during the light-hearted meetings.

No one ever has all the right answers when it comes to raising a child, but Mile Bluff was able to help dozens of area parents gain the tools needed to feel more in control when dealing with the ever-changing challenges of being "Mommy" or "Daddy." Thanks to this program, the community has learned how to keep parenting fun!

The Aurora Midwifery and Wellness Center, the largest midwifery group in Wisconsin, provides access to high quality, holistic obstetrical/gynecological care to a medically underserved population of Milwaukee. Nearly 90 percent of patients, ages 15 to 44, live in zip codes with the highest infant mortality rates – neighborhoods noted for housing insecurity, unemployment and poverty. The center addresses teen pregnancy, prematurity, access to quality care, interpersonal violence, risk assessment and infant mortality.

The Center’s nurse-midwives engage in community-oriented primary care, reaching out to African-American and Latino populations. Outreach includes group prenatal visits at a local high school, Aurora Clarke Square Family Health Center and Milwaukee Health Services. They are community-based within Aurora’s integrated health care system while remaining actively engaged in teaching and community-based research projects in Milwaukee. The midwives work in collaboration with the physicians from the Aurora Women’s Health Center at Aurora Sinai Medical Center.

With deliveries at Milwaukee Health Services and other Aurora UW Medical Group clinics taken into account, the Midwifery and Wellness Center’s services and prenatal care result in more than 400 deliveries per year, with fewer low birth-weight babies for both adult and adolescent women.

"The Aurora Midwifery and Wellness Center has done much to contribute to improved perinatal outcomes in Milwaukee…Eighty percent of the women reside in neighborhoods noted for high rates of infant morbidity and mortality…Clearly, the clinical approach of the Midwifery and Wellness Center is making a difference in Milwaukee." -- Ann E. Conway, MS, MPA, RN, Executive Director, Wisconsin Association for Perinatal Care

"…The work done by your Center has a positive impact on one of the most serious health issues facing Milwaukee: poor birth outcomes, with infant mortality rates in the city among the highest in the nation… Marquette student nurse-midwives are educated alongside medical students and residents in a setting that encourages teamwork among the next generation of health care providers." -- Leona VandeVusse, PhD, RN, CNM, FACNM, Associate Professor and Nurse-Midwifery Program Directors, Marquette University

Imagine a woman carrying a new life within her body. Then try to imagine she is living with the fear that harm could come to her and her unborn baby.

For the past four years at Aurora Sinai Medical Center, the Safe Mom Safe Baby program has helped women living in constant fear of abuse at the hands of their partners – the men who are the fathers of their babies. With the devoted assistance of a nurse case manager and an advocate from the Sojourner Family Peace Center, expectant moms have had somewhere to turn to receive the support they need.

Since the program started in 2005, nearly 400 pregnant women with abusive partners have received perinatal care, along with solace and support. Safe Mom Safe Baby has served nearly women living in every zip code in the metropolitan Milwaukee area, particularly those where unemployment rates have been high and are growing worse.

Many women who participate in Safe Mom Safe Baby find the strength to turn their lives around to protect themselves and their babies.

"To see each woman become stronger and empowered is our reward and what makes this program an honor to be affiliated with," says Alice Kramer, RN, a founder of the program. "Very few medical organizations put forth the effort, support, and assistance to carry out this must-needed program as generously as Aurora Health Care. We are very grateful for all Aurora does."

An outgrowth of Aurora’s Domestic Violence and Abuse Response Services, the long-term goal for Safe Mom Safe Baby, is to expand this dedicated core service to other sites.

The Newborn Certification Program of the Aurora Women, Infants and Children’s (WIC) program at Aurora Sinai Medical Center celebrated the fact that it certified more than 14,000 newborns for WIC benefits when it reached its 11-year anniversary in June 2008. By the end of the year, this unique program had certified 1,177 infants.

This unique program is the only hospital-based WIC site in the state and is a community partnership with the State of Wisconsin to serve residents who are pregnant, breastfeeding or postpartum, and children to age 5.

One of the most important benefits of the WIC program at Aurora Sinai Medical Center is bedside newborn certification, which ensures nutritious foods for low-income and at-risk women who deliver at the hospital. The mother receives a month’s worth of WIC vouchers for formula that can be redeemed at the hospital pharmacy, as an added convenience. The goal is to prevent nutrition-related health problems and promote breastfeeding.

An additional benefit of the program at Aurora Sinai is easy access to classes such as prenatal care, breastfeeding, asthma and special classes for teens and single parents, as well as access to programs to ensure personal safety.

Because breastfeeding has been linked to reductions in infant mortality as well as reduced incidence of SIDS, asthma, food allergies, diabetes and obesity in children, breastfeeding training and support is emphasized in this WIC program. Benefits to mothers include better healing after birth and a reduction in breast and ovarian cancers. However, a mother will receive a month’s worth of formula if she chooses not to breastfeed.

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