Wisconsin is ranked as the top state in the nation based on the quality of its health care, but even the best can do better. Whether the recently-passed federal health reforms will increase or promote quality and address issues related to creating "value" for purchasers and patients remains uncertain. What is known is the health care environment in Wisconsin will be shaped by the newly-passed federal health reform bill. While federal health reform addressed coverage improvements, it did little to encourage reform of the health care payment system.

On April 6 in Waukesha, nearly 200 executives and thought leaders representing large and small businesses, hospitals, health care systems, physician groups, the insurance industry, and organizations that support these groups, gathered in small work groups to explore new health care payment options and opportunities at the Wisconsin Payment Reform Leadership Summit.

"Wisconsin has never waited for others to innovate, which is why we are a national health leader," said Department of Health Services Secretary Karen Timberlake. "I hope you believe it and I hope you get around the country to get an appreciation of the unique features of Wisconsin’s health care delivery system that make us a leader."

Timberlake said in spite of the state’s position as a quality leader in the country, variability across the patient care spectrum remains an issue.

"We have a problem, but now also an opportunity to do a better job of rewarding higher value providers, increasing access, and improving our prevention efforts," Timberlake said.

Harold Miller, executive director, Center for Healthcare Quality and Payment Reform, who facilitated the Summit, told the group federal health reform did "nothing about health care costs." He said there are only three ways to reduce costs: keep people well, manage patient’s health care needs outside of the acute care system, and if they require acute care, ensure that it is delivered efficiently and in a way to help ensure a successful outcome. The problem, according to Miller, is that providers don’t get paid if they reduce utilization.

"Better payment systems require good quality measurement," Miller said. "Giving health care providers more accountability for cost reduces their incentive for overuse, but it raises concerns about whether patients will receive too little care."

The solution, according to Miller, is to measure health care quality and include incentives for providers that reward efforts they take to reduce hospitalizations and help patients manage chronic disease conditions.

Following Miller’s presentation, the audience was divided into six work groups where they participated in a facilitated discussion on an array of payment reform options. Leo Brideau, president/CEO, Columbia St. Mary’s, and George Quinn, WHA senior vice president, served as two of the work group facilitators. Many hospital and health system executives attended the Summit.

At day’s end, Miller summarized the work groups’ discussion and found sufficient support for further work on some of the key payment reform ideas formulated in the groups.

"The sponsors of this Payment Reform Summit will regroup soon to chart a course designed to sustain the momentum achieved during today’s program," said WHA President Steve Brenton. "Payment reform and redesign is in our future and a collaborative approach involving all stakeholders is the optimal way to do it the right way."

Pressure at the Capitol continues to build with April 22 scheduled as the last day of regular business floor activity for the Wisconsin Legislature fast approaching.  Public Policy Council members were updated at their April 8 meeting in Madison on the status of WHA’s top priorities.

"We are entering the vortex," said Executive Vice President Eric Borgerding, describing the sometimes contentious waning days of the two-year legislative session when politics and policy collide in a whirlwind of activity and debate.  Borgerding went on to provide the latest significant developments.

The Critical Access Hospital bills, AB 770 and SB 553, have both been scheduled for floor votes in the Senate and Assembly on April 13, WHA’s Advocacy Day.  The bills previously completed the committee process by passing on bi-partisan votes out of the standing committees of both houses and in the Joint Finance Committee The expedited committee process, along with the strong bi-partisan support (41 legislative co-sponsors), were both testaments to the significant efforts of rural hospitals and their leadership in building the case for the urgent need for this legislation, Borgerding added.

Proposed by Governor Doyle as the bare bones, low-cost coverage alternative for those on the waiting list for BadgerCare Core, the Senate added several WHA-backed amendments to the proposal that will help ensure the intent of Basic as a safety-net health care program for low-income individuals who truly have no other options.

One of the most important amendments includes language ensuring reimbursement rates for Basic services can go no lower than Medicaid rates.  Other amendments require DHS to verify the eligibility of participants monthly, to provide information about other coverage options to plan applicants, and to report on the program to the legislature, and require a legislative audit.

 Basic awaits action by the full Assembly.

 Ban on Mandatory Overtime

Legislation banning the use of mandatory overtime (Assembly Bill 152 and Senate Bill 108) remains stalled in the Capitol.  Legislators are learning that while there is no evidence of a need for this bill when it comes to non-government hospitals, State-run facilities are another story.

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.

WHA remains opposed to applying the legislation to non-government health care facilities, and Borgerding described members’ grassroots efforts on the issue as "outstanding" and reiterated WHA's commitment to and interest in working with legislators and other stakeholders to find common approaches to addressing workplace fatigue.   

Signed into law in early March 2009, 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.

Federal Issues

In reviewing federal health care reform, WHA President Steve Brenton said the recent efforts in Washington focus on 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 massive Medicare cuts to health care providers—including hospitals—as well as a significant increase in taxes, penalties, and fees.

Because Wisconsin has already made major strides in covering the uninsured, the impact of federal reform on coverage will be limited in Wisconsin.  The Health Insurance Risk-Sharing Plan (HIRSP) covering high-risk individuals and, as a result of recently passed legislation, expanded coverage for adult children up to age 27 under state regulated policies are already available here.  Other insurance reform initiatives such as state exchanges for individuals and small groups; individual and small group mandates; and guaranteed issue and renewability will result in greater degrees of change.

Brenton discussed other and more significant "real reforms" along with a growing number of questions and concerns surrounding the newly passed reform provisions, including:

• An approved and pending study and resulting recommendations focused on health care value efforts by the states, especially Wisconsin;
• Incentivizing accountable care organizations (ACOs);
• Additional dollars for Federally-Qualified Health Centers (FQHCs) and a "very strong potential that Wisconsin will benefit."
• Reform package redistribution of "mothballed" residency slots, especially in rural areas;
• The Governor’s newly-created Office of Health Reform, assigned with looking at timelines and implementing health reform in Wisconsin (see article below);
• New dollars flowing into the Medicaid program starting in 2014.  Of concern, how do we get from 2011 with our current Medicaid program until then?
• The potential for high-income Medicaid recipients to move into the statewide insurance exchange.  This is a significant issue because a large segment of the population falls between 133 percent and 200 percent or more of the FPL; and,
• A final physician payment fix.

"What we do know it this:  the current health reform bill will cost Wisconsin providers $2.6 billion over the next decade," Brenton said.  "The big cuts hit in 2012 and they are huge."

Brenton said WHA staff started its detailed analysis of the health reform package shortly after final passage with the goal of creating a blueprint that aligns with the implementation timeline.  A key component of the plan is to determine how the state’s Medicaid program can be sustained until the significant changes are implemented in 2014. In addition, WHA will give special attention to the new community benefit and related requirements. 

Prof. Franklin: State, National Polling Results Track Closely with Public’s Sense of Well-Being

Some states have suffered devastating job losses, such as Michigan, which has the highest unemployment rate in the country at 15 percent.  Wisconsin’s unemployment rate was 9.7 percent, just slightly less than the country as a whole.  Madison, on the other hand, is well below the state level and is even lower than the unemployment rate in North Dakota, which at less than five percent, is the nation’s lowest.  Wisconsin’s ability to recoup job losses or make gains is very much tied to the national economy, according to Franklin.

"Unemployment dominates the conversation.  The relationship between unemployment and mid-term elections, however, is that there has not been a relationship since 1900," according to Franklin.  "It is a stunning fact, there is no relationship. Real GDP or real per capita income or other measures of well being and income are the key drivers that have a bigger impact," he said.

There has been some growth in the economy the last two quarters.  At the end of the month, if the GDP drops from the third quarter, then it might show the economy is faltering and that would affect the midterm elections.  If, however, growth is sustained in the next quarters, then people might go to the polls in the fall with a more optimistic outlook. 

Regarding health reform, Franklin said the percentage of Americans supporting the recently-passed bill is less than the number who oppose it.   Franklin noted that about six percent of those who oppose it are "disappointed progressives" who oppose it "because it doesn’t go far enough." 

WHA is working on several issues related to the implementation of and rules associated with health information technology at both the state and federal levels, according to Joe Kachelski, vice president, WHA Information Center. Kachelski said WHA’s recently-formed Health Information Technology Task Force, chaired by Sandy Anderson, St. Clare Hospital in Baraboo, is playing a key role by providing technical, legal and strategic expertise and guidance to WHA on issues related to federal and state HIT policy. 

Grassroots Tools Boost HEAT Participation

 Jenny Boese, WHA vice president, external relations and member advocacy, said the new grassroots action center, which was launched in January of this year, is proving successful.  Boese said users report that it is easy to use, which is reflected in the metrics that show the new action center is generating more contact between hospital advocates and legislators.

Advocacy Day 2010 is Tuesday, April 13.  Boese said more than 600 people have registered for the event and of that, nearly 400 signed up to visit with their legislator while they are in Madison.

At news conferences April 6 at Meriter and Froedtert Hospitals, Governor Jim Doyle announced the creation of the Office of Health Care Reform. The office will be co-led by Secretary of Health Services Karen Timberlake and Commissioner of Insurance Sean Dilwig.

The Governor directed the Office to develop a health reform implementation plan to ensure that Wisconsin’s residents and businesses have access to the information they require to make informed decisions on their health care coverage. The Office also will:

• Assess insurance market reforms needed to prepare Wisconsin for final implementation of national health reform in 2014;
• Develop a plan to pursue federal funds for a temporary high-risk health insurance pool to maximize affordable coverage options for uninsured persons with pre-existing conditions;
• Create a health insurance purchasing exchange that will:
• Create a Web site where small business owners and individuals can find an apples to apples comparison of insurance policies – what they offer and how much they cost;
• Provide a single point of access for all eligible residents and businesses to choose their insurance;
• Promote consumer choice by providing easy comparability of health plans and lower health care premium costs by creating a large pool of employees to increase consumer purchasing and bargaining power; and,
• Ensure that the health insurance purchasing exchange is structured to reward the highest quality and most cost-effective health care providers and insurers.

Doyle said the state created a new Web site—www.healthcarereform.wisconsin.gov—that will provide Wisconsin residents with information about reform, the phases of implementation, and how changes may benefit them.

The U.S. Food and Drug Administration (FDA) has approved a new alternative to the Steris System 1 device processing system to process endoscopes and other reusable heat-sensitive medical devices. According to Steris, it expects to begin delivery of the new Steris System 1E Liquid Chemical Sterilant Processing System by the second quarter of 2011.

Shortly after passing the massive health care overhaul, Congress sent to President Obama the reconciliation package to remove some of the embarrassing provisions in his signature legislative achievement. But a serious fix for what ails health care in America will entail far more than merely tweaking the new law of the land; we will need to repeal the entire faulty architecture of the government behemoth and replace it with real reform.

To be clear: it is not sufficient for those of us in the opposition to await a reversal of political fortune months or years from now before we advance action on health care reform. Costs will continue their ascent as the debt burden squeezes life out of our economy. We are unapologetic advocates for the repeal of this costly misstep. But Republicans must also make the case for a reform agenda to take its place, and get to work on that effort now.

So what can we do?

Health care experts across the political spectrum acknowledge that a fundamental driver of health inflation is the regressive tax preference for employer-based health insurance. This discriminatory tax treatment lavishes the greatest benefit on the most expensive plans while providing no support for the unemployed, the self-employed or those who don’t get coverage from their employer.

Reform-minded leaders like Senator Ron Wyden, Democrat of Oregon, and Senator Tom Coburn, Republican of Oklahoma, pushed legislative proposals that would directly address this issue. I helped write a plan—The Patients’ Choice Act—that would replace the bias in the tax code with universal tax credits so that all Americans have the resources to purchase portable, affordable coverage that best suits their needs, with additional support provided for those with lower incomes. All these ideas, though, were dismissed early on, as they didn’t fit with the government-driven plan favored by the majority. But going forward it’s important that we reconsider this regressive tax issue.

Then, when helping Americans with pre-existing conditions obtain coverage, we should focus on innovative state-based solutions, including robust high-risk pools, like the ones we have here in Wisconsin, reinsurance markets and risk-adjustment mechanisms. I intend to continue advancing true patient-centered reforms like attaching tax benefits to the individual rather than the job, breaking down barriers to interstate competition, and promoting transparency and consumer-friendly coverage options.

We must also immediately begin dealing with our crushing debt burdens, which this legislation will worsen. The Democrats’ fiscal arguments never did add up: they claim that their program will reduce the deficit even though the federal government will pick up the tab for more than 30 million uninsured Americans and subsidize millions more. Even after accounting for the $569 billion in tax increases and $523 billion in Medicare cuts, the true costs of this legislation will make the deficit explode, plunging us deeper into debt.

We cannot afford a serious conversation on real entitlement reform—the key driver of our looming fiscal crisis. By taking action now, we can make certain that our entitlement programs are kept whole for those in and near retirement, while fulfilling the mission of health and retirement security for future generations.

The case for attempting health care reform was not difficult to make. Skyrocketing health care costs are driving more and more families and businesses to the brink of bankruptcy, leaving affordable coverage out of reach for millions of Americans and accelerating our path to fiscal ruin. The challenge was how to deal with the seemingly inexorable increase in health care costs.

Yet the Congressional majority went at this goal backward: with the force of the federal government, cover all Americans—then figure out which screws to twist to contain costs. Democrats opted for this approach because their concern was never about costs. It was about expanding coverage through an expansion of government.

Going forward, we must work to steer this country back in the right direction. The opposition must always speak with vigor and candor on the need for wholesale repeal and for real reform to fix what’s broken in health care and to restore the promise and prosperity of our exceptional nation.

Paul Ryan, a Republican, is a representative from Wisconsin.

On a 12-3 vote, the Joint Committee on Finance authorized $10 million in state funding to construct a dental school at the Marshfield Clinic, which requires a clinic match by July 2015.

Poor access to dental care in rural Wisconsin has long been a huge problem. Tim Size, executive director of the Rural Wisconsin Health Cooperative, said a consultant’s recent report to Wisconsin’s Department of Health Services noted that "The Marshfield Clinic’s proposal has special merit and is a model for the rest of the country."

"I hope that the whole Legislature will approve this investment as a match to the Clinic’s fund raising for this much-needed new school," Size said.

Marshfield Clinic currently operates five dental clinics in northwest Wisconsin and plans to open two more this year. In 2008 it served more than 20,000 patients and the Ladysmith clinic served patients from 42 counties.

The dental school fits within the Clinic’s mission of outreach to underserved populations, according to Marshfield Clinic President Dr. Karl Ulrich. Also, the clinic is three years into a similar program—the Wisconsin Academy of Rural Medicine—to train University of Wisconsin Medical Students to work in rural areas.

Health care today requires that hospital IT leaders prepare for the many challenges they face. Starting April 15, WHA is offering an eight-part webinar series focused on translating current legislative requirements into successful health care IT implementation strategies. The series will help participants gain new insights into priorities and practical approaches to organizing their IT efforts for compliance and maximum effectiveness. Those interested can register to participate in the full series or can register for individual sessions. All sessions are held via webinar from 1:30 - 3 p.m. CST on their scheduled date.

The eight sessions will include:

Phil Stravers, CEO, ICE Technologies, will present all eight sessions. Stravers has more than 15 years of experiences in the health care IT arena and more than 20 years experience in IT operations improvement.

Register online for the full series or for any individual sessions at www.wha.org/education/hospitalIT2010.aspx. For questions, contact Lisa Littel at llittel@wha.org or 608-274-1820.

Mental disorders vary in severity and in their impact on people’s lives. The symptoms can be severe and extremely destructive, causing immeasurable suffering for the patient and their families. Hospitals see an ever-increasing number of patients seeking treatment for mental disorders in their emergency departments. Inpatient mental health services are offered at 44 hospitals in Wisconsin and are generally operated at a loss, but because of the importance of treating these patients in the community, hospitals continue to place a high priority on providing mental health services to patients and their families. Sadly, nearly a third of those who are homeless suffer from serious mental illness.

For several years the Aurora Medical Center in Two Rivers has partnered with the Aging & Disability Resource Center, Wisconsin Caregiver Alliance, and Rivers Bend, a local long-term care facility, to offer "Taking Care of You - Powerful Tools for Caregivers."

This six-week, interactive class is offered at no charge to members of the general public and is targeted to those family members and friends who are caring for older adults with stroke, Alzheimer’s, Parkinson’s disease and other long-term conditions.

The class has been described as a wonderful resource and respite by participants who learn techniques to reduce personal stress, guilt and anger, and techniques to communicate effectively and with confidence with medical professionals and other family members.

Arlene Kunesh is a retired Aurora registered nurse retained by Aurora Medical Center in Two Rivers to teach the class. Arlene brings years of experience and caregiver expertise to leading the interactive lessons, discussions and brainstorming that make the program so lively and extremely beneficial.

Powerful Tools for Caregivers is offered two times a year.

At the first meeting of St. Francis Home’s visually impaired person (VIP) support group, Activities Director Audrey Uhl asked the gathering how many suffered from macular degeneration. Everyone there raised his or her hand.

"It was amazing. I told them that although you may not be able to see it, you have all raised your hands," she recalls.

It was an enlightening moment for Uhl, who knows that visual impairment is a major issue for people as they age. But it was also the reason for forming the VIP support group for residents of St. Francis Home, St. Francis Terrace and St. Clare terrace.

"We noticed that a lot of residents were struggling with vision loss, and it was affecting their lives. Even when we asked them to join in our activities, they would say they couldn’t because of their vision problems. They felt very isolated."

The VIP support group has been able to bring these individuals together so they can understand that others have the same problem too. Plus it allows residents to share stories, voice their concerns and learn more about vision concerns.

"Cognitively they are a very sharp group," says Uhl. "During our meetings we try to focus on their other senses, with activities such as listening to music, tasting food and hearing guest speakers, including a physician specializing in macular degeneration."

Residents are embracing the support group, whose membership includes more than 20 people.

Uhl admits it has been a learning experience for her too. "Just doing little things can make life easier for these individuals; things the average person would not think about … such as always placing food in the same location on their plate during meals, so they know what is where when they eat."

She adds: "Our initial meetings have gone well and I am optimistic about what is possible for the future. We will continue to focus on the positive—what these individuals can still do and enjoy doing."

A Grief Support Group for people who are grieving the loss of a loved one was held Tuesday evenings for six consecutive weeks October 6 through November 10 at the United Methodist Church in Black River Falls. The support group, sponsored by Black River Memorial Hospital, was open to the public at no cost. Facilitated by hospital social worker Denise Gearing, the group provided the opportunity to meet with others who are experiencing the loss of a loved one and to provide the tools to help people go through the grieving process. Material and information on the grieving process was shared with the participants.

There is something therapeutic that occurs when the ups and downs of one’s medical condition are shared with others. Emotional progress, if not physical progress, is much more likely to occur when patients can share their experiences and support one another. Whether the healing is physical or emotional, Fort HealthCare understands the importance that human connections have in the healing process.

Both hospital-based and registered community support groups are able to gather for free at Fort Memorial Hospital in Fort Atkinson. The support group leaders and participants attend at no charge, and complimentary refreshments are provided by the hospital.

Additionally, Fort Memorial Hospital’s Health Promotion department prints and mails out monthly member newsletters on behalf of certain support groups that request the service. Fort HealthCare covers the cost of the printing and postage.

Support groups are a valuable addition to professional treatment for a wide variety of conditions. Fort HealthCare serves groups of individuals that are experiencing physical limitations or recovery from major surgeries, individuals and families that have been victims of abuse, educational presentations, and just a gathering place for other community groups inspired to develop caring programs for our friends and neighbors. Support groups using Fort HealthCare services and facilities include Bariatric/LAP-BAND Support Group, Diabetic Support Group, Friends Through Multiple Sclerosis, Ostomy Support Group, Postpartum Depression Support Group and others.

Creating an environment for members of the community to gather together and support one another is one of the ways that Fort HealthCare lives the organization’s Mission on a daily basis, which is to provide excellent, compassionate care for the people of our communities.

Loss touches everyone in a different way, and the holiday season can be an especially difficult time. So every year, leading up to the holiday season, Gundersen Lutheran Health System offers "Turkey, Tinsel and Tears: How to Live Without a Loved One," a program to help people deal with loss. The program is offered in five rural communities where people are often isolated and/or do not have easy access to professional help in dealing with grief.

The program includes informational displays, local speakers who discuss their experiences in dealing with their personal loss, a panel discussion and audience questions. Further help is available to participants through Gundersen Lutheran Bereavement Services and the local health care facilities.

Coping with and helping out a loved one who struggles with depression is not an easy task. Whether it’s a spouse, child, parent, grandparent or friend; depression hurts more than that individual.

At the request of a mother whose teenage daughter suffers with depression—and to meet the growing needs of the community—Mile Bluff Medical Center in Mauston formed the Victory Over Depression support group.

The group covered topics such as: the definition of depression, how loved ones can help, the purpose of depression, treatment options, types of depression, and how diet aids in recovery and prevention of depression.

The benefit of having local resources—such as this program at Mile Bluff—has proved to be very beneficial in helping families cope with daily stresses due to the depression their loved ones face. The group has given a number of community members the tools necessary to gain Victory Over Depression!

Losing a child through miscarriage, stillbirth or infant death is very emotional and can be hard to deal with for families. Upland Hills Health’s Obstetrics and Social Services Departments see the need for these families to be able to acknowledge and remember their losses.

A group of bereavement counselors specially trained in pregnancy loss organized "A Time to Remember," an event to honor those babies who have died through miscarriage, ectopic pregnancy, stillbirth or infant death.

The event highlights Pregnancy Loss Awareness Month, designed to bring awareness about what causes pregnancy losses and the emotional struggle they can be for families.

The event, held in October, is free to all and gives families the chance to remember their lost babies, network and socialize, and speak with bereavement counselors if they choose to.

We’ve all heard the old adage that "laughter is the best medicine," but few people realize how true it is.

"Laughter is a natural high," said Cyndy Solliday-McRoy, PhD, a psychologist with Wheaton Franciscan Medical Group and Certified Laughter Yoga Leader who has leads a free class, "Laughing our Way to Optimal Health," at Wheaton Franciscan Healthcare – Wauwatosa.

"When we laugh, our bodies release hormones & chemicals that have startling positive effects on our entire system, including our mental health," said Solliday-McRoy, who speaks nationally on the subject. "It focuses your awareness on happy feelings in the here and now while distracting you from any negative thoughts, emotions or situations in your life.

The class, which has about 70 loyal participants, combines yoga breathing and laughter. The hour-long session is divided into three stages, starting with a "grounding" exercise, similar to more traditional yoga offerings. Here, participants are asked to clear their minds and focus on the exercise. Next, participants are asked to find a partner, make eye-contact with them and act out a "pose" or scenario that simulates laughter. Students then rotate partners for 20 minutes conducting the same exercise. Finally, the class closes with an instructor-guided meditation.