Meeting via conference call this week, the WHA Board agreed to "stay the course" in opposing the Doyle Administration’s hospital tax and payment initiative.

Board members received a comprehensive overview of technical aspects of the new plan, which was the result of almost three months of redesign work undertaken by Administration staff and consultants. As the Valued Voice goes to press, WHA staff continues to analyze details and methodology used to frame the proposed higher payments, especially focusing on consistency with approaches that have received CMS approval in other states. "At first blush, this new plan appears to address several issues raised by WHA back in February when we analyzed the hugely flawed original proposal," said WHA President Steve Brenton. "But very real technical questions remain unanswered and as we discovered three months ago…the consequences of a plan that fails to align with federal law and CMS guidelines are enormous." Brenton said that WHA staff will continue to engage in discussions with Administration officials in coming weeks.

"There are still a lot of assumptions, risks and unknowns associated with the tax plan, as no one, even the most renowned ‘experts,’ can predict what the federal government will approve or reject — SeniorCare is a perfect example of that," said WHA Senior Vice President Eric Borgerding. "Until CMS approves the reworked payment plan, all we do know is that over $200 million in taxes, the first payment of the $418 million tax, is supposed to be collected in full by December. The proposed payment increases are not in the budget bill; the $418 million tax is. As it stands now, without CMS approval of the payment plan, which will take many months, the tax simply increases the cost of health care. Though unintended, that should be a bipartisan concern."

Brenton said that the WHA Board position opposing the hospital tax initiative goes beyond addressing important technical concerns identified in the critique of the original proposal. "Huge public policy issues remain unaddressed, including: 1) the insistence on taxing hospitals prior to CMS plan approval; 2) the likelihood that HMOs will pass on the higher payments to hospitals; and 3) the ability to ‘protect’ hospital tax revenues from current and future raids," Brenton said in describing ongoing WHA Board concerns.

(From a Commentary in the May 15 issue of Modern Healthcare)

A diverse crowd ranging from clinicians to academics met in Irving, Texas, in March at the wonky but well-named National Conference on Small Numbers. The purpose was to address "the measurement of indicators of quality of care in small community hospitals and rural facilities that experience small cell size issues." Translation: The lack of sufficient data to make meaningful judgments on quality and outcomes is beginning to affect public opinion about rural health and how rural providers are paid.

Some rural providers prefer to stay out of the line of fire of pay-for-performance and public reporting of quality data; they say that they and their data should just be left alone. Some payers and quality reporters say their work is complicated enough without needing to deal with the challenge of small numbers. But all of America’s health care providers, including those in rural America, are challenged to be publicly accountable and to demonstrate that what they do makes a positive difference.

Not playing is not an option. Saying there are no good data for rural providers is not the answer. Many patients may assume that if the data are not available it means the results are bad. Rural providers must be given the opportunity to demonstrate that their quality of care and cost effectiveness are driven by evidence-based medicine and cost-effective leadership.

Complicating the challenge of small numbers is the national context—a dysfunctional cacophony of measurement voices. Is anyone, other than those voices, well served with more than a dozen disparate national quality and safety standard-setters? There is an urgent need for a coherent national strategy for quality accountability. Going beyond collaborative lip service to national measurement alignment is particularly urgent for rural providers; they simply do not have the resources to waste addressing multiple versions of similar demands.

Creating a coherent national strategy requires that individuals who understand rural health be at the table. The Medicare Payment Advisory Commission is the major public forum for Medicare’s new payment and reporting strategies, but it has almost no rural representation. In all settings, there is an unavoidable tension between waiting for perfect measures vs. using the best science we have at the moment. Only by fair rural representation in the process can subjective recommendations and decisions be credibly made. Appropriate rural representation increases the likelihood of confounding factors being taken into consideration.

A recently published study from the University of Iowa showed, contrary to some previous studies, that rural hospitals in Iowa do not have higher death rates when compared with urban hospitals. The study in the March-April Annals of Family Medicine "controlled for the finding that the sickest heart-attack patients may stay at rural hospitals (close to family) while the healthiest are transferred to an urban hospital," according to a news release.

From a statistical perspective, "small counts" (typically fewer than 25 or 30 events in a reporting period) raise concerns about reliability and validity. Reliability looks at the repeatability of the measure and validity at whether the intended target population is being measured. Some say if you count all the patients in a rural hospital, you have described everyone so statistics don’t matter. However, if you intend to generalize from what happens during one reporting period for one group of patients to what can be expected to happen in the future for another group of patients, statistics related to small numbers do matter.

Solutions either expand sample size by aggregating data over time or create composite measures by aggregating data across metrics. Aggregating data over time is the simplest approach, but slows feedback sought by providers and consumers. Composite measures can be effective, but may be less informative. Nancy Dickey, president of the Health Science Center at Texas A&M University, says that when numbers are too small to show the quality of care provided, peer-review mechanisms should be used to assure appropriate care.

Rural providers, clinicians and advocates must actively engage with both public reporting and value-based purchasing as well as redefine it to include our role in promoting healthier communities. While the cost of doing so is a barrier, we must help lead this movement, not be dragged along by it or left behind.

When CheckPoint first began publishing hospital quality data, WHA suppressed the rates for hospitals that had fewer than 25 cases in four rolling quarters since small numbers can create wide variation in the rates, misleading the consumer. Over time, Wisconsin hospitals indicated a willingness to have rates reported even when the number of cases in the denominator is less than 25, as long as WHA makes it clear to consumers using the information that these rates should not be compared to the rates of hospitals with at least 25 cases in their denominator. To accomplish this in the newest revisions to www.wicheckpoint.org, which will be released this summer, WHA will continue to show a (+) sign on the CheckPoint reports that show multiple hospitals indicating that the hospital has reported data, but that there are not enough cases to use that information to compare hospitals. CheckPoint will publish the rate, as well as the number of cases in the denominator, on a trend report that will display only one measure for one hospital at a time. In this way, the consumer can more easily see the variation and change in rate over time.

What started as perhaps a stretch goal—all hospitals in Wisconsin becoming tobacco-free campus wide by November 2007—is closer to becoming a reality. With 97 hospitals already tobacco-free campus wide and many more well on the way to joining those ranks, the WHA Board’s recommended goal in late 2006 of having all hospitals become tobacco-free by the next Great American Smokeout is within reach.

The hospitals that have gone through the process are quick to share what they have learned along the way. Michael Schmidt, president of Saint Joseph’s Hospital in Marshfield, said they directed communication strategies at patients, family and staff, with a special emphasis on supporting employee efforts to stop smoking. Schmidt also credited their success to having a path forged by other health care providers.

"It is now more accepted for hospital campuses to be smoke-free, thanks to the early efforts of Wisconsin hospitals," Schmidt commented. He advised hospitals that are now starting to implement tobacco free policies to allow for extended planning timelines, foster respectful communications on the topic, and encourage employee ownership of the importance of becoming tobacco-free.

Physicians play an important leadership role in the process. Dr. Tom Voelker, past president of the Riverview Hospital Medical Staff and a family practitioner and current president of Aspirus Doctors Clinic in Wisconsin Rapids said, "We should be a leader in providing the example of good health care. Smoking is the No. 1 health problem in our country, and smoking affects not only the individual smoker, but also those around him or her. The main reason…a ‘strong majority’ of doctors voted to make our health care facility 100 percent smoke-free…is that if we are promoting good health, then our facility should be a place of good health as well."

Mary Starmann-Harrison, immediate past chair of the WHA Board and regional president/CEO of SSM Health Care-Wisconsin, was instrumental in ushering the tobacco-free campus wide recommendation through the Board. "Eliminating tobacco on your campus is not without its challenges," she said, based on SSM’s experience. "It takes a tremendous amount of planning and follow through from writing the policy to providing employees, patients and visitors with alternatives to tobacco."

Starmann-Harrison said the early roadblocks to becoming tobacco-free are slowly being removed. "The first hospitals to adopt the policy met the most resistance and Mike Schmidt is right—they helped knock down the roadblocks. ‘It can’t be done’ was replaced with ‘why not?’ in many communities," Starmann Harrison added. Starmann-Harrison predicts that sometime in the near future, the public will just expect hospitals to not allow tobacco on their campuses.

That day can’t come too soon for the health of the people in Wisconsin.

The following hospitals are now tobacco-free campus wide:

Agnesian HealthCare/St. Agnes Hospital, Fond du Lac

All Saints-St. Mary’s Medical Center, Racine

Amery Regional Medical Center, Amery

Appleton Medical Center, Appleton

Aspirus Wausau Hospital, Wausau

Aurora BayCare Medical Center, Green Bay

Aurora Memorial Hosp. of Burlington, Burlington

Aurora Lakeland Medical Center, Elkhorn

Aurora Med. Ctr. of Manitowoc Co., Inc., Two Rivers

Aurora Med. Ctr. of Washington Co., Inc., Hartford

Aurora Medical Center, Oshkosh

Aurora Medical Center-Kenosha, Kenosha

Aurora Psychiatric Hospital, Inc., Wauwatosa

Aurora Sheboygan Memorial Medical Center, Sheboygan

Aurora Sinai Medical Center, Inc., Milwaukee

Baldwin Area Medical Center, Baldwin

Barron Medical Center—Mayo Health System, Barron

Beaver Dam Community Hospitals, Inc., Beaver Dam

Berlin Memorial Hospital, Berlin

Black River Memorial Hospital, Black River Falls

Bloomer Medical Center-, Mayo Health System, Bloomer

Bond Health Center, Oconto

Boscobel Area Health Care, Boscobel

Children’s Hospital of Wisconsin-Fox Valley, Neenah

Children’s Hospital of Wisconsin-Kenosha, Kenosha

Columbia St. Mary’s, Inc. - Columbia Campus, Milwaukee

Columbia St. Mary’s, Inc. - Milw. Campus, Milwaukee

Columbia St. Mary’s, Inc. - Ozaukee Campus, Mequon

Columbia St. Mary’s-Sacred Heart Rehab Inst., Milwaukee

Community Memorial Hospital, Menomonee Falls

Cumberland Memorial Hospital, Inc., Cumberland

Divine Savior Healthcare, Portage

Door County Memorial Hospital, Sturgeon Bay

Eagle River Memorial Hospital, Eagle River

Elmbrook Memorial Hospital, Brookfield

Flambeau Hospital, Park Falls

Franciscan Skemp Healthcare-Mayo Health Sys., Arcadia

Franciscan Skemp Healthcare-Mayo Hlth. Sys., La Crosse

Franciscan Skemp Healthcare-Mayo Health Sys., Sparta

Good Samaritan Health Center, Merrill

Grant Regional Health Center, Lancaster

Holy Family Memorial, Inc., Manitowoc

Howard Young Medical Center, Woodruff

Hudson Hospital, Hudson

Kindred Hospital Milwaukee, Greenfield

Ladd Memorial Hospital, Osceola

Lakeview Medical Center, Rice Lake

Langlade Memorial Hospital, Antigo

Luther Hospital, Eau Claire

Memorial Health Center, Medford

Mercy Health System Corporation, Janesville

Mercy Medical Center, Oshkosh

Mercy Walworth Hospital and Med. Ctr., Lake Geneva

Mile Bluff Medical Center, Mauston

Moundview Memorial Hospital & Clinics, Friendship

New London Family Medical Center, New London

Oconomowoc Memorial Hospital, Oconomowoc

Orthopaedic Hospital of Wisconsin, Glendale

Osseo Medical Center, Osseo

Our Lady of Victory Hospital, Stanley

Prairie du Chien Memorial Hospital, Prairie du Chien

Red Cedar Medical Center, Menomonie

Reedsburg Area Medical Center, Reedsburg

River Falls Area Hospital, River Falls

Riverside Medical Center, Waupaca

Riverview Hospital Association, Wisconsin Rapids

Sacred Heart Hospital, Eau Claire

Sacred Heart-St. Mary’s Hospitals, Rhinelander

Sacred Heart-St. Mary’s Hospitals, Tomahawk

Saint Clare’s Hospital, Weston

Saint Joseph’s Hospital, Marshfield

Saint Michael’s Hospital, Stevens Point

Sauk Prairie Memorial Hospital, Prairie du Sac

Southwest Health Center, Platteville

Spooner Health System, Spooner

St. Clare Hospital & Health Services, Baraboo

St. Croix Regional Medical Center, St. Croix Falls

St. Elizabeth Hospital, Appleton

St. Francis Hospital, Milwaukee

St. Joseph Regional Medical Center, Milwaukee

St. Joseph’s Hospital, Chippewa Falls

St. Mary’s Hospital, Madison

St. Mary’s Hospital Medical Center, Green Bay

St. Nicholas Hospital, Sheboygan

Stoughton Hospital Association, Stoughton

SynergyHealth St. Joseph’s Hospital, West Bend

The Monroe Clinic, Monroe

The Wisconsin Heart Hospital, Wauwatosa

Theda Clark Medical Center, Neenah

Tomah Memorial Hospital, Tomah

Tri-County Memorial Hospital, Whitehall

Vernon Memorial Healthcare, Viroqua

Watertown Memorial Hospital, Watertown

Waukesha Memorial Hospital, Waukesha

Waupun Memorial Hospital, Waupun

West Allis Memorial Hospital, West Allis

Westfields Hospital, New Richmond

The Kalahari Resort Room Reservation Cut-Off: June 6 (or when block is full)
Conference & Golf Registrations: Due June 6 to WHA

On May 18, Spooner Health System hosted Representative Mary Hubler (D-75th District) to a question and answer session relating to the Governor’s budget proposals. Mike Schafer, CEO of Spooner Health System, along with administrative staff, physicians, board members and employees had the opportunity to directly question Rep. Hubler on legislative matters important to them. Topics discussed included the hospital bed tax, nursing home bed tax, and Medicaid reimbursement issues. Hubler shared with the group that the budget process has several months to go yet before being finalized with three big issues to be addressed: cigarette tax, hospital bed tax and hospital assessments.

Attendees expressed their appreciation to Rep. Hubler for her continued support of health care facilities in northwest Wisconsin.

Submitted by Ann Bergmann, Spooner Health System

Nominations are now being accepted for WHA’s annual Distinguished Service Award and Trustee Award, as well as for the ACHE Young Healthcare Executive Award. These important awards recognize those who display leadership, dedication and professionalism to their community or the Association.

WHA will recognize the award winners at the 2007 Annual Convention in September. You may know someone in your region, in your hospital or on your Board of Directors who deserves such an honor. You now have an opportunity to nominate them for one of these annual awards:

• Distinguished Service Award is presented to a senior health care executive who has made an exemplary commitment to WHA, his/her hospital, and the communities he/she serves.
• Trustee Award honors a trustee of a WHA member organization who has made an exemplary commitment to his/her community and to the organization on whose board he/she serves.
• ACHE Young Healthcare Executive Award is presented to a member of the American College of Healthcare Executives under the age of 40 who has shown exceptional professional development. Nominations for this award should be sent to Mary Hansen, Berlin Memorial Hospital, AHCE Young Healthcare Executive Award, 225 Memorial Drive, Berlin, WI 54923.

Administrators, trustees, senior managers, nurse leaders, volunteers and others are encouraged to review the criteria for the awards and consider nominating someone to receive one of these honors.

The deadline for submitting nominations is July 20. Details about the nomination process and criteria for nomination can be found in the annual awards brochure included in this week’s packet and on the WHA Web site at www.wha.org/about. For more information, contact Sherry Rabuck or Steve Brenton at WHA, 608-274-1820.

Honor one of your hospital’s community health projects by nominating it for a 2007 Global Vision Community Partnership Award, presented by the WHA Foundation.

This competitive grant award is presented to a community health initiative that successfully addresses a documented community health need. The Award, launched by the WHA Foundation in 1993, seeks to recognize and support ongoing projects that support community health.

Any WHA member can nominate a community health project. The project must have been in existence for a minimum of two years and must be a collaborative or partnership project that includes a WHA member hospital and an organization(s) within the community. The official call for nominations for the 2007 Award is included in this week’s packet.

The Award will be presented at the WHA Annual Convention on September 20, 2007. Nominations are due July 13, 2007. Nomination forms can also be found on the WHA Web site at www.wha.org. For more information about the Award, contact Jennifer Frank at jfrank@wha.org or 608-274-1820.

On August 7 and 14, WHA will offer a two-part audioconference focused on the Joint Commission updates related to the Life Safety Code® and utilities systems, for hospital Joint Commission compliance staff, facility managers, quality managers and hospital administrators.

On August 7, during part one of the series, faculty Susan McLaughlin will discuss the current requirements of the Joint Commission with respect to compliance with the Life Safety Code®. Topics to be addressed include the electronic Statement of ConditionsTM, the new role of the Life Safety Code® surveyors in 2008, and the value of using a Building Maintenance Program.

There have also been several recent changes made to the Joint Commission’s utility management requirements, particularly with respect to emergency generators, and on August 14, during part two of the series, the current standards will be reviewed and the new ones explained. In addition, there is an impact on utilities management in the soon to be released (scheduled for release in July) emergency management standards, effective January 1, 2008, which will be discussed.

The deadline to complete the WHA Community Benefit online survey is May 30. The data from the survey, along with "real life" stories, will be used to compile the second annual WHA Community Benefit Report and to update www.wiservepoint.org. Last year, 100 percent of WHA’s member hospitals completed the survey and all hospitals submitted at least one story.

"The community benefits reporting initiative provides hospitals the opportunity to let the public know about all the services, programs and assistance that hospitals provide in the communities they serve," said WHA’s Mandy Ayers. "Our goal this year is to match the success that we had last year in telling our story."

With the survey deadline rapidly approaching, WHA reminds hospitals to complete the survey soon. WHA will contact those hospitals that have not started entering data to offer any assistance that might be necessary to finalize the survey. Questions about the survey can be directed to Mandy Ayers at mayers@wha.org or 608-274-1820.

Sharing health information technology (IT) with physicians would not jeopardize a not-for-profit hospital’s tax-exempt status, the Internal Revenue Service (IRS) announced May 11 in a memorandum. The agency said it "will not treat the benefits a hospital provides to its medical staff physicians as impermissible private benefit or inurement" if the benefits fall within the range of health IT services that are allowed under the Department of Health and Human Services’ (HHS) regulations on electronic health records (EHR) and the agreement meets certain criteria. The agreement should ensure continuing compliance with the HHS regulatory requirements, and allow the hospital to access all EHRs created by a physician using the health IT subsidized by the hospital, the IRS said. The agreement also should offer the same level of subsidy to all medical staff physicians, or vary the level of subsidy as appropriate to meet the health care needs of the community. The AHA met with the IRS on this issue in February, and is "pleased that the IRS moved quickly in responding to hospitals’ request for guidance," said AHA Counsel Lawrence Hughes.

The Healthy Wisconsin Leadership Institute is offering a year-long education opportunity that supports the development of collaborative leadership and public health skills among teams that are mobilizing communities to address health problems. The curriculum includes training in technical and scientific skills that equip learners to successfully impact community health improvement initiatives. Learners will:

• Build individual and collaborative leadership skills
• Apply community health improvement models
• Use practical evidence-based approaches to address health issues
• Advance skills needed to effectively communicate with policymakers and the media
• Gain insight into building and maintaining strong partnerships and coalitions

Each team is assessed a $500 per participant fee, with a $3,500 maximum per team. The fee can be adjusted according to the team’s ability to pay.

Wisconsin Literacy is offering a one-day "Health Literacy Summit" June 21, 2007, in Wisconsin Dells. The Summit will focus on communication between health care professionals and adult literacy educators and the exchange of ideas on how to improve the delivery of health care to Wisconsin adults with low literacy and limited English speaking skills.

The WHA Foundation is one of the lead sponsors of this free event, and as a sponsor and a participant in the planning process, the WHA Foundation encourages the WHA member hospitals to send a representative.

The Summit will include a report by Dr. Paul Smith, UW Department of Family Medicine, on the results of a health literacy focus group project involving adult literacy students; a workshop on creating health care documents for low literate adults; and a practitioners’ panel focusing on health literacy initiatives throughout the state.

To register online, go to: www.wisconsinliteracy.org, or contact Georgia Weier at 608-257-1655 or Georgia@wisconsinliteracy.org. You’ll be asked for a registration ID and password. They are as follows:

Registration ID: guest
Password: health

During a trip to Washington, DC earlier this month, hospital representatives from Wisconsin met with legislators to discuss the impact of the proposed Inpatient Prospective Payment (IPPS) rule recently released by CMS. During those meetings, legislators were asked to sign on to "Dear Colleague" letters opposing the proposed IPPS cuts. To date, Senators Kohl and Feingold, and Representatives Baldwin, Kagen, Moore and Petri have signed onto these letters. WHA applauds our legislators for standing up in support of Wisconsin’s community hospitals.

Under the proposed IPPS rule, Wisconsin hospitals are projected to lose over $400 million in the next five years, primarily due to a provision referred to as the "behavioral offset." This "offset" is a 2.4 percent reduction in both FY 2008 and 2009 to eliminate what CMS claims will be the effect of coding or classification changes it anticipates will occur due to improved documentation and coding under the new system of DRGs. In essence, this 2.4 percent reduction is a way for CMS to take back three-quarters of the marketbasket inflation update. The IPPS rule would also have an especially hard impact on metro areas like Milwaukee through two other provisions—a freeze in capital payments for urban hospitals (zero marketbasket update) and the elimination of the 3 percent large urban add-on to capital payments.

When the Price County Department of Human Services has to make an emergency placement, whether for a family or an individual, many times the persons being placed have no supplies at all. A group of Flambeau Hospital employees, who call themselves the "Living the Mission" group, prepare emergency placement kits containing assorted daily living products, along with a fleece blanket for the children.

"Please accept our deep and sincere thanks and appreciation for the numerous acts of kindness and charity expressed by your organization in 2006. It is always amazing to us that so many are willing to share so much with those who often have so little," said Mary Hahn, director of the Price County Department of Human Services. "Each year our staff is restored, renewed, and energized by witnessing the generosity demonstrated throughout our community. On behalf of our board, our staff, and the citizens we serve, our heartfelt thanks!"

The "Living the Mission" group works on numerous projects to benefit others. Examples include a "Mitten Tree Project" at Christmas, which assists in the purchase of toys, clothing, and household items for needy families. Employees participated in the project by making polar fleece blankets to help comfort the children going into emergency care. Another favorite project is "Project May Basket." One hundred May baskets are assembled – and with the tremendous help of volunteer drivers – are delivered to homebound elderly in the community.

"The kind and selfless efforts of a group like this strengthen the bonds of partnership between the employees and the hospital, as well as the community," said Jim Braun, CFO, Flambeau Hospital. "We’ve living our mission within the community in order to help the underserved and vulnerable populations, giving people a glimmer of hope in a time of hardship."

Submit hospital community benefit stories to Mary Kay Grasmick, editor, mgrasmick@wha.org or call 608-274-1820.

Froedtert Hospital President & CEO Bill Petasnick received an Honorary Doctor of Health Sciences degree from the University of Wisconsin–Milwaukee (UWM) on May 20 at the university’s spring commencement festivities.

According to Carlos Santiago, chancellor for UWM, the university’s faculty and the board of regents of the University of Wisconsin System chose to present this honorary degree to Bill because of his professional and personal achievements.

"Bill is committed to clinical and organizational excellence, and has a vision for meeting the health care needs of Milwaukee’s most vulnerable citizens," said Santiago. "These qualities, combined with his work as Froedtert’s CEO, made him an exemplar of the ‘best and brightest’ in health care administration."

Petasnick is the 2007 chair-elect of the American Hospital Association Board of Trustees and chairs the Long-Range Policy Committee.

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