Assembly Majority Leader Mike Huebsch (R-West Salem) addressed a number of issues when he appeared before WHA’s Public Policy Council this week, including health care costs and medical liability reform. But his thoughts on reforming Wisconsin’s Medicaid program drew the most attention.

"I think consumers need to have more skin in the game when it comes to health care; we need to better understand how we use the health care system and the impact it has, not just on our personal health, but on our personal economies," Huebsch told the 30 attendees. "We also need to bring that same level of personal ownership, if you will, to the Medicaid program. There have to be better, or at least some, incentives for better use of the system because we can’t afford what is happening now."

At the same time, Huebsch, who has strong ties to his local health care systems (Franciscan Skemp and Gundersen Lutheran), knows that "reforming Medicaid" does not simply mean paying health care providers less for the care they deliver.

"In my eyes, reducing payments to providers is not an option in reforming Medicaid," Huebsch bluntly stated. "We already have a huge problem with cost shifting and the Medicaid hidden tax that is driving up the cost of health care for Wisconsin employers. We have to address that very real problem, not make it worse."

Huebsch also commented on the tremendous importance of communicating with elected representatives and maintaining strong relationships with legislators, a grassroots priority for WHA.

"While WHA is very good at what they do, they are only as good as the people, their members, who stand behind them," Huebsch said. "I personally have a very good relationship with the two health care facilities in my district. I know that I can pick up the phone and call them at any time, on any issue and get a straight answer that I can trust. That’s the kind of relationship you must have with your legislators."

WHA’s Eric Borgerding recognized Huebsch for the excellent two-way relationship he has with his hospitals, a trait that was evident during the recent battle to restore a cap on non-economic damages.

"Both of Rep. Huebsch’s hospitals spent a great deal of time talking with him about the importance of reestablishing the cap on non-economic damages for health care in the La Crosse area, and he listened," said Borgerding. "There is no question that without Mike’s strong support, we would not have gotten this issue back on the table and done."

It was a full agenda that, in addition to Rep. Huebsch, included a discussion by WHA staff and Council members of the recently completed 2005-06 legislative session. Passage of a new medical liability cap, the defeat of the Taxpayer Protection Amendment (TPA) and Governor Doyle’s veto of the WHA-backed Quality Improvement Act were highlighted – all of which happened since the Council last met in January.

WHA’s Jodi Bloch briefed members on the kick-off of the 2006 Wisconsin Hospital PAC and Conduit campaign. She noted a number of new strategies that would be employed in an effort to reach the 2006 goal of raising $185,000. Council president David Olson urged his fellow members to take a lead role in the campaign.

The Council is scheduled to hold its next meeting on Tuesday, September 12.

On May 23, Governor Doyle signed SB 650 into law as Wisconsin Act 449, which amends provisions of Wisconsin’s mental health records statute, §51.30, Wis. Stats., relating to the confidentiality of those records. The Act changes the definition of registration and treatment records, amends a treatment related exception to confidentiality, and creates a new exception to confidentiality permitting the release of limited information to health care providers in a related health care entity. This law takes effect June 6.

Over the course of the last few months, representatives from Aurora, Affinity, ThedaCare, the Wisconsin Medical Society and WHA have been meeting with the mental health advocates along with representatives from Sens. Roessler and Darling’s offices and Rep. Strachota’s staff to discuss selected continuity of care issues addressed in the Act.

The Act amends the definition of "registration records" and "treatment records" in §51.30 to include records "created in the course of providing services to individuals" for mental health issues. This new language takes the place of language in the statute that had previously included records concerning or identifying "individuals who are receiving or who at any time have received services for" mental health issues.

Act 449 also amends a treatment related exception to the confidentiality of mental health treatment records. Under the amended statute, such records may be released "for treatment of the individual in a medical emergency, to a health care provider who is otherwise unable to obtain the individual’s informed consent because of the individual’s condition or the nature of the medical emergency." This new language replaces language that provided an exception "to a licensed physician who has determined that the life or health of the individual is in danger and that treatment without the information contained in the treatment records could be injurious to the patient’s health."

A new limited exception to the confidentiality of mental health records was also created that applies "to health care providers in a related health care entity" and "to persons acting under the supervision of such a health care provider who is involved with an individual’s care." The exception permitting release of confidential treatment records only applies if the release of the record is "necessary for the current treatment of the individual," and only if the information released is limited to "the individual’s name, address, and date of birth; the name of the individual’s mental health treatment provider; the date of mental health service provided; the individual’s medications, allergies, and diagnosis; and other relevant demographic information necessary for the current treatment of the individual." For purposes of this exception, a related health care entity has been defined to mean either "an entity that is within a clinically integrated care setting in which individuals typically receive health care from more than one health care provider," or "an organized system of health care in which the health care providers hold themselves out to the public as participating in a joint arrangement and jointly participate in activities."

In late April, the American Hospital Association (AHA) Board of Directors approved a bold and proactive transparency/accountability agenda that well positions the field for current and future advocacy activity.

The AHA agenda addresses three very current national issues: hospital pricing transparency, hospital billing and collection guidelines, and mandatory reporting of community benefits.

Here are highlights of the AHA initiatives and their likely impact on current WHA activities:

• Hospital Pricing Transparency – The AHA Board position supports federal requirements for states, working with state hospital associations, to make hospital charge information available to consumers. Similarly, the AHA position suggests that insurers make available in advance of medical visits information about an enrollee’s expected out-of-pocket costs.
  
  For Wisconsin, the AHA position is late arriving, as WHA-IC’s PricePoint is already in sync with the AHA hospital pricing transparency position. In fact, PricePoint has been branded in several other states to facilitate hospital pricing transparency in those venues.

• Hospital Billing and Collection Guidelines – In addition to AHA’s previous support for specific and readily available billing guidelines associated with low-income patients, the new AHA initiative clearly states that hospitals should offer up-front financial assistance to uninsured patients with income in excess of 200 percent of the federal poverty. Importantly, this information should be readily available to these uninsured patients and their families. The AHA guidelines appropriately suggest a responsibility for affected patients to cooperate with the billing office and pay their discounted bills.

For Wisconsin, the current WHA Board guidelines align with the AHA position. But work needs to be done to advance transparency for higher income uninsured patients. PricePoint could become an access portal for hospital-specific billing policy information to advance this objective.

• Mandatory Reporting of Community Benefits – The AHA Board policy supports the annual mandatory reporting of hospital community benefits using uniform definitions. The recommendation also supports reporting hospital-specific community benefits as an attachment to the current IRS Form 990.

For Wisconsin, WHA’s Community Benefit Reporting Initiative is in lock-step with the AHA-approved policy in its totality. We continue to expect our first annual statewide community benefits report to be released in late 2006. Our early commitment to public reporting positions Wisconsin hospitals to easily accommodate this anticipated federal requirement.

The AHA Board (Froedtert President and CEO Bill Petasnick serves as an AHA Board member) deserves recognition for aggressively embracing these significant transparency initiatives. Given the diversity of the AHA membership, reaching consensus was a challenge. But as Wisconsin hospitals have already learned, the proactive nature of these initiatives will serve the field well during current and upcoming legislative debate.

Steve Brenton
President

Over the past month, the State Senate Committee on Health Care Reform held hearings in Milwaukee and Chippewa Falls on health care and recommendations for change. Wisconsin hospitals were represented at both.

As the Committee traveled to Chippewa Falls on May 11, St. Joseph’s Hospital CEO David Fish saw a golden grassroots opportunity to testify to the problems that Medicaid underfunding and dental care access have in northern Wisconsin communities and hospitals.

"I would tell you in our area and probably in many other areas of our state, there is a dental access crisis for the neediest, the poorest, and the most marginalized among us," Fish said. "When people utilize an emergency service to deal with dental problems, it is exceedingly expensive, does not inclusively deal with or completely eradicate the problem and, all-in-all, is not the most effective way of helping those in need."

In 2001, St. Joseph’s joined with the Chippewa Falls 2010 Achieving a Healthier Community to aggressively work on improving access to dental care for the underserved and uninsured in Chippewa County. In January 2002, the Chippewa Oral Health Initiative was formulated and St. Joseph’s Hospital worked with it and CESA 11 to open a dental clinic at the hospital. It opened in 2003. In 2002 the hospital also approached Marshfield Clinic to work collaboratively with them to replicate the federally qualified dental clinic it operates in Ladysmith. After six years of effort, a federally qualified dental clinic, operated by the Marshfield Clinic, will become a reality in Chippewa Falls.

While Fish provided the Committee with examples of how St. Joseph’s is reacting to this very critical need, he also stressed that these are woefully inadequate to meet current demand. In fact, there are over 600 children and individuals on area waiting lists right now.

Fish also testified about the fiscal impact that Medicaid underpayments have on rural hospitals like his. As a not-for-profit hospital, St. Joseph’s has been serving its community for over 123 years. It is a short-term acute care facility and also designated as a Disproportionate Share Hospital (DSH).

"The Medicaid Disproportionate Share Program provides ‘special payments’ to high Medicaid utilization hospitals. Unfortunately, state funding for Medicaid DSH payments has not kept up with hospital expense inflation or rising utilization," Fish testified. "In fact, DSH payments haven’t increased for roughly a decade."

Fish went on to tell Committee members that in Fiscal Year 2004, 3,563 inpatient days or 22.2 percent of his inpatient service was provided to Medicaid recipients. Excluding Critical Access and specialty hospitals, that means that St. Joseph’s Hospital had the seventh highest Medicaid utilization rate in Wisconsin.

"Wisconsin not-for-profit hospitals are the backbone of our state’s health care safety net, providing care to all patients who come through their doors, regardless of their ability to pay," Fish said. "That being the case, Wisconsin hospitals experience severe payment shortfalls when treating Medicaid patients."

In 2005 alone, it is estimated that Medicaid paid Wisconsin hospitals just 49 cents for every $1.00 it cost to provide care to Medicaid patients – a total of $546 million less than what it cost Wisconsin hospitals to provide the care. Fish testified that Medicaid funding was even worse at St. Joseph’s Hospital, which was reimbursed only 41 cents for every $1.00 it cost them to treat Medicaid patients. The total amount of underfunding at his hospital was $3.8 million in 2004.

This means some Wisconsin hospitals, like St. Joseph’s, receive just $99 for outpatient surgeries that cost thousands to perform. These costs have to be made up somewhere -- like through Wisconsin employers who are forced to absorb them through higher insurance premiums. This equals a "Hidden Health Care Tax" of roughly $450 million in 2004 and $546 million in 2005.

"One area that you can impact is to appropriately fund the government’s health care programs like Medicaid," Fish told Committee members. "This will slow growing health care costs and slow the levels of cost shifting necessitated by payment shortfalls, thereby slowing the growth of the ‘Hidden Health Care Tax’ on Wisconsin employers and employees."

HEAT Action Alert: Dental Care Access

On June 8 a state legislative committee will vote on a provision to allow dental hygienists to bill Medicaid directly for services, such as providing sealants. WHA strongly supports this rule as a means to treat the thousands of needy individuals outside of hospital emergency rooms and in a more appropriate care setting. If you live in one of the following districts, please contact your legislators and urge their support for this provision, without modification, in CR 05-033.  Senators: Grothman, Stepp, Reynolds, Jauch and Miller. Representatives: LeMahieu, Friske, Towns, Schneider and Black.

Email your legislators by logging on to www.wha.org/speakUp/emailLegislator.aspx or contact Jenny Boese at 608-268-1816 or jboese@wha.org for more information.

Has your hospital been involved in grassroots advocacy on health care issues? HEAT is always interested in hearing from you! Contact Jenny Boese at 608-268-1816 or jboese@wha.org so WHA can showcase your efforts in the Grassroots Spotlight!

To be effective at balancing a successful government relations program, there needs to be three strong legs to support the whole stool. If one of those legs is weak, the whole stool is in jeopardy of collapsing. The same is true for a successful government relations program, which needs to be balanced by strong legs representing lobbying in the Capitol, an effective network of member grassroots contacts, and of equal importance, strong individual participation in the Association’s political fundraising campaign.

This year, the Campaign’s goal is to raise at least $185,000. 2006 marks an election year, and in Wisconsin this is a big election as the Governor’s seat is up for grabs along with all 99 Assembly seats, 17 State Senate seats, all members of Wisconsin’s Congressional delegation in the U.S. House of Representatives, and one U.S. Senate seat. Shortly thereafter, the Spring 2007 elections will provide voters a chance to elect a new Supreme Court Justice with the announced retirement of Justice Jon Wilcox. This coming year will make for a busy election year, and there will be many campaigns Wisconsin Hospitals Political Action funds will be looking to support financially.

Individual participation in this Campaign sends a message to policy-makers and those running for office that individuals affiliated with Wisconsin hospitals are united in getting out the message of the important role Wisconsin hospitals play in their respective communities. Recognizing the importance of these funds provides an opportunity to positively impact the election of candidates who understand that important role.

If you would like additional information, please contact Jodi Bloch or Jenny Boese at 608-274-1820.

The WHA Toolkit includes a new white paper on Wisconsin’s community benefits initiative. WHA will unveil a voluntary, statewide community benefits report in the summer of 2006. The new Toolkit paper provides an overview of that initiative, tips on telling the hospital story and other resources.

"The Task Force surveyed national and state activities on community benefits and determined that Wisconsin hospitals have so much to be proud of," said Bob Fale, WHA Community Benefits Task Force chair. "That is why we recommended a statewide community benefits report—to make certain the public and policymakers are aware of Wisconsin hospitals’ continued commitment to and investment in our communities."

This first statewide community benefits report will be a significant step forward in qualitatively showing the value of Wisconsin hospitals to their communities. However, numbers alone cannot always convey the direct impact of hospitals in their community—that is why telling the hospital story is so important.

The Toolkit white paper helps hospitals with telling their stories, including several examples from across the state, as well as provides insight on localizing the issue for key audiences such as the public, community leaders, news media, and policymakers. Additional background resources are incorporated.

"WHA and its member hospitals have a proud tradition of being at the forefront of initiatives regarding transparency and quality," said Mary Starmann Harrison, WHA Board chair. "We are looking forward to this summer when our first voluntary, statewide community benefits report will be unveiled."

The Internal Revenue Service (IRS) has recently begun sending tax-exempt hospitals a detailed inquiry known as a "Compliance Check Questionnaire" seeking information about their operations. The questionnaire includes sections on uncompensated care policies, community care programs, compensation practices, and board organization. The compliance check is not an audit, but an examination of tax-exempt entity compliance with rules and regulations. However, the IRS noted in a recent teleconference that some examinations this year have resulted in audits. These recent IRS mailings are part of an investigation into tax-exempt entities that the IRS has conducted for the past year.

The questionnaire and subsequent audits were not unanticipated, given what has been happening in Washington, DC. WHA has been keeping up with these developments, and the WHA Board approved a process where the Association will for the first time this year, collect and publish community benefit data from its member hospitals. A move, according to WHA Senior Vice President George Quinn, that should help hospitals plan for and prepare to answer the very questions that the IRS is now asking.

"We thought something like this might be coming with the Congressional hearings last summer, chaired by Sen. Chuck Grassley of the Senate Finance Committee. The WHA Community Benefits Task Force moved forward with a plan that included publicly reporting community benefits," Quinn said. "When and if any of our member hospitals receive an inquiry from the IRS, they should be prepared to present the financial information that they are seeking related to community benefits."

If a member hospital receives the questionnaire and needs assistance completing it, contact Quinn at gquinn@wha.org or 608-274-1820.

As a reminder, June 30 is the deadline to submit your quality and safety improvement projects for inclusion in the 2006 Wisconsin Quality & Safety Forum Project Showcase. Only those projects submitted by June 30 will be included on the 2006 Wisconsin Quality & Safety Forum Showcase, included on the CD-ROM of all submitted projects, be considered to offer a breakout presentation at the Forum, and published in the December issue of the Wisconsin Medical Journal focused on quality and patient safety.

As in 2005, Showcase projects submissions will only be accepted via completion of the online submission form at www.wha.org/QSFshowcase. The online form is now available and all submissions are due to WHA, via the online form, by Friday, June 30, 2006. For questions about project submission, contact Brian Competente at 608-274-1820 or bcompetente@wha.org.

Projects that have not previously been submitted are eligible, as are new phases of a previously submitted project. A full project submission brochure, describing all submission criteria, is available on WHA’s Web site at www.wha.org and is included in this week’s packet.

For those involved in research projects, you are also encouraged to submit a manuscript for peer review, to be considered for publication in the December issue of WMJ. The deadline to submit manuscripts is October 9, 2006. To view "Instructions to Authors," visit the Wisconsin Medical Society Web site at www.wisconsinmedicalsociety.org/health_news/wmjauthorinstruct.cfm.

CMS has published a notice of proposed rulemaking (Federal Register, Vol.71, No.65, page 17052) that will revise the hospital inpatient discharge notice by requiring hospitals to provide each beneficiary with a standardized, generic discharge notice one day prior to discharge (see May 5, 2006 Valued Voice article "New Discharge Notice Requirements Proposed" for details). Although Wisconsin hospitals are committed to the belief that all patients are entitled to be clearly informed of both their benefit coverage and right to appeal regardless of their payer source, a review of the proposed rule by WHA concludes that it is operationally impractical, overly burdensome to hospitals and unsupported from a patient’s rights perspective.

The proposed rule would implement a process which matches requirements for home health, skilled nursing facilities and hospice care However, WHA contends that there is a fundamental difference between acute care settings where a patient’s medical condition is subject to rapid changes, and home health, skilled nursing facilities and hospice care which, by its nature, assumes a more stable patient condition. Furthermore, hospitals are already required to provide the "Important Message from Medicare" to all patients upon admission, making the proposed requirement duplicative in the inpatient setting.

Finally, WHA believes that CMS has underestimated the cost of implementing this rule by failing to include costs that will be incurred when a physician discharges a patient with less than one day’s notice or a discharge date is delayed.

Discussions about health care costs are important ways for communities to better understand the issue, and for providers, employers, insurers and patients to come to a consensus on strategies to deal with rising costs. WHA co-sponsored and participated in such a forum in Manitowoc this week. The forum, entitled, "An Exploration of Cost Drivers and Potential Solutions," was hosted by the Wisconsin Manufacturers and Commerce (WMC) and co-sponsored by Manitowoc Corporation, WHA, Holy Family Memorial Hospital, and the Health Care Coalition Cooperative. It was attended by some 80 business and health care leaders from the Manitowoc and Two Rivers areas.

Clark Slipher of Milliman Consultants and Actuaries provided the keynote address, which focused on health care cost drivers. When discussing the role of employees in making health care decisions, Slipher said, "[Employees] can understand much more complicated things in life," Slipher said. "I believe consumer-directed health plans have reached a tipping point, are not a fad, and are not going away."

Following Slipher’s presentation was a panel discussion which included Terry Growcock, CEO of Manitowoc Company; John Brixius of Safe Harbor Insurance; and George Quinn of WHA. Each panel member was asked to comment on a range of issues such as how underfunding of Medicaid impacts employers and employees, and local or regional measures for industry to take that create a positive influence on health care costs.

Panelists saw Medicaid payments as a major cost driver, and all agreed that efforts were needed to address the issue. WHA has long advocated that underfunding of Medicaid due to dismal reimbursements rates for hospitals equals a hidden health care tax on Wisconsin employers and employees. That hidden health care tax was $546 million in 2005 alone. During the 2005 budget bill, WHA partnered with WMC to advocate for increased Medicaid outpatient reimbursement rates. Although the increase was approved by the Legislature, Governor Doyle vetoed it. WHA will work again with key stakeholders in 2007 as the next budget bill process begins.

In discussing measures that will have a positive influence on health care costs, WHA Senior Vice President George Quinn said, "We think making this [price and quality] information available will bolster consumer-driven plans," Quinn said, citing WHA’s CheckPoint and PricePoint programs on quality and pricing, respectively.

However, panelist John Brixius commented that a "paradigm shift" was needed to move employees more towards consumer-driven health care purchasing and away from an entitlement mentality.

Overall, the consensus of all panelists was that employers, insurers and providers need to work together to improve the health of employees, promote better quality in health care, and to make employees and patients more informed consumers of health care.

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