Debate that began late Thursday afternoon (May 28) lasted until the sun was coming up Friday morning, but when the final votes were counted, the Joint Finance Committee completed their work and passed an amended version of the state budget proposed earlier this year by Governor Doyle.

As previously reported, the process for tackling Wisconsin’s nearly $6 billion deficit was made all the more difficult with news earlier this month that the state was facing an additional $1.6 billion shortfall.

The first item discussed during the Committee’s final session was an omnibus motion that included the expanded hospital assessment. Under this proposal, the assessment will increase by roughly 20 percent, with the distribution formula negotiated earlier this year remaining complete and intact. The plan allows hospitals to receive additional Medicaid payments to help address growing program enrollment. The initiative was approved by the WHA Board last week.

Also as previously reported, the expanded assessment will mean additional funding to help shore up the state’s Medicaid program and allow expansion of coverage to low-income, currently uninsured childless adults to move ahead statewide without delay.

This and other safety net health care programs remain a priority for WHA, especially as charity care and bad debt skyrocket for hospitals in the midst of one of the worst economic downturns in recent history.

In addition to the expanded hospital assessment, a new assessment was included on ambulatory surgery centers (ASCs). While additional details will be released soon from the Doyle Administration, this plan is similar in design to the hospital assessment and will use the revenue generated to leverage additional federal dollars to bolster reimbursement rates for Medicaid patients seen by ASCs.

Other items addressed by the Committee included larger motions related to the state’s transportation and corrections programs and various provisions not yet covered during earlier discussions.

Tort provisions remain; New copy fee language inserted

Only a slight change was made to one of three very concerning liability provisions that remain in the budget bill and are opposed by WHA.

The Joint Finance Committee increased the threshold percentage for the application of joint and several liability from the one percent causal negligence proposed by the governor to 20 percent causal negligence. Under current law, a person must be at least 51 percent causally negligent before they could be held joint and severally liable for allowed damages. Even at the 20 percent threshold, Wisconsin will have the lowest fault threshold in the Midwest.

A motion by Senator Alberta Darling (R-River Hills) to remove this provision from the state budget bill was defeated 11-5, with Sen. Julie Lassa (D-Stevens Point) joining all four Republicans.

Provisions relating to comparative negligence and juror instructions also remain in the bill.

WHA opposes these provisions because of the likelihood they will drastically change Wisconsin’s litigation landscape and negatively impact the Injured Patients and Families Compensation Fund (IPFCF) and continues to lobby to have them removed in their entirety and instead be given consideration outside the budget process.

Another troubling motion, offered by Rep. Cory Mason (D-Racine), will set permanent limits on the fees that can be charged for copies of medical records. The motion narrowly passed on a divided 9-7 vote, with Democratic Senators Dave Hansen (D-Green Bay) and Julie Lassa along with Representative Jennifer Shilling (D-La Crosse) joining Republican Senators Alberta Darling and Luther Olsen (R-Ripon) and Representatives Phil Montgomery (R-Green Bay) and Robin Vos (R-Racine) in opposition.

Among other provisions, the language sets the per page fee health care providers can charge to a person other than a patient at 35 cents per page and provides no index to inflation for future increases to account for increased costs of making copies.

This issue has been contentious over many legislative sessions and health care providers and medical record copying firms have for years complained that the amount they are allowed to charge does not cover the cost of making copies.

The rollback of Wisconsin’s negligence protections, which were enacted with bipartisan support in 1995, and the action taken on copy fees warrant separate and thorough debate outside the budget process.

Both budget provisions are strongly supported by the Wisconsin Trial Lawyer Association.

Also included in the final version approved by the Committee was a motion to require the Department of Health Services (DHS) to submit a report to the Legislature on proposals intended to improve the quality of care for Medicaid recipients and reduce Medicaid program costs.

The motion specified that the report include a discussion of: (a) the potential effect of each proposal in improving the quality of care for Medicaid recipients; (b) the estimated savings that may result by implementing each proposal; and (c) the feasibility of implementing each proposal. Authored by Sen. Judy Robson (D-Beloit), the measure passed 15-1.

Both houses of the Legislature must now pass identical versions of the budget before it is forwarded back to Governor Doyle for his consideration and line-item veto authority.

The entire budget process is expected to be completed by early to mid-summer.

The Wisconsin Medicaid program this week sent a modest incentive payment to Wisconsin hospitals in an effort to begin to re-align payment with participation in quality improvement efforts. Speaking at the Wisconsin Quality Steering Committee meeting May 28 at WHA, Denise Runde, policy initiatives advisor to the Wisconsin Medicaid program, said the intent going forward is to use measures that are included in CheckPoint (www.wiCheckPoint.org) as the basis for determining incentive payments.

"As the Department and other payers initiate financial incentive programs, CheckPoint will be even more important," Runde said.

The first payment was based on whether hospitals reported the following four CheckPoint measures:

Type of Measure                         Focus Area

Outcome patient-centered care     Patient Experience of Care

Prevention                                   Flu Vaccine: Percent of pneumonia patients given flu shots

Process - Effectiveness of care     Surgical Infection Prevention: Surgical infection rate post-surgical procedure

Process – Safety                         Error Prevention: Medication reconciliation

While the first payments were based on public reporting, options for future payments that are being discussed in the Department of Health Services would reward performance.

WHA staff worked closely with DHS staff in establishing the basis for a pay-for-reporting incentive program within the Medicaid Program that would promote, and reward, quality improvement.

"WHA supports the Department’s decision to use existing publicly-reported measures as the sole basis for their payment incentive program. They clearly understand that collecting and reporting data is resource intensive and chose not to add to the administrative burden that already faces every hospital in the state," said WHA President Steve Brenton.

Budget uncertainties delayed, but did not stop, the expansion of BadgerCare to low-income, uninsured childless adults. The Department of Health Services said statewide implementation of the program will still move forward as planned, but applications will be delayed until June 15 with benefits beginning no earlier than July 15, 2009. The Department is now promoting enrollment in the plan.

"Even during this difficult budget environment, we are committed to keeping options open for people who need access to health care coverage," said Secretary Karen Timberlake. "When the uninsured show up at hospitals and clinics, we all pay. Providing coverage for this group of people who have often gone years without health care coverage is a key part of our efforts to reform health care."

Contrast Wisconsin’s plan to expand coverage to poor, uninsured adults to proposals in California that threaten to dismantle safety net programs. According to a May 27 report in the LA Times, California Governor Arnold Schwarzenegger is looking to eliminate "Healthy Families," which provides coverage to nearly a million children and teens, along with dramatic cuts to other essential health programs. Health care advocates fear that cuts will force poor, uninsured patients to hospital emergency rooms, which will drive expenses up, not down, in the programs.

WHA President Steve Brenton said Governor Jim Doyle and the Wisconsin Legislature should be commended for protecting the state’s most fragile population, even as the state faces its worst economic environment in decades.

"Protecting vulnerable populations continues to be a shared priority. Without the hospital assessment, this expansion of BadgerCare Plus would not have been possible. It gives another group of people that have few resources and many health needs the ability to access care without the fear of a bill that may have prevented them from seeking help in the past," according to Brenton.

BadgerCare for childless, uninsured adults is a limited plan that covers basic health care services, including primary and preventive care and generic drugs to low-income, chronically uninsured adults without dependents. The Department will begin accepting applications on June 15, 2009 and encourages people interested in applying to do so online at www.badgercareplus.org. Once an individual has been approved, their health care benefits will begin on the next available enrollment date (always the 1st or the 15th of the month).

Eligibility for the new program is limited to those that meet the following criteria:

• Are a Wisconsin resident between the ages of 19 through 64;
• Are a U.S. Citizen or qualifying immigrant;
• Do not have dependent children, under age 19, living with them and are not pregnant;
• Have a monthly family income at or below 200 percent of the federal poverty level ($1,805.00 for a single person and $2,428.33 for a married couple);
• Do not have health insurance or had access to private or employer subsidized health insurance during the previous 12 months, with a few exceptions; and
• Are not enrolled in or able to enroll in BadgerCare Plus, Medicaid or Medicare.

Funding for the BadgerCare Plus Core Plan is provided through the hospital assessment that was approved by the Legislature and signed into law earlier this year.

Wisconsin hospitals continue to improve their capabilities related to stroke care, according to Victoria O’ Brien, American Heart Association director of state integration. O’Brien presented the findings from the Stroke Systems of Care Survey of Wisconsin Hospitals at the May 21 Council on Medical and Professional Affairs (MPA) meeting in Madison. The survey was conducted in 2008 in nearly all states to gauge progress toward the ideal environment for stroke care on a state-by-state basis. With 98 percent of acute care hospitals represented in the results, the survey indicates that 21 percent of Wisconsin hospitals are currently certified by The Joint Commission as Primary Stroke Centers, 60 percent meet the requirement to be classified as acute stroke capable, 18 percent classified as non-acute stroke capable and one percent did not respond.

"Just a few years ago, there were only a handful of certified Primary Stroke Centers in Wisconsin. The results of this survey clearly reflect the urgency and value of creating an organized system of stroke care to ensure that all Wisconsin citizens, regardless of where they live, have access to high-quality, evidence-based stoke care," according to MPA Council Chair Brad Manning, MD.

Bill Bazan, WHA vice president, Milwaukee region, presented information to the Council on Physicians Orders for Life-Sustaining Treatment (POLST). Bazan indicated that POLST is not an advanced directive, but a portable physician order that complements the advanced directive for patients nearing the end of their life. The Wisconsin Medical Society is leading activities, in partnership with WHA and other collaborating organizations, to change Wisconsin laws to support the use of POLST.

Nancy Nankivil, Wisconsin Medical Society senior vice president of quality and efficiency, reported on the Society’s new Performance Improvement Continuing Medical Education (PI CME) process. In November 2008, accredited CME was linked to the physician practice setting, bridging the gap between continuous learning and improvement. With PI CME, credit can be awarded for participating in quality improvement activities in any clinical practice setting if the improvement is linked to practice-based gaps, the intervention matches the scope of the learner’s practice, and measurements of change are evaluated using the PDSA model.

Register today for the 2009 Wisconsin Rural Health Conference scheduled June 17-19 in Wisconsin Dells. This year’s event will focus on two of the biggest issues identified by hospital executives in the recent WHA member survey—the economy and its effect on the future of health care, and improving hospital/physician relationships.

Nationally-known economist and futurist Dr. Lowell Catlett will deliver the keynote address and share his entertaining perspective on the economy and how it will shape the future of health care during the opening keynote session. Several of the 11 concurrent sessions, as well as the closing presenter, Dr. Tray Dunaway, will focus on improving hospital/physician relationships.

This year’s conference will once again offer the popular governance education track, offering board of trustee members three sessions focused on health care reform, board accountability requirements and trustee recruitment and selection.

The annual Wisconsin Rural Health Conference 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!

The American Hospital Association (AHA) has raised big concerns about health reform financing "options" that were included in a recent Senate Finance Committee report. Although the report is short on detail, it signals that Medicare and Medicaid payment cuts will be a key component of the Senate’s coverage expansion financing strategy. That’s bad news for the nation’s hospitals and physicians.

The Finance Committee report proposes possible reductions to Medicare and Medicaid DSH payments that support the nation’s most vulnerable hospitals—the very hospitals that disproportionately serve large numbers of medically-indigent patients. The theory is that "coverage expansions" will eliminate the need for those payments. But that’s a preposterous claim given the fact that at least one third of the currently uninsured population will continue to be uninsured according to every study that’s examined the issue. And in the "reformed" world, most of the newly covered are likely to be enrolled in a public program like Medicaid that woefully underpays providers.

The report also discusses the potential for eliminating Graduate Medical Education (GME) payments to teaching hospitals, another appalling idea that arrives at a time when just about everyone acknowledges that a physician shortage, especially in primary care, will undermine access for the soon to be "covered." So teaching hospitals that are likely losers when DSH payments are eliminated and certain losers with GME cuts happen will somehow find new money to sustain vital teaching programs? Shouldn’t the focus be on new investments that can fast track increased capacity?

Another idea in play, apparently, is paying for coverage expansion via the elimination (for at least some hospitals) of tax-exempt status. That nugget comes from Iowa Republican, Senator Chuck Grassley.

AHA notes that the Senate report is intended to "spur conversation." But we are beyond the conversation stage and entering the serious policy formation stage. And other new revenue options ("cap and trade" taxes, new "sin" taxes, ending the tax deductibility of health benefits) appear to be imploding. That’s why there is urgency behind AHA’s warnings to the field.

We also must add to this unfortunate mix the likely impact on future Medicare payments of the new Inpatient Payment rules that will wipe out inflationary updates for years to come.

All this means that we can expect a long summer of opposing this notion that Medicare and Medicaid "savings" can finance health reform. Medicare margins that are already negative will plummet further.

Steve Brenton
President

In a letter to Wisconsin Members of Congress, WHA came out in support of HR 1898, the Life Sustaining Treatment Preferences Act of 2009.

In addition to supporting traditional advance directives, WHA indicated its support for advancing other appropriate programs for orders for life sustaining treatment. One example of which is the Physician Orders for Life-Sustaining Treatment, otherwise referred to as POLST.

POLST has been used in concert with the La Crosse area’s Respecting Choices program. This program was developed by the health care organizations in the area and has provided the city with valuable outcomes.

"The La Crosse region has successfully helped adults with advance care planning for over 20 years," said La Crosse area Gundersen Lutheran’s Bud Hammes, Ph.D. and director of medical humanities. "That includes honoring a person’s preference for medical care. POLST is an essential part of this success."

A decade of research has shown that orders for life sustaining treatment effectively help convey treatment preferences, and, WHA believes HR 1898 can assist in encouraging individuals to have these important treatment discussions.

This week the Wisconsin Hospital Association joined with other stakeholders at a health roundtable discussion hosted by Rep. Tammy Baldwin in the State Capitol in Madison. Participating on behalf of WHA was senior vice president George Quinn.

Rep. Baldwin opened the discussion with a brief update on how health care reform legislation is progressing in the U.S. House of Representatives. Baldwin indicated the Energy & Commerce Committee, on which she serves, is one of several committees crafting health care reform legislation for the House.

"I am excited to be a part of the [Energy & Commerce] health care subcommittee. I thought it very valuable to have your thoughts, your advice," Baldwin told roundtable participants. "It’s extremely important for me to hear diverse perspectives when crafting bold health care reform legislation."

In addition to WHA, participants included representatives from WPS, AFL-CIO, Epic, Rural Wisconsin Health Cooperative, Dean-SSM Health Care, federally-qualified health care centers, and patient advocacy. Each took turns providing their thoughts on health care reform.

During his comments, Quinn outlined WHA’s health care reform principles, which were developed by the Association’s Access and Coverage Task Force. Quinn then provided specific comments to proposals already being raised nationally in terms of health care reform, such as a public plan option and Medicare payment reforms.

"We need to be cautious about the public plan option," said Quinn. "If as suggested by some, it used the low Medicare or Medicaid rates to pay providers, the lower premiums would attract a substantial number of beneficiaries. Imagine an environment where payments were based on Medicare rates."

Providing the perspective of an integrated health care delivery system, Dean/SSM Health Care Vice President Michael Heifetz said, "Value, quality, efficiency are key words right now. The challenge is defining them… They don’t yet translate down to the patient level, but we have a better start here than in other states."

Tim Size, executive director of the Rural Wisconsin Health Cooperative, gave insight into how proposals may impact rural areas. Size noted that some of the Medicare payment reforms being discussed, such as bundling payments, remind him of efforts from 20 years ago and how those were devastating to rural areas. In addition, he reminded participants that Wisconsin has and continues to do it better than the rest of the country, as demonstrated by the Dartmouth Atlas.

"There are regional issues," Size commented with respect to geographic variations. "If everyone looked like the upper Midwest, we’d have the money [for health care reform]."

In closing Rep. Baldwin said, "Wisconsin has been a national leader on access and coverage…I am hopeful states such as Wisconsin can try out more innovations…if they work, they can be exported. If they don’t, they can be tweaked or put on the shelf."

St. Nicholas Hospital hosted Suzanne Brault Pagel, the Fox Valley Regional Coordinator for Sen. Russ Feingold, recently at their facility. Pagel, who is responsible for constituent outreach in 17 counties in northeast Wisconsin, discussed various health care issues, including federal health care reform, with hospital leadership. Pagel indicated health care is the number one issue the Senator hears about from constituents.

During the visit, hospital leadership asked Pagel about Senator Feingold’s position on the Employees Free Choice Act ("card check"), legislation that would essentially remove the right to a secret ballot in union organizing. Pagel indicated the Senator supports the legislation, but would be interested in hearing from his constituents as to how the bill could be improved.

Prior to leaving, Pagel toured the hospital’s Comprehensive Wound Care Center, which provides hyperbaric oxygen therapy for patients, and the Emergency Department.

Froedtert & Community Health announced that Dennis Pollard has been chosen as the new president of Community Memorial Hospital in Menomonee Falls.

Pollard currently serves as Froedtert & Community Health’s senior vice president and chief operating officer. Pollard succeeds William E. Bestor, who retires June 30 as president and chief executive officer at Community Memorial, after 32 years of service.

Pollard is a distinguished physical therapy alumnus of Marquette University and has a master’s degree in health care administration from Cardinal Stritch University. He joined Community Memorial as rehabilitation program manager in 1990 and has been on the hospital’s executive team since 1994. He was active in planning the combination of Community Memorial and Froedtert in 2001, advanced to the senior vice president level in 2004 and became chief operating officer for the health system in 2007. He’ll continue those duties in his new position.

Hundreds of Aurora Health Care caregivers bundled up and braved the cold and windy conditions Saturday, November 15, 2008 to offer residents in communities across eastern Wisconsin the chance to bring in many items that will help others. While it was cold, it was also rewarding to see the response at each of the 16 collection sites at Aurora hospitals and clinics. Nearly 1,200 residents brought a variety of items to our collection.

As one site coordinator put it, "The day demonstrated the commitment, passion, and fortitude needed to withstand the biting wind off Lake Michigan to partner with our community!"

Hundreds of Aurora volunteers teamed with local Boy Scouts, Girl Scouts, school groups, community volunteers and others to collect a variety of items that will be recycled or redistributed to places like domestic abuse shelters, Goodwill Industries, Salvation Army, Lions Clubs and environmental groups.

"In every way, the expansion of America Recycles Day into Aurora’s first Good Neighbor Day was a major success," said Kimberly Welch, Aurora senior vice president of corporate affairs. "It was heart-warming to see so many residents brave this cold day to not only be good environmental stewards, but also help a neighbor in need. From the many Aurora volunteers who helped organize and work this day to the residents who made multiple trips to drop off items, we saw a wonderful spirit of care and community."

Many of the donated items will help women, children and others in communities throughout eastern Wisconsin:

• Walkers, crutches and other home medical equipment will be provided to patients who cannot afford these essential items to help in their recovery.
• The personal care items, new clothing and snacks will assist women and children who are being treated at Aurora’s Sexual Assault Treatment Center.
• The stuffed animals, teddy bears and coloring books will help comfort children who come to hospital emergency departments or face other traumatic situations.
• Cell phones are helping women who rely on shelters to escape abusive situations.
• The used clothing will help people who rely on Goodwill Industries and the Salvation Army.
• The new hats, mittens and books will be provided by Aurora Family Service to children whose families cannot afford these items.
• Old medication was brought in for proper disposal so it doesn’t end up in our lakes, rivers and streams.
• Boxes of old eyeglasses were collected that the Lions Club will use to help people to better see.
• We collected truckloads of old computers that will be renovated and reused by those in the communities we serve who don’t have the resources to afford a computer.

The specific items collected and totals include:

Good Neighbor Day reflects Aurora’s commitment to be good stewards of the environment. As the state’s leading health care provider, it’s important that we look at how to go beyond delivering health services to people. A healthy environment and healthy community are interconnected and Good Neighbor Day reflects Aurora’s commitment to be good stewards of our resources. It also was a chance to help some of our neighbors.

The Annual Safety Camp on July 15 at the Lunda Community Park was a huge success. The Greater Black River Area Safety Council, Jackson County Public Health Department, Black River Memorial Hospital, UW Extension, and many volunteers joined forces to educate, encourage and entertain more than 50 children who will soon enter the 4th and 5th grade. Area presenters offered their expertise and enthusiastic participation while attendees were presented with a variety of 30-minute safety topics designed to help make their world safer.

Safety presentations were done in break-out groups and included safety topics on electricity, first-aid, boating, seat belts, bikes, weather, animals, guns, hand washing, and Internet/personal safety. There was a bike rodeo in the afternoon to test out the children’s bike safety skills. The activities ended with a family picnic, and children were asked to tell their families about the many safety-oriented experiences they learned. It was obvious they were paying close attention to presenters because parents heard enthusiastic reports from their children about being safer.

John Elliott, AmeriCorps volunteer for Public Health, noted, "We sincerely hope that children and families will be just a little safer in the future due to our program and the presenters’ generous and enthusiastic participation."

Christine Hovell RN, BSN, public health manager/health officer, Jackson County Health Department, said, "We had parents and children who thanked us for the day, and at the end of the day when they were asked about what they learned, it was evident they had been listening."

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