May 7, 2004
Volume 48, Issue 19


Health Care Leaders Voice TABOR Concerns
Proposal could lead to Medicaid "Hidden Tax" hike

Five of Wisconsin’s leading health care organizations raised concerns on May 6 about the potential unintended consequences of the Taxpayers Bill of Rights (TABOR) proposed as an amendment to the state constitution. TABOR would cap government spending at a yet-to-be determined annual growth rate.

Representing managed care, nursing homes, hospitals and physicians, the Wisconsin Association of Health Plans, the Wisconsin Association of Homes and Services for the Aging, the Wisconsin Health Care Association, the Wisconsin Hospital Association and the Wisconsin Medical Society are expressing concerns about the proposed amendment and its potential impact on the already underfunded state Medicaid program.

"This is not a partisan issue; we have no qualms with the notion of limiting taxes and spending," said Wisconsin Hospital Association President Steve Brenton. "However, TABOR comes at a time when the state is already chronically underfunding its own health care programs, particularly Medicaid, and passing those costs on to employers and employees."

Medicaid is the state-run health insurance program for low-income women and children and the disabled. Wisconsin Medical Society President Michael Reineck, MD, is concerned about access to health care for these vulnerable populations. "No matter what the plan, we must ensure that our neediest patients have access to care when they most need it," Reineck said. "If nothing else, the debate about TABOR should include serious discussions on how Medicaid works — and doesn’t work — in this state, and how reforming Medicaid could help the state’s spending problem regardless of any constitutional amendment."

According to the groups, both Medicaid and BadgerCare, which mimics Medicaid benefits, already provide some of the lowest payment rates for services in the country, reimbursing health care providers far below what it costs to deliver care. The result is a situation known as "cost-shifting" – when unpaid costs from Medicaid/BadgerCare patients are shifted to others.

Dubbed "Medicaid’s Hidden Tax" by the Wisconsin Manufacturers & Commerce (WMC), cost shifting occurs when government doesn’t pay the basic cost of its health care programs. Those unpaid costs must be recouped from the private sector, and are shifted to people covered under individual and employer health plans.

"Cost-shifting from government health care programs already adds nearly a billion dollars to the cost of commercial health insurance in Wisconsin each year," said Nancy Wenzel, executive director of the Wisconsin Association of Health Plans. "Private health insurance consumers cannot afford to shoulder more of the cost of public programs such as Medicaid."

Medicaid and BadgerCare are just two of several government health care programs that routinely pay far less than cost, a situation that has developed even without a TABOR in Wisconsin. The groups fear Medicaid and BadgerCare payments may get worse with TABOR.

"Without TABOR, Medicaid has fared poorly, and facility rate increases have been funded by provider taxes and other schemes to leverage federal funding," said Wisconsin Association of Homes & Services for the Aging Executive Director John Sauer. "Given Medicaid’s track record, we are concerned that under some form of a TABOR, cost shifting could get worse and the state’s ability to capture additional federal Medicaid dollars may be compromised."

"During the past decade, the differential between provider costs and state reimbursement for the care of Medicaid recipients has expanded to the point that few facilities have had their allowable Medicaid costs fully reimbursed," stated Wisconsin Health Care Association Executive Director Tom Moore. "We are legitimately concerned that any proposed constitutional spending limitations that may be welded to fiscal indexes may limit the state’s responsibility to address the health care needs of its most aged, vulnerable and needy citizens."

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Pride Program Celebrates Health Care Workforce
65 Health Care Employees Recognized at May 6 Event

"Don’t think we don’t celebrate each other and feel pride as we see our caring skills at work. We see ourselves as a team and yet individuals caring for the body, mind and spirit." — Sherry Clark, Respiratory Therapist, St. Joseph’s Community Health Services, Hillsboro, in her winning essay.

It was an evening to remember. For more than 200 people who attended the May 6 Pride Program recognition dinner, it was an opportunity to honor the 65 persons who were being recognized for their dedication to a career in health care. For the 65 people who were chosen to represent their hospital, their department, and their career, it was a well-deserved evening in the spotlight.

"…People who join the health care workforce make one thing very clear—they do it because they have a strong desire to help others." — Sue Stariha, Respiratory Therapist/Director, Spooner Health System, Spooner

"Health care employees rise to the challenges before them every day with care, competence, and compassion. It is a privilege to stand before you this evening and have the opportunity to say, ‘thank you,’ which seems like such a small gesture when the work that you do is so important and essential to the health of our patients, communities and state," said WHA President Steve Brenton in his message to the honorees during the program. "You can have the best technology in the world, but what our patients remember about being in a hospital is meeting you, seeing how much you care about them and their families. You are the face of health care."

The audience at the Kalahari in Wisconsin Dells listened intently as short vignettes were read from each honored employees essay as they were congratulated by Judy Warmuth, WHA VP, workforce; Gerri Staffileno, past-president, Wisconsin Organization of Nurse Executives (W-ONE) and Trudy Achterhof from the Wisconsin Society of Healthcare Human Resources Administration (WSHHRA). WHA, W-ONE, WSHHRA, and the Wisconsin Healthcare Public Relations and Marketing Society sponsor the Pride Program.

The Pride Program is designed to celebrate the health care workforce and the factors that distinguish it from other careers. Employees wrote passionately about the importance of their career to them, and how all the talents, skills and dedication of each employee in a health care setting is related to the same goal—delivering high quality patient care.

"The thing that makes working in health care far more interesting and rewarding is that the services we, as technical support people provide, all tie back to the care of the patients." — Connie Cone, Telecommunications Manager, Meriter Health Services, Madison

The Wisconsin Health Care Employee Pride Program award recipients are:

Affinity Health System, Menasha
Debbie Ebel, RN

Agnesian Health Care, Fond du Lac
Amy Uhrmacher, RTR(M), Radiological Technologist

Amery Regional Medical Center, Amery
Jean Bruner, RN

Aurora BayCare Medical Center, Green Bay
Shenandoah Greenwood, CNA

Aurora Medical Center, Hartford
Karen Kottwitz, RN

Aurora Sinai Medical Center, Milwaukee
Molly Windorski, RN

Baldwin Area Medical Center, Baldwin
Sandy Somsen, RN

Beaver Dam Community Hospital, Beaver Dam
Kristine Bahr, CNA

Bellin Health, Green Bay
Judy Stasko, Health Unit Coordinator

Beloit Memorial Hospital, Beloit
Jenna Mangold, Occupational Therapist

Black River Memorial Hospital, Black River Falls
Dorothy Halvorson, Hospice Registered Nurse

Boscobel Area Health Care, Boscobel
Charles Carpenter, LPN

Burnett Medical Center, Grantsburg
Julie Mead, PA, Physician Assistant

Children’s Hospital of Wisconsin, Neenah
Tania Hassler, MD, Pediatric Hospitalist

Children’s Hospital of Wisconsin, Kenosha
Joan Pacetti, RN, BSN, Pediatric Nurse

Columbia St. Mary’s, Glendale
Colleen Chamberlain, RN, Nurse Instructor

Community Health Care - Wausau Hospital, Wausau
Susan Hoffman, RN

Community Memorial Hospital, Oconto Falls
Vickie Keigley, Occupational Therapy Coordinator

Eagle River Memorial Hospital, Eagle River
Mary Rewolinski, RN

Elmbrook Memorial Hospital, Brookfield
Jamie Udulutch, Senior Radiation Therapist

Flambeau Hospital, Park Falls
Margaret Morgan, RN, ER Coordinator

Fort HealthCare, Fort Atkinson
Jackie Schwemmer, LPN

Franciscan Skemp Healthcare, La Crosse
Debra Kramer, Administrative Assistant

Franciscan Skemp Healthcare, Sparta
Carol Aslesen, RN

Franciscan Skemp Healthcare, Arcadia
Diane Daffinson, RN

Grant Regional Health Center, Lancaster
Pamela Myhre, RN, BSN, Certified Diabetic Educator

Gundersen Lutheran, La Crosse
Sandra Sawyer, Senior Office Assistant

Howard Young Medical Center, Woodruff
Jennifer Bond, RN, BSN

Hudson Hospital, Hudson
Marilyn Strandquist, CNA

Kindred Hospital Milwaukee, Greenfield
Holly Ainsworth, Receptionist

Langlade Memorial Hospital, Antigo
Gail Behlke, Hospice Nurse Assistant

Memorial Health Center, Medford
Steve Heil, Medical Technologist

Memorial Hospital of Lafayette County, Darlington
Susan Burke, PT, Rehab Services Supervisor

Memorial Medical Center, Neillsville
Mary Jurgaitis, Night Desk Clerk

Memorial Medical Center, Ashland
Jan Perkins, RN

Mercy Health System, Janesville
Tammy Lawver, COMT, Team Leader Ophthalmology

Meriter Health Services, Madison
Connie Cone, Telecommunications Manager

Moundview Memorial Hospital, Friendship
Kelley Chase, RN, Registered Nurse and EMT

Oconomowoc Memorial Hospital, Oconomowoc
Rea Kae Rhodes, RN

Orthopaedic Hospital of Wisconsin, Glendale
Tammie Cain, Health Unit Coordinator

Our Lady Of Victory Hospital, Stanley
Becky Herman, RHIT, Health Information Supervisor

Sacred Heart Hospital, Eau Claire
Amy Kassing, Rehab Occupational Therapy Aide

Saint Joseph’s Hospital, Marshfield
Christine Wenta, Dispatcher/Medical Transportation

Saint Michael’s Hospital, Stevens Point
Sherry Boyce, RN, Nursing Supervisor

Sauk Prairie Memorial Hospital, Prairie du Sac
Mary Kay Sutter, GI Scrub Technician

Shawano Medical Center, Shawano
Shirley Venz, RN, Staff Development Coordinator

Southwest Health Center, Platteville
Pam Wunderlin, Admitting Representative

Spooner Health System, Spooner
Sue Stariha, Respiratory Therapist/Director

St. Clare Hospital & Health Services, Baraboo
Lisa Meyer, RN

St. Francis Hospital, Milwaukee
Barbara Stepanski, RN

St. Joseph Regional Medical Center, Milwaukee
Georgene Trapp, Financial Counselor

St. Joseph’s Community Health Services, Hillsboro
Sherry Clark, Respiratory Therapist

St. Joseph’s Hospital, Chippewa Falls
Brad McNutt, RRT, Respiratory Therapist

St. Luke’s Medical Center, Milwaukee
Kathleen Vega, RN, BSN

St. Luke’s South Shore, Cudahy
Jodi Gaglione, Patient Access Services Training Specialist

St. Michael Hospital, Milwaukee
Marilyn Mueller, RN, BSN, Director of Care Management

St. Nicholas Hospital, Sheboygan
Kim Ogea, Homemaker

St. Vincent Hospital, Green Bay
Faith Thiel, Respiratory Therapist

The Monroe Clinic, Monroe
Gail Vita, RN

The Richland Hospital, Richland Center
Linda, Tyler-Doudna, RN, BSN

The Wisconsin Heart Hospital, Wauwatosa
Nicole Richarz, RRT, Respiratory Therapist

Tomah VA Hospital, Tomah
Laura Bishop, Voluntary Services Coordinator

Vernon Memorial Healthcare, Viroqua
Alice Sloane, Supervisor of Environmental Services

Watertown Memorial Hospital, Watertown
Tina Larson, RN

Waukesha Memorial Hospital, Waukesha
Susan Kern, RN

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Know Your Legislators – an Interview with Leah Vukmir

1. There is talk about putting some form of a "Taxpayer Bill of Rights" (TABOR) into the state’s constitution. With provider reimbursement rates falling below 60% of cost when hospitals see MA patients and this cost shift or hidden tax is passed along to third party private payers, how do you think TABOR if enacted would impact the MA budget and the cost shift?

Certainly it is an issue I plan to watch. At this time, there is no consensus on TABOR. I am one of the original authors of the bill and it has changed a lot, and continues to change. I agree it will potentially affect health care, particularly Medicaid. At the same time, there are elements of TABOR that are important because it forces state and local government to set priorities, and it can cut waste, fraud and abuse. TABOR helps everyone focus on the areas of government that are most important. There is a consensus that health care and education are very important.

Any proposals that I look at related to TABOR will be viewed through the lens that we have to protect our taxpayers without threatening our commitment to health care.

2. WHA along with WMS just completed a study on the physician shortage. GME sustained major cuts

Funding Graduate Medical Education (GME) will absolutely make a difference in our ability to deal with the physician shortage. I strongly advocated for GME and for the patient compensation fund. Both of those initiatives need to be protected fully because of the long-term effects that they have on our health care worker population. GME not only impacts medical doctor training, but it also funds dental residencies and other health care professional training. That is why I advocated tirelessly with the Joint Finance Committee to not cut GME. As a freshman coming into my first budget cycle, it was a glaring problem I decided to take on because of the long-term impact of cutting these funds. Cutting the program funding temporarily and then possibly restoring it was not an option. The position I tried to share with the JFC was that we attract the best and brightest to our medical residency programs. You can’t tell them it is here this year, and out the next. I was glad that it was not completely eliminated, but I will continue to push for funding GME.

GME is not an urban vs. rural issue. Some of my colleagues in the legislature tried to paint that picture since my district includes several hospitals, but I pointed out to them that medical residents deliver care in all parts of Wisconsin. It is an issue that affects everyone regardless of where you live.

3. In addition to physician shortages, hospitals report difficulty recruiting other professions as well. The reform package, Healthier Choices, suggests changes that can be made to increase the number of health care professionals by streamlining the training process. What else do you think Wisconsin should do to increase the number of graduates in the health care fields?

Workforce is a concern of mine. As a nurse practitioner, one of the things that I try to point out to high school kids it that the field of medicine provides flexibility to individuals who want to work and raise families. As I went through nursing school, I found I had the option to work full time or part time, and I try to stress that to people as they look at career choices. We need to market that flexibility as more people are looking for this.

I fully agree that training for health care careers can be streamlined. We also have foreign trained nurses who are having difficulty getting into the system because of testing and other issues. I think if they can meet the same standards as nurses who are trained in the states, we could certainly make it less difficult for them to obtain a license.

GME factors into the discussion about workforce shortages, too. Nurses are attracted to work in health care facilities that have quality physicians. So it is a ripple effect.

4. Anything more you’d like to add?

As a freshman coming in with a background in health care, I can say that it is a privilege to serve on the Assembly Health Committee. I take my role very seriously given my expertise, and I am not afraid to share my opinions. I feel fortunate to be in a position to influence my colleagues.

Wisconsin faces many health care challenges. The problems are multi-faceted and do not lend themselves to quick fixes. It is very complex and the typical economic principles tend not to apply. We want people to have the best and newest technology and that costs money. As new technology becomes obsolete, medical professionals and hospitals are compelled to offer the latest advancements. This continuous improvement process is about providing the best possible care, while at the same time mitigating medical liability risks. It is easy for those who don’t understand the health care industry to question why it doesn’t operate like other industries. I understand those differences. I want to work with people in the industry to come up with solutions. Government can help, but the industry is in a better position to propose the ideas and arrive at solutions that will work.

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Guest Column
By Judy Warmuth, WHA Vice President of Workforce Development

On May 6, 65 employees were recognized for their dedication to the field of health care at the PRIDE Program reception and dinner at the Kalahari Resort in Lake Delton. I am a soft touch, so the event made me teary eyed with pride. Even for the less emotional among us, it was an event that made you proud to be involved in the hospital industry. The stars of the evening were hospital employees…and they were inspirational! Employees were invited by their hospital employers to submit essays describing why they chose to work in health care. One winner from each participating hospital was honored last night. I had the privilege of meeting each winner, introducing them to the audience and highlighting their winning work.

The winners have been inspired by family members--often moms and grandmoms who encouraged them, by co-workers and frequently by patients themselves. They spoke of feeling, every day, that they made a difference…in the business office, at the main desk and on the clinical units.

Winners from hospice units spoke with pride of the difficult work of helping patients and their families deal with the final stages of life. Others told of the joy of working in an obstetrics unit. They talked of helping patients with their bills and paperwork, of offering directions from the main desk and of just being there for people.

They also spoke with great pride of their hospitals. They highlighted the role that hospitals play in our communities. They often mentioned the role their hospital had played in helping them obtain an education, a job, a promotion.

We all know how valuable our workforce is to our industry. We understand that we can’t provide health care without them. We know they are the front line with patients, family and the community. Last night we celebrated with employees their pride in doing those great things.

If you didn’t participate in the PRIDE program this year, a booklet of the essays will be mailed to you next week. If you did participate, you picked a booklet up at registration. If you would just like a copy, call WHA and we’ll be happy to send one to you. Keep it handy. It is the perfect antidote. Open to any page and read about our employees’ pride. It will help you appreciate the skill, compassion and dedication of the very special people who are caring for others in every community in Wisconsin.

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Governor Doyle Unveils 1st Chapter of KidsFirst at Meriter Children’s Center

On Monday, May 3, Governor Jim Doyle unveiled KidsFirst, a comprehensive initiative to invest in Wisconsin’s children. His first press conference took place in Madison at Meriter Children’s Center. Governor Doyle unveiled Ready for Success, a series of proposals, goals and priorities that will help ensure that Wisconsin’s children have the skills and tools they need at a young age to be successful later in life.The Governor said Kids First encompasses the priorities he will have as he puts together the next budget.

Terri Potter, Meriter President and CEO welcomed the Governor, First Lady Jessica Doyle, Secretary of Workforce Development Roberta Gassman, Superintendent of Public Instruction Elizabeth Burmaster, Secretary of Health and Family Services Helene Nelson and Secretary of Corrections Matt Frank to the Meriter Children’s Center in Longfellow School. Joining the Governor in support of this initiative were Representatives Sondra Pope-Roberts, Spencer Black and Tom Hebl.

Coincidentally, several present had fond memories of the Longfellow School, a former Madison school. The Governor grew up not too far from Longfellow School and remembered playing on the playground, Superintendent Burmaster and her mother had taught music there and Representative Tom Hebl had attended school at Longfellow.

Meriter Children’s Center (MCC) provides childcare for 135 children ages six weeks to six years old from two on-campus locations. MCC has made a commitment to provide high quality early childhood programming and is accredited by the National Association for the Education of Young Children (NAEYC).

For more information on the KidsFirst initiative go to www.wisgov.state.wi.us.

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MetaStar Offers Hospital Public Reporting Workshop Series

MetaStar is offering a workshop series that will assist hospitals in understanding the various public reporting initiatives and will provide hospital teams an opportunity to integrate public reporting with quality improvement. Teams will also learn how to communicate publicly reported data to consumers. The first seminar will be held June 29-30 at the Kalahari Resort, Wisconsin Dells.

Hospital teams made up of the hospital administrator/CEO, medical director, quality improvement director, VP of nursing, public relations director, and a hospital board member are encouraged to attend. Hospital teams will work together over a nine-month period. They will learn from faculty, and more importantly, from each other by sharing ideas, problems and successes. Teams will come together for three workshop sessions and will participate in conference calls, web-based trainings, and list serve discussions between workshop sessions.

MetaStar will hold three one-and-a-half day workshop sessions: June 29-30, 2004; September, 2004; and January 2005. The one-time fee of $500 per team covers materials, meals, and meeting room costs for all team members for all workshop sessions. Teams are responsible for individual travel and lodging costs. For more information, contact Rebecca Tobie at 800-362-2320 or email rtobie@metastar.com.

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Register Now for the May 20 Outpatient Code Editor Seminar

The Outpatient Code Editor (OCE) is one of the most important components of the APC payment system. Presenting both challenges and frustrations to most coding and billing staff, the OCE is quite often misunderstood. During the May 20 seminar "Outpatient Cost Editor: Friend or Foe?," attendees will review the 60 edits, gain exposure to the role modifiers play in the billing functionality, and receive actual clinical documentation and coding examples.

The seminar is scheduled May 20, 9 am to 4 pm at Holiday Inn in Stevens Point. A brochure and registration form are available on the web site at www.wha.org. Easy, on-line registration is available there as well. The American Health Information Management Association (AHIMA) has approved this seminar for five (5) continuing education hours.

For registration questions, contact Sherry Rabuck at 608-274-1820 or email srabuck@wha.org.

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Inpatient Rehabilitation 75% Rule on Display

The Centers for Medicare and Medicaid Services (CMS) put on display the Final Rule on the inpatient rehabilitation 75% Rule. The final rule reflects only minor changes from the September 2003 proposed rule. WHA is concerned that the final rule will create access problems for patients who require inpatient rehabilitation care.

WHA will share a detailed analysis of the Final Rule soon. It is expected that the Final Rule will be published in the Federal Register on May 7. The text of the Final Rule is available at www.cms.hhs.gov/providers/irfpps/default.asp.

The Final Rule takes effect with cost reports beginning on or after July 1, 2004. During the first year of implementation, Inpatient Rehabilitation Facilities (IRF) with a cost report beginning on or after July 1, 2004 and before November 1, 2004, will undergo an initial compliance assessment based on less than 12 months of data.

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WHA Financial Solutions - Protect Your Organization With Volunteer Insurance

Every health care organization relies on the good works of volunteers, including auxiliary members, board members and trustees. While these volunteers make many valuable contributions to your organization, they also create exposure for potential liability. As with employees, employers must insure themselves against potential risk, should volunteers be involved in an accident - on or off premises - while they are engaged in authorized volunteer activities.

A program designed to provide insurance coverage for hospital volunteers is available to cover this potential exposure. Volunteer liability coverage offers various benefit and coverage levels for you to choose from. Unlike medical insurance, benefits are paid in flat dollar amounts, with no deductibles or co-pays. Benefits typically included are medical expenses, including hospital coverage, physician charges, ambulance expenses, outpatient services and supplies. Accidental Death and Dismemberment coverage, as well as dental expense coverage is included.

Find out more in Solutions Spotlight, included in this week’s packet or contact Michelle White at mwhite@wha.org.

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Court Finds Medical Resident Protected By Peer Review Statutes, But Not Caps On Damages
"Is He Is, Or Is He Ain’t"

A Wisconsin Court of Appeals decision filed on April 27, 2004, addressed the issue of whether a medical resident is a "health care provider" for purposes of the protections provided under the peer review statutes and the caps on noneconomic damages under the medical malpractice statutes.

The court held that a medical resident is a "health care provider" afforded protections under the peer review statutes. On the other hand, the court found that the medical resident, who was in his twelve-month postgraduate training period and thus did not have a license to practice medicine, was not a "health care provider" for purposes of the statute imposing caps on noneconomic damages. The caps, therefore, did not apply to actions brought against the resident. The court held that the caps on noneconomic damages are applicable only to those who are health care providers under the Wisconsin Patients Compensation Fund, which provides coverage to health care providers who are licensed.

Further, the court reaffirmed that in Wisconsin, a physician is held to the standard of care applicable to his or class (in this case, a first year medical resident), and not to the class of physician that the patient’s condition might require. The court recognized that the percentage of causal negligence attributable to the physician impacts the percentage of the hospital’s causal negligence; the percentage of the hospital’s causal negligence is higher when the physician is held to a lower standard of care.

This case is Phelps v. Physician Insurance Company of Wisconsin, Appeal No. 03-0580, and can be viewed in its entirety at www.wicourts.gov/opinions/aopinion.htm.

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2004 Rural Health Conference Information Now Available at www.wha.org

A full conference brochure and registration materials for the 2004 Wisconsin Rural Health Conference are now available, as of today, May 7, on the WHA web site at www.wha.org. The Rural Health Conference will be held June 23-25, 2004, at the Kalahari Resort & Convention Center in Wisconsin Dells. A printed copy of the full brochure and registration form will be included in the May 14 WHA Friday packet as well, so watch for it. Conference registrations will be accepted through Friday, June 11.

The Kalahari Resort is also accepting reservations for the WHA room block as of today, May 7. Conference attendees can make a reservation by calling 877-253-5466, and asking for a room in the WHA Rural Health Conference block, by June 4. The group rate is $129 for a basic room/$149 for a suite. The final cut-off date for room reservations is June 4. Due to it being the busy summer season at the resort, the group rate will not be honored after that date and no additional rooms will be held for conference attendees, so make your reservations early and get your registration forms in to WHA.

WHA is continuing its partnerships with the Wisconsin Office of Rural Health, Rural Wisconsin Health Cooperative, and the Wisconsin Primary Health Care Association, to bring this conference to you, your staff and your trustees. Additionally, the conference is supported by WHA’s Corporate Champions: Fitzgerald, Clayton, James & Kasten; The MHA Group; and WHA Financial Solutions.

For more information on program content, contact Jennifer Frank at 608-274-1820 or jfrank@wha.org. For registration questions, contact Sherry Rabuck at 608-274-1820 or srabuck@wha.org.

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Member News

Steve Nockerts, CEO, the Richland Hospital, Inc., was recently appointed to the Southwest Technical College Board in Fennimore, which serves all of Richland County. WHA has encouraged member participation on Wisconsin’s technical college boards. As hospital members are appointed to technical college boards, please notify Judy Warmuth at WHA.

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