"I’d like to share one last story about a little girl seen in one of the school-based sealant programs. When it was her turn, the program coordinator found tissue in her mouth. When she asked her to explain, she replied that she had a bad toothache, but her Mom could not find a dentist that would take them as patients. So this little girl had discovered that if she shoved tissue in the huge cavity, she could at least control some of the pain when exposed to cold or hot air or liquids. How can we expect this little girl to concentrate in school and live up to her potential when her day is entirely focused on pain management? Could you be here today doing your important work if you were in this situation?"

- From testimony provided by Cherrie Marti, Director of Mission Integration (and Project Director for Ministry Dental Center in Stevens Point), Ministry Health Care

The dental access issue was the focus of two news conferences held this week, one in Madison, the other in Milwaukee. A rule change proposed by the Wisconsin Department of Health and Family Services (DHFS) would allow dental hygienists to be certified as Medicaid providers and bill the program directly for services related to preventive dental care. The care would be provided in schools, public health clinics, and at technical colleges that train hygienists, where the services are being performed now, but are not billable.

On June 8, 30 people—5 WHA members—testified at the Joint Committee for Review of Administrative Rules (JCRAR) hearing that gathered public comment on the administrative rule modification that would allow state licensed dental hygienists to bill Medicaid directly for their work. The rule change, proposed by DHFS, would allow dental hygienists to be certified as Medicaid providers and bill for services they have been providing in schools and public health clinics for years. It does not change the scope of their work.

Those who testified provided the Committee with stories about children and adults who seek help in the ED as a last resort for dental distress. Doctors and nurses in emergency departments have struggled to find a remedy to what is a problem for thousands of low income families in Wisconsin.

The number of Medicaid patients seeking dental treatment in hospital emergency departments is staggering. At Beloit Memorial hospital, more than 300 Medicaid patients were seen in the ED. St. Mary’s Hospital of Superior, 232. In Milwaukee, 3,400 Medicaid patients found care for dental problems in the ED, 720 of those at St. Michael’s, which is slated for closure. All total, 11,243 Medicaid-eligible patients were seen for dental-related health problems in hospital emergency departments.

Ray Myers of St. Joseph’s Hospital in Chippewa Falls provided testimony at the hearing, along with Georgia Fischer from Langlade Memorial Hospital, Antigo, and Cherrie Marti, Ministry Health Care, Stevens Point.

The Wisconsin Dental Association (WDA) contended that WHA supported the rule change because "its members want to end emergency room visits by Medical Assistance patients seeking relief from dental pain." Myers agreed. "We don’t want to see then in the ED, they are right! We want to see them have another way to get dental care," Myers said.

Jodi Bloch, WHA’s vice president of government affairs, said in her testimony that taking the step to certify dental hygienists as Medicaid providers won’t stop all dental-related ED visits, but "it’s a start. It might not make a difference today or tomorrow, but over time, we will see a difference if people can receive basic preventive oral care."

Ron Hermes of DHFS in his testimony pointed out this is not a new "feel good" program (dental) for Medicaid, as the WDA said in a news release, but rather it is a "very underutilized program."

"There is a concern that this is going to have a negative affect on the Medicaid budget; however, these services are already covered by Medicaid. The problem is many recipients cannot find a provider. This rule will not solve this situation; however, it will allow more access to prevention programs. Wouldn’t the state rather pay $17 for a sealant than pay over $325 for a root canal if the tooth goes untreated and needs this kind of treatment?" asked Matt Crespin, oral health project manager for Children’s Health Alliance of Wisconsin.

While those who provided testimony recognized that it is not the perfect solution, it is acknowledged by supporters that getting dental hygienists certified in the Medicaid program is a small step in the right direction.

The committee is expected to meet next week to vote on the rule.

The IRS recently sent a "Compliance Check Questionnaire" (Form 13790) to approximately 600 tax-exempt hospitals across the country requesting that they voluntarily respond. We are aware of three hospitals in Wisconsin that have received Form 13790 and are in the process of preparing their replies to this rather lengthy and involved questionnaire. WHA, with the assistance of Hall Render, has prepared a memorandum providing some guidance to those hospitals that have received the questionnaire.

The Medicare Program plans to implement two of the most significant changes in DRGs since the beginning of the inpatient PPS over 20 years ago. The proposed changes would significantly redistribute payments among the DRGs and among hospitals. WHA has been working with the American Hospital Association (AHA) to identify any problems in the methodology and to assess the impact on Wisconsin hospitals.

CMS proposes major changes to the DRG weights for Federal Fiscal Year 2007 that will redistribute payments away from surgery-related (for example, cardiac) DRGs and dollars toward medical DRGs. WHA projects an aggregate loss for Wisconsin hospitals of $5.4 million, or 0.3 percent, with the bulk of those losses incurred by hospitals with significant cardiac surgery programs.

CMS also proposes changes to the classification system, refining the DRGs to account for patient severity. This change is recommended for the 2008 Federal Fiscal Year. It will greatly expand the number of DRGs, from the current total of 526 to 861. Again the projected result for Wisconsin is expected to be negative, at $2.9 million, or 0.2 percent.

While WHA should support improvement in Medicare’s Prospective Payment System, WHA should also support the AHA position that more time is needed to understand the changes and their potential impact. AHA has discovered a number of errors in the data and the application of the methodology; and has observed that the methodology is unstable - small changes in method lead to substantial changes in payment. Furthermore, CMS has not provided a validation process to ensure accuracy; in other words, we would like to see the data that supports these massive changes.

It is for these reasons that we should support the following:

• A one-year delay in the proposed regulation.
• A request that more analysis and refinement be done to correct what may be a flawed system at this point.
• A phased-in implementation of the changes over three years.
• A commitment to working with CMS to develop and evaluate new weights and classification methodologies.

Finally, it is worth noting that while much effort has gone into refining the existing payment system, little focus has been on developing new payment systems that would reward providers of high quality and cost-effective care – and we have plenty of them in Wisconsin. The Medicare Program should move expeditiously in that direction.

On May 31, Senator Ron Brown (R-Eau Claire) stopped by the meeting of the WHA Western Region to share his thoughts on several issues, including malpractice liability, the Taxpayer Protection Amendment, Medicaid and health care reform. Brown, who serves on the Senate Committee on Health, Children, Families, Aging and Long-Term Care, represents a cross section of mid-sized urban and rural hospitals and is well versed on the issues affecting these facilities.

Also a member of the Senate’s Insurance Committee, Sen. Brown played a key role in the passage of a new medical liability cap, supporting the bill in Committee and on the Senate floor.

"I’m very pleased we were able to pass the malpractice cap," Brown told the group. "In rural areas, we have a hard enough time attracting physicians and we sure can’t afford to lose any, but that’s what was starting to happen."

Brown was also one of seven Republicans in the Senate who voted against the Taxpayer Protection Amendment. Despite tremendous pressure, Brown stood firm against the proposal.

"I just do not believe we should be putting spending controls into the Wisconsin Constitution," Brown said. "If we make a mistake, it’s a lot easier to change the statutes than it is the Constitution."

Brown also talked of rising health care costs and the growing frustration of individuals and employers in his district. "Consumers have been taken out of the health care equation, we need to change that," Brown said. "I am a long time supporter of health savings accounts as one way to give consumers more ownership of their health care dollars and decisions. That will also make them better health care consumers. But HSA’s are not the only answer. This is an issue that shouldn’t be partisan; we need to sit down together and come up with ideas and workable solutions."

Bill Bruce, president and CEO of St. Joseph’s Community Health Services in Hillsboro, took the opportunity to relay a number of concerns about the state’s Medicaid and long-term care programs, including declining reimbursement rates and the absence of information about state-contracted care management organizations. His views were shared by several of those attending the meeting, and Senator Brown promised to pursue these issues directly with the Department of Health and Family Services.

WHA members have called to notify staff of longer than expected waits for nursing licenses. Members have been especially concerned about graduate nurses hoping to start new jobs unable to do so because they have not received a permit to practice. WHA raised this issue at the Board of Nursing meeting held June 8 and found that the Integrated Voice Response system that records and directs phone calls has not been functioning correctly. During this high volume time for the Department of Regulation and Licensing, an additional problem such as this creates backlog and confusion. The Department has added three temporary workers to assist in resolving delays.

The Department has the following recommendations to keep their progress on track and allow licensees to keep informed:

• Use the Regulation and Licensing Web site to check the status of your request. Each applicant is issued an identifying number which allows access to individual progress reports that are updated daily.
• Some schools of nursing have taken up to three weeks (post graduation) to verify graduations. If an account says that school of nursing data has not been received, follow-up with the school is appropriate (not the Department).

WHA asked the Board to examine the paper intensive and time-consuming process of initial licensure and licensure by endorsement for timesaving opportunities. "Long waits for licenses are very frustrating to nurses who are unable to begin employment and to hospitals, as well, who are waiting to move these nurses into the workforce," according to Judy Warmuth, WHA vice president of workforce.

Faculty co-signature of student notes was also discussed at the Board meeting. An Edgewood College of Nursing faculty member asked the Board for clarification of their position on nurse faculty co-signature of student notes in the patient record. The Board verified that they have no position on this issue, and that care facilities are responsible to create and implement policy around documentation in the record.

WHA and the Wisconsin Society of Healthcare Human Resources Administration (WSHHRA) are co-sponsoring their third annual seminar focused on best practices for health care human resource professionals.

This is an opportunity to find out what strategies and programs your colleagues are implementing that have had proven success in improving their HR departments. Sessions will focus on a variety of HR best practices from around the state and will include an overview of a successful regional alliance, integration of a nurse practitioner program into a hospital-based employee health program, creating a cost-effective training program, and ways to enhance leadership skills.

The "Best Practices for HR Departments" seminar will be held on August 17, 2006, from 9 a.m. to 4 p.m. at the Jefferson Street Inn, Wausau. A brochure with registration form is included in this week’s packet and on the Web site at www.wha.org. Online registration is available.

Register today for Fred Lee’s service excellence and patient loyalty workshops. The "Part I" seminar sold out in 2005, and is expected to again in 2006, so register soon! These programs will take a critical look at service excellence initiatives, quality and performance improvement efforts, and patient satisfaction surveys. The programs are filled with pertinent stories and practical examples, which will leave attendees inspired with fresh insight.

Back by popular demand, Fred Lee will present his service excellence and patient loyalty workshop, "If Disney Ran Your Hospital: Some Things You’d Do Differently," for WHA members on July 18. Additionally, on July 19, Lee will present a new, advanced Part II program entitled "If Disney Ran Your Hospital: Keys to Culture and Customer Service." Special two-day and team discount registration rates are available.

The seminars will be held at the new Holiday Inn Hotel & Convention Center in Stevens Point. Part I will be held on July 18 and Part II on July 19, running from 9 am to 4 pm each day. A brochure with registration form is included in this week’s packet and available online at www.wha.org. You can register for either or both parts.

The 16-year old girl in this true story, desperate to help ease her mother’s pain, turned to her mother’s close friend and Parish Nurse Barb Cowle. When the phone rang that Sunday night at 10:30, Barb knew that it could only mean trouble. Still, she answered the call and immediately drove over to her client’s house to help. "The drive was only seven minutes," Barb said, "and I prayed to God for guidance and wisdom."

Once there, Barb did an assessment and reviewed the ambulance report. To gather more information, she called the client’s nurse who had just cared for her at the cancer clinic earlier that day. Together, they evaluated the type of pain the client was experiencing and which medications she had taken in the last six hours. The nurse made some recommendations based on the information Barb provided.

Barb discussed the options, including going to the emergency room, with her good friend. Thanks to Barb’s input, the client was able to make education decisions. The next day, Barb followed up and made an appointment with the client’s oncologist to help manage her pain with medication. "My client and friend died five months later," Barb said. "I am so grateful I could help her on her final journey to heaven."

Parish Nurses like Barb often go above and beyond the call of duty for their clients. Even if they are unable to visit their clients in person, Parish Nurses can direct their clients to the resources they need or someone who can help. Their goal is to help educate their clients about their conditions and their choices, so they can make informed decisions.

Quality of Life

It happens to everyone at some point in life — a loved one will suffer from a life-changing illness. Caring for loved ones with chronic conditions can be very rewarding … and very challenging. Family members who assume the role of caregivers may become isolated, emotionally drained and overwhelmed by the new 24/7 responsibilities.

This happened to the family of Lillian, an 89-year-old women suffering from Alzheimer’s disease. Lillian’s impaired judgment and limited mobility meant that she needed 24-hour care, which her son and daughter-in-law lovingly provided. But after more than a year of constant care for Lillian, the couple needed a respite. They also had concerns for Lillian’s health and safety, including worries that Lillian might fall when stepping into the tub and about Lillian’s recurring urinary tract infections that left her agitated and combative. The couple turned to Parish Nurse Shirley Allison for assistance.

Shirley met with the family and assessed home safety needs. "Lillian was well cared for," Shirley said, "and the home met all safety criteria. The caregivers were performing their role very well, but becoming burdened by the 24/7 nature of this task without respite."

Shirley wanted to help ease the couple’s caregiver strain. She arranged for church volunteers to provide respite for the couple so they could enjoy some evening outings. In addition, Shirley informed them about community resources they could access, including agencies that could help give Lillian her baths. She also gave them information about preventing urinary tract infections.

"I want my mother to stay with us until she dies," Lillian’s son told Shirley. This was a possibility, though Shirley knew that home care is not always be the best option for the patient. Shirley shared examples of times a person might best honor the infirm relative by placing them in professional care. "The couple seemed relieved by the sharing of all this information," Shirley said.

Shirley encourages others in similar situations to seek help. By reaching out and connecting to community resources, "the quality of life is improved for the caregivers."

St. Nicholas Hospital has been providing high quality, compassionate care to all who come to us regardless of race, creed, or ability to pay since 1890. In Fiscal Year 2005, we provided $1,257,778 in charity care to help:

• A 30-year-old unemployed man with thyroid cancer
• A schizophrenic nursing home resident with dental expenses not covered by Medicare
• An illiterate immigrant who had just lost his job
• A frail underinsured 70-year-old retiree who had to take a part-time job to help with medical expenses
• A self-employed truck driver who had to give up his job to care for his wife
• An unemployed woman with a long history of mental illness
• An uninsured 54-year-old woman with cancer of the brain
• An aging widower still trying to pay off his wife’s funeral expenses

The Hospital’s provision of charity care to those unable to pay their bills has had enormous impact on the lives of the patients and families we serve:

• "Words cannot express the gratitude my family and I feel toward St. Nicholas Hospital…We have never been able to get out from under our debt…"
• "All I can say is, THANK YOU, from the bottom of our hearts…We had been such a good double income family until last August when I was laid off due to company reorganization."
• "The care I was given in your hospital was top notch, even without my having insurance. I was treated with dignity and great care by all doctors and staff…thank you for your generosity in these difficult financial times."

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Imagine if you had to decide whether you should buy the medication your doctor wanted you to have or buy food for yourself and your family – or perhaps pay your heating bill that month. For many low-income individuals and families, that choice is being made all too often.

Now, many low-income Stevens Point area residents are avoiding those difficult decisions through an easy, low to no cost prescription medication program. Provided as a service of Rice Medical Center, its satellite clinics, and Saint Michael’s Hospital, the Medication Assistance Program provides one centralized source for patients to obtain free medications, or those that require a low $5 co-pay.

Nicole Rineck, LPN, the full-time coordinator of the Medication Assistance Program, reports that the program has already helped to secure close to half a million dollars (at wholesale cost) in medications for participants – just eight months into its first formal year of existence. "It’s been really incredible how we’ve been able to help people get the medications they need," she said. "And I know as we make more people aware of the program, we’re going to see even greater savings to come."

Prescription drug manufacturers offer qualifying low-income people the ability to receive low to no cost medications on their own through the Internet; however, many people are unaware of this and the application process can be complicated. The Medication Assistance Program facilitates the enrollment process. "Basically, all a patient has to do is sign the form," Rineck shared. "I take care of everything else and because of our experience, the turnaround is so much faster. The medications are mailed here and patients can pick them up right from our office."

As an added service of the program, Sid Ellenbecker, a retired pharmacist, is on duty four hours each week to answer any questions a patient may have about medications. "I let our patients know that Sid is here during those hours and will be able to talk with them about the medications they’re picking up or any others they might be taking," Rineck said. "It’s just one other way we can help our patients easily get the medications they need."

Fred McCutheon, age 64, relies upon the Rice Medical Center/Saint Michael’s Hospital Medication Assistance Program to help him attain a variety of ongoing medications, including inhalers which alone have been costing over $150 per month. "The program has been just great for me – and such a big savings," Fred shared. Nici (Rineck) always makes sure I get everything I need before I run out. She takes really good care of me. Nici is just like family to me."

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

Mercy Health System was one of nine companies in Wisconsin recognized for environmental achievements at the 17th Annual Environmental Policy and Awards Conference in Waukesha on May 17. Mercy Health System was recognized in the environmental stewardship category and won a Wisconsin Business Friend of the Environment Award for outstanding achievements in environmental protection.

These awards honor companies that have set the standards for good environmental citizenship in Wisconsin and use innovation to go beyond government mandates to keep Wisconsin clean.

ProHealth Care this week received the American Hospital Association (AHA) NOVA Award. The award recognized five collaborative hospital-led programs that improve community health by extending help to low-income and uninsured children and adults, the chronically ill and racial and ethnic minorities. On June 8, AHA’s Rick Wade presented the Nova Award to ProHealth.

ProHealth Care’s Community Health Outreach Initiative is being recognized for its accomplishments in improving the health and quality of life of local residents. The program brings together various community organizations with a mission to serve the most vulnerable populations – the underinsured, uninsured, working poor and those hard to reach populations due to language and cultural challenges. ProHealth’s Community Outreach Initiative provides access to nurses in more than 40 different locations throughout the community including churches, schools, shelters and more. In addition a broad-based Hispanic Health Initiative was launched including a Hispanic Community Health Resource Center with bilingual staff and culturally competent services and education.

"A good hospital knows the community it serves and then learns how to help make it better," said AHA President Dick Davidson. "The AHA NOVA Award demonstrates how hospitals can and do make communities healthier and better places to live. Uniting together and working with like-minded groups to bring about change in their communities is why we are honoring these hospitals today."

Care management isn’t just for big organizations anymore. An increasing number of employers with 500 or fewer workers are adding wellness, disease management, and similar services.

A full-fledged wellness program typically includes:

• On-site clinical screenings for blood pressure, cholesterol, body mass index, and other basic indicators of risk.
• Health risk assessments, in which people self-report smoking, exercise, and other habits.
• One-on-one consultations to explain results to individuals and suggest changes, such as weight loss or more exercise.
• A report of aggregate data for the employer to guide future wellness efforts.
• A health coaching program to motivate and guide lifestyle changes in workers at high risk for chronic conditions.

To pick a cost-effective program that’s best for your workforce, first determine your needs based on demographics and medical-cost drivers. Small groups may focus on wellness for all workers rather than disease management for a relative few. The greatest savings long term comes from the opportunity to keep people who are healthy from getting sick.

Contact WHA Financial Solutions at whafs@wha.org for more information on the many programs we can tailor to your specific needs and budget.

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