July 11, 2008
Volume 52, Issue 27

• WHA Sets Recovery Audit Contractor Audits Program
• WHA Releases "Preparing for RAC Audits" Paper
• Twelve Health Care Organizations Receive Wisconsin Forward Awards
• President’s Column: Every Vote Should Count...Except in Labor Organizing Campaigns
• State Finances, Medicaid and Health Care Reform Dominate Public Policy Council Agenda
• Supplement Your Consumer-Directed Health Plan With Voluntary Benefits
• CMS Releases the Proposed Medicare Outpatient Rule for CY 2009
• Stories From Our Hospitals: Beloit Memorial Hospital
• Stories From Our Hospitals: Aurora Sinai Medical Center, Milwaukee
• Stories From Our Hospitals: Black River Memorial Hospital, Black River Falls

Based on the recommendation of the WHA Recovery Audit Contractor (RAC) Task Force, WHA and the Wisconsin Chapter of HFMA are offering a one-day program entitled "Minimize Compliance and Financial Risk While Preparing for the RAC" August 6 in Wisconsin Dells.

Following the mantra "the best defense is a good offense," this program will help hospitals unite the utilization review committee, medical staff and financial departments to establish a proactive program to achieve audit preparedness and compliance success, which is especially important in light of the RAC audits that will be coming to Wisconsin in 2009.

Join national experts Robert Corrato, MD, president and CEO of Executive Health Resources (EHR) and John Bartell of Bay Area Healthcare Consulting, for insight into building and optimizing a U.R. committee and processes, ensuring an effective observation status and one-day stay certification, a discussion of why these issues have become a major compliance concern, and why hospitals often lose significant revenue from inappropriate observation claims. Also, learn about verification processes to ensure claims are supported by clear and irrefutable documentation, as well as the importance of accurate charge master descriptions, capture procedures and claim generation processes.

The August 6 program will be held at the Wintergreen Resort in Wisconsin Dells. A brochure with registration information and a full agenda is included in this week’s packet and on the Web site at www.wha.org/education/compliance.aspx. Online registration is available. For registration questions, contact Lisa Geishirt at 608-274-1820, or email lgeishirt@wha.org.

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Based on the recommendation of the WHA RAC Task Force, a WHA RAC work group has developed a white paper to assist hospitals as they prepare for the upcoming RAC audits.

The 36-page paper summarizes the experiences from the RAC demonstration project, highlights various components of claims review, and includes "best practices" from Wisconsin hospitals to assist facilities focus on those areas that could be audited by RACs. In particular, the paper emphasizes the types of inpatient claims that were targeted during the RAC demonstration (CMS RAC Status Document). It also references the QIO PEPPER reports, the OIG workplan and compliance guidance, AHA and WHA materials, along with other strategies and tools organizations can utilize to minimize the impact of future RAC audits.

The paper is available on the WHA Web site in the Toolkit or directly at www.wha.org/financeAndData/pdf/RACwhitepaper7-08.pdf. Stay tuned for more information about the RAC program and its rollout as it becomes available.

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Health care organizations continued to dominate the Forward Awards again this year at the July 8 recognition ceremony held at the Monona Terrace in Madison. The Wisconsin Forward Award is the state’s premier organization for the promotion and recognition of high-performance management principals.

Twelve of the 15 organizations recognized were related to health care. Two received the prestigious Governor’s Award of Excellence—Agnesian HealthCare, Fond du Lac and St. Mary’s Care Center, Madison. According to Roberta Gassman, secretary, Wisconsin Department of Workforce Development, these organizations demonstrate refined approaches, good-to-excellent results, and are considered industry leaders and role models for others.

WHA President Steve Brenton said, "Hospital and health system domination of the prestigious Forward Awards over the past few years speaks to their commitment to performance improvement—performance that has led Wisconsin hospitals to continuously top the AHRQ quality rankings."

The health care organizations recognized included:

Governor’s Award of Excellence: Agnesian HealthCare, Fond du Lac; St. Mary’s Care Center, Madison

Mastery: Bay Area Medical Center, Marinette; Physicians Plus Insurance Corporation, Madison; Sacred Heart Hospital, Eau Claire; St. Clare Hospital & Health Services, Baraboo; St. Clare Meadows Care Center, Baraboo; St. Mary’s Hospital, Madison

Proficiency: Franciscan Skemp Healthcare – Mayo Health System, La Crosse; Red Cedar Medical Center – Mayo Health System, Menomonie; Stoughton Hospital; Saint Michael’s Hospital, Stevens Point

Mercy Health System, Janesville, was also recognized at the ceremony for receiving a 2007 Malcolm Baldrige quality award.

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But for a handful of votes in the U.S. Senate this year, workers would have lost their right to privately vote on whether or not their workplace would become union organized …or… remain nonunion. The legislation, labeled by its supporters The Employee Free Choice Act, is arguably one of the most important election issues this year. The proposal clearly calls into question the fundamental individual right to secret ballot and has potential to significantly alter the current collective bargaining equilibrium.

Although the Legislature has largely flown under the radar screen to date, that will likely change later this summer and into the fall as well-heeled issue advocacy campaigns ramp up their messages and call out candidates. Look for millions of dollars to be spent convincing us that this is either a terrific advancement of workers "rights" or a dangerous threat to longstanding constitutional protections.

The facts involved here are relatively simple. Powerful and motivated labor unions have determined that "card check" legislation is their litmus test for candidate support in 2008. They see it as a path to undo a several decade long decline in representation of the nation’s workforce. To labor, this issue is more important than other priorities like health care and restrictive trade legislation. Their proposal basically replaces the current, National Labor Relations Board sanctioned election process with a system that allows for automatic representation if a majority of workers sign cards indicating they wish to be represented by a union.

Critics of this legislation point to the potential for widespread intimidation from paid union activists going door-to-door in an effort to secure enough "card checks" to effectively organize targeted workplaces. While supporters argue that such claims wildly exaggerate what will actually happen, an even casual examination of recent "corporate campaigns" designed to demonize major and respected employers…including hospitals… foreshadows a likely future.

A lesser known but equally sobering provision of the initiative is a clause that upends current collective bargaining rules by mandating that government arbitrators determine final contract provisions when union and management fail to reach contractual agreement. Any urgency for either side to be realistic in the collective bargaining process evaporates quite quickly when faced with such an end game.

The Employee Free Choice Act is an issue that should be discussed and addressed by all Congressional candidates this fall. The question is this….Do you support retaining the right to secret ballot when it comes to union organizing campaigns?

Steve Brenton, President

State finances, the 2008 elections and their impact on the direction of health care policy in Wisconsin were among the key discussion items when the WHA Public Policy Council met July 8 in Madison.

State Budget Director David Schmiedicke kicked off the meeting with an update on the state’s fiscal situation heading into the second and final year of the 2007-2009 biennium and a preview of what is in store for the 2009-2011 state budget bill.

Schmiedicke, a veteran of the budget office who has served under both Democratic and Republican governors, provided an historical recap of the state budget. Several trends he highlighted were increases in the corrections budget as well as an increase in school aid. On the other hand, Medicaid funding has had level funding at 10-12 percent of the state budget even with increases in eligible populations.

Schmiedicke provided Council members with an overview of the Governor’s health care priorities, such as government doing what it can to ensure everyone has health care, government working with employers to provide affordable health care and that no child should be without insurance.

Turning to the 2009-2011 budget, Schmiedicke said the biggest challenge will be an uncertain economy. Big ticket budget items will be property taxes, school finances and transportation funding, and all will have significant impacts on state finances. The overview provided a beneficial look into Medicaid funding in the larger context of the state budget, and Council members had several good questions for Schmidicke.

WHA Executive Vice President Eric Borgerding outlined the emerging political landscape, what it means for WHA’s legislative priorities and the actions WHA is taking to address it.

Due to the resignation of Democrat Senator Roger Breske (now Wisconsin’s Railroad Commissioner), Democrats hold a 17-15 majority in the State Senate. And with Republicans holding a 52-47 majority in the State Assembly, much is at stake. In both houses, WHA remains committed to building relationships with legislators and challengers that support hospitals.

As part of his presentation, Borgerding provided a recap of the 2007-09 budget deliberations, including BadgerCare Plus coverage of childless adults and the challenges to fully fund the expanded program, the continuing lack of payment increases for hospitals serving Medicaid patients, and the role of the hospital assessment.

Aspects of each of these issues remain unresolved as we move into the next legislative session and are compounded by an ever-uncertain economy and a state revenue situation that will likely be worse before it gets better.

Health care reform will also remain a top issue, as debate continues on Healthy Wisconsin and further expansions of BadgerCare Plus. Other likely issues mentioned by Borgerding for next session include continuing efforts to expand transparency, a ban on unavoidable overtime, mandating staffing ratios for nurses and potential challenges to hospital tax-exempt status.

To round out the discussion, WHA VP-External Relations & Member Advocacy Jenny Boese alerted Council members to two upcoming WHA grassroots educational programs. The first is a continuation of last year’s well-received half-day Grassroots Leadership Training Workshop. Beginning this summer and into the fall, the workshop will be offered directly to hospital boards and leadership teams at their facilities. Each workshop will include a legislative update as well as grassroots training. The second educational program will be a legislative webinar to be offered later this year. The program will focus on issues on the horizon for 2009.

WHA’s Jodi Bloch provided information on the status of the 2008 Political Fundraising campaign. To date, $123,000 has been raised, equaling 59 percent of the 2008 goal of $210,000.

WHA’s Senior Vice President George Quinn detailed the Association’s efforts on workers compensation and Medicaid payment reforms. Efforts to reduce workers compensation costs are ongoing and, as previously reported in Valued Voice, have largely focused on reducing provider payments. Quinn also summarized recent discussions with DHFS regarding several Medicaid payment issues, which could include welcome changes to both inpatient and outpatient reimbursement rates and structures.

WHA’s Associate General Counsel Matthew Stanford provided an update on the pending lawsuit filed by the Wisconsin Medical Society regarding the Injured Patient & Families Compensation Fund. Stanford closed by detailing the amicus brief ("friend of the court") WHA filed last week.

The next meeting of the Public Policy Council is November 18.

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(From Solutions Spotlight, included in this week’s packet.)

With the continued rise of health care costs, employers are using Consumer-Directed Health Plans (CDHPs) to do more for employees while spending fewer dollars. According to Employee Benefits News, nearly 60 percent of human resources executives identify cost control as the top reason for adopting a CDHP. Now, employers are finding that voluntary health products can offer an exceptional fit with all types of CDHPs, including everything from account-based plans, such as Flexible Spending Accounts (FSAs), Health Reimbursement Arrangements (HRAs), and Health Savings Accounts (HSAs), to high deductible plans.

Examples of medical plan characteristics that may lead to a need for voluntary health products are:

• Recent reductions in benefits within a medical plan

• Recent increases to co-insurance, annual deductibles, or out of pocket maximums

• Only one medical plan option offered to employees

• Plans with separate deductibles for hospital admissions

Plan design combinations can be created that incorporate voluntary health products into employee benefit programs. This has the effect of increasing employee engagement in health care costs and decision making, reducing gaps created by higher deductibles and coinsurance, and increasing overall employee satisfaction with the breadth and flexibility of benefit offerings.

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The Centers for Medicare and Medicaid Services (CMS) proposed outpatient rule for Calendar Year (CY) 2009 includes provisions that would significantly change Medicare payments and reporting requirements over the next several years while promoting higher quality and efficient services to Medicare beneficiaries. The proposed rule is scheduled to be published in the July 18 Federal Register.

Significant provisions of the proposed rule include:

Quality Measures: CMS is proposing to increase the reported outpatient quality measures from 7 to 11 in CY 2009. Hospitals that fail to report the 11 measures in CY 2009 will receive a reduction of 2.0 percentage points to the full marketbasket update in CY 2010. The four additional measures focus on imaging efficiency. CMS also proposes to expand the requirements to include eighteen potential quality measures including cancer care, emergency department throughput, screening for fall risk, and management of certain clinical conditions such as depression, stroke and rehabilitation, osteoporosis, asthma, and community-acquired pneumonia in future years.

Validation of Quality Reporting: CMS is proposing to implement a data validation approach for CY 2010 beginning with encounters from January 2009.

Preventable Conditions: CMS is seeking suggestions for an outpatient methodology that would be similar in concept to the inpatient hospital-acquired condition policy. CMS has not made a specific proposal, but is seeking input on alternatives for modifying payments for treating conditions that are generally preventable under the Outpatient Prospective Payment System (OPPS).

Composite Ambulatory Payment Classification (APC) Groups: CMS is proposing to increase the composite APCs from five to ten for CY 2009. Composite APCs provide a single payment when a specified combination of HCPCS codes are reported on the same date of service, rather than paying for each service individually. The additional five composite APCs cover imaging services.

Type B Emergency Department Visits: Type B emergency departments (ED) offer emergency level services but are not open 24 hours per day, 7 days per week. Currently, these services are paid using clinic APCs. CMS is proposing to create four new APCs for Type B ED visits. Based on data collected over the past few years for the Type B ED visits, CMS’ analysis shows that they are more expensive than clinic visits but less costly than an emergency visit.

Marketbasket Factor: CMS is proposing a full marketbasket update of 3.0 for CY 2009. Hospitals that are non-compliant with the reported outpatient quality measures will receive the full marketbasket update minus 2.0 percentage points. CMS is proposing to increase the conversion factor from $63.694 in CY 2008 to $65.684 in CY 2009.

Outliers: CMS is proposing an increase in the outlier fixed-dollar threshold from $1,575 in CY 2008 to $1,800 in CY 2009. Outlier payments would be provided when the cost of furnishing a service exceeds 1.75 times the APC payment amount and exceeds the APC payment rate plus a $1,800 fixed-dollar threshold.

Drugs and Pharmacy Overhead: CMS is proposing to create two new cost centers within the Medicare cost report that would allow hospitals to report drugs with high and low pharmacy overhead costs. This would allow CMS to estimate drug and pharmacy overhead costs for possible future payment changes.

A display copy of the rule is available at http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage, click on "Year Descending" and refer to CMS-1404-P. Please note that the display copy is double spaced and over 1,000 pages long.

CMS has also posted a fact sheet on the proposed rule at http://www.cms.hhs.gov/apps/media/fact_sheets.asp.

Comments on the proposed rule are due to CMS no later than 5 p.m. on September 2, 2008.

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Not everyone who requests financial assistance for health care needs is on long-term assistance. Sometimes, such as the case with Kelly O’Brien of Beloit, you just need a little help getting back on your feet. In October 2007, Kelly found a lump in her breast that turned out to be a very aggressive form of breast cancer. It was then that she knew her world was going to change.

Kelly, 49, is a single part-time student/waitress/graphic designer who has always supported herself and taken her financial responsibilities seriously. She had just started a job at Starbucks that would eventually offer her health insurance benefits after she was able to get through the probationary time period. When she started getting medical bills which she knew she couldn’t pay, she pursued possibilities to see how she was going to handle her continuously growing accumulation of health care bills- three surgeries, PET scans, Emergency Room visits for infections, four months of chemotherapy and five weeks of radiation to name just a few.

"At the age when other people are thinking of retiring, I had just discovered a field of work that I wanted to pursue for the next 20 years," explained Kelly. "As a student, I had a $50,000 maximum benefit student insurance plan, however, that maxed out relatively soon into my illness. I was worried how I was going to pay my bills."

Beloit Memorial Hospital’s financial assistance program allows patients at low income levels to qualify for benefits. At this time, the hospital has covered about $26,000 of medical bills that Kelly had no way to pay.

"I can’t tell you what a relief that was for me. Here I was going through a very scary time after my diagnoses, not feeling well due to my treatments, and concerned about how I was going to pay the bills. When the hospital covered some of these costs, it was a dream come true. I was afraid I was going to dig myself into a financial hole that I could never repay."

"I can’t say enough good things about Beloit Memorial Hospital and all of the people who cared for me there. Not only was the treatment the best, but the people who cared for me were respectful and compassionate. They never made me feel like I was a loser because I couldn’t pay my bills and that gave me a lot of confidence to get back to work," she adds.

Kelly, who has always been a hard working, organized person, is now nearly back on her feet and learning to move on as her cancer treatments become less time consuming. "I still have monthly treatments, but I am back taking classes to improve my foggy "chemo-brain" after affect. I have a future now and have the hospital to thank."

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Stories From Our Hospitals
Aurora Sinai Medical Center, Milwaukee, Aurora Sinai Medical Center’s Bread of Healing Clinic

The Bread of Healing Clinic at Cross Lutheran Church in Milwaukee was founded in 2000 by one of Aurora’s parish nurses, Rick Cesar, RN, in partnership with a medical resident at Aurora Sinai Medical Center. Rick is Aurora’s nursing supervisor for academic clinics. He explains, "Bread of Healing serves people who are trying to stay as healthy as possible. It gives them hope for their future. There is no health without hope."

Today Bread of Healing holds clinics at two sites and serves patients who receive primary care services, free of charge, at the clinic. At any given time, 700 to 1,000 patients are active with the clinic.

This vital, volunteer-driven community resource helps patients who don’t have access to health insurance. It provides medication free of charge or assists patients in obtaining the medications and medical care that fall outside the clinic’s resources. In partnership with the University of Wisconsin Internal Medicine program, it has become a valuable teaching site that provides much-needed primary health services to a vulnerable population of working adults without access to health insurance.

Providing patients with regular primary care and follow-up for conditions such as diabetes and hypertension gives them a better chance to live healthier lives. Aurora Sinai Medical Center supports the Bread of Healing Clinic through in-kind donations, including staff time (nurses and diabetic educators), laboratory and pharmacy services.

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Stories From Our Hospitals
Black River Memorial Hospital, Black River Falls, Health, Wellness and Safety Fair was a great success

Over 450 people attended the Health, Wellness and Safety Fair September 20, 2007 at the National Guard Armory. The event, sponsored by Black River Memorial Hospital and Seniors Avoiding Falls and Emergencies (SAFE), featured speakers, exhibitors, screenings, educational materials, door prizes, a silent auction to raise funds for senior exercise programs and refreshments.

Forty two exhibitors showcased their services, and screenings were offered for bone density, blood sugar, hearing, blood pressure, balance, oxygen, carbon monoxide, body composition, foot assessment, sleep apnea and total cholesterol. Certified child passenger safety technicians were also available to inspect children’s car seats and provide safety information.

Throughout the day there were a variety of presentations by various health and wellness professionals. To kick off the event with the Jackson County Bank’s Prime Time Club’s Walk for Health was Krohn Clinic physician Paul Greenlaw, MD who spoke on the "Benefits of Exercise." During the Health Fair at the armory, other presenters and topics included Kathleen Clemons, MS, exercise physiologist, Ho-Chunk Nation, "Senior Exercise Demonstration;" Becky Windsor, PTA, Black River Memorial Hospital, "Fall Prevention;" Lisa Malmo, Lunda Community Center, and Sherrie Cowley, "Yoga, Pilates and the Stability Ball;" Beth Smetana, MSW, HelpLink, "Tae Kwon Do;" and John Jordan, DC, Jordan Chiropractic Clinic, "Facts, Food and Fiction – The Truth About What We Eat and How to Optimize Your Body’s Potential."

Several students from the Black River Falls High School attended, including Sarah Halverson’s Careers Class and Tina Gilbertson’s Family Consumer Education Classes. The students had the opportunity to visit exhibits, attend presentations and interview exhibitors to get information on a wide variety of fields of study. The Health, Wellness and Safety Fair Planning Committee consisted of representatives from Black River Memorial Hospital, SAFE, Jackson County Department of Health and Human Ser-vices, Ho-Chunk Nation, Krohn Clinic, Jackson County Bank, Pine View Care Center, Family Heritage Care Center, Jackson County Interfaith Volunteer Caregivers, Curves and River Country Fitness.

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