As more and more Wisconsin hospitals enroll in the WHA Quality Public Reporting Initiative, I can’t help but notice that demand for this information is growing at an increasing pace. As consumerism in health care gains momentum, it is imperative that hospitals proactively participate in the ensuing conversations about quality, safety and cost. The WHA Quality Public Reporting Initiative provides a comprehensive, coordinated avenue for you to communicate with purchasers and consumers in your community and throughout the state.

At this time, a vast majority of hospitals from all parts of Wisconsin have committed the resources necessary to demonstrate their accountability to the public. (See list of participating hospitals on page 6.) It is my goal to see the participation rate climb even higher. I believe that this is possible as hospitals see the many benefits of publicly providing information that will lead to a vibrant marketplace.

We know that actively involving consumers in decisions that affect their quality of care is ultimately in everyone’s best interest. To that end, we need all Wisconsin hospitals to actively participate in the quality initiative as we design a new health care environment in a state that is well known for innovative reform.

If you have not returned the enrollment materials, please do so as soon as possible so your hospital will be included in future communications. If you have questions, contact Dana Richardson, WHA vice president, quality initiatives, drichardson@wha.org  608-274-1820.

Reports filed with the State Ethics Board covering January through June of 2003 show that for the first time WHA has moved into the top 10 of Wisconsin lobbying organizations.

"We have assembled a top notch team, and we don’t do a lot of sitting behind our desks," said WHA Senior Vice President Eric Borgerding. "WHA is in the halls of the Capitol and the bowels of state agencies more than ever before, and this report reflects that."

According to documents released today, WHA now ranks #7 in total expenditures ($220,910), and #9 in total hours spent lobbying (2,018) out of roughly 621 registered lobbying organizations. Both measures show significant increases over the same reporting period in 2001, with lobbying hours jumping a whopping 71% and expenditures rising 62%.

"Government will always play a large role in health care, especially in Wisconsin were we have a full-time legislature and very active bureaucracy," said Borgerding. "Given those circumstances, lobbying and, in the broader sense, advocacy will continue to be WHA’s very highest priority. Our members expect nothing less."

But lobbying is only one piece of WHA’s comprehensive advocacy strategy. "Even if we are ranked number one, our advocacy efforts will fall short without the commitment of our members," Borgerding said. "It’s their commitment to our PAC, conduit and most of all grassroots advocacy that makes the difference. The letters, emails and phone calls, often made on a moment’s notice, are the substance of our lobbying efforts. That’s what really counts."

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As the U.S. Senate wound down their business in July, a number of "Dear Colleague" letters were circulated to garner support and provide direction to Senate conferees for key provisions in the Medicare Prescription Drug Bill. "Dear Colleague" letters are often used to demonstrate bi-partisan support for key legislative provisions, and are a way for individuals not serving on key committees or conference committees to show the depth of support for key issues. The Medicare bill has a number of provisions key to Wisconsin hospitals. Both Senators Kohl and Feingold, and their legislative staffs, have been working to ensure DSH, the Rural Equity provisions and Indirect Medical Education are included not only in the Senate passed bill, but also in the final Medicare bill.

"We know how important these issue are to our Wisconsin hospitals, and we are glad to do what we can," said Senator Herb Kohl.

Copies of the letters can be found at: www.wha.org, government relations, federal issues.

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The Toronto Star, Canada’s largest circulation newspaper, recently ran a series of articles about that nation’s government-run, single-payer health system.

In an eye-popping piece that ran July 25, Toronto Star Columnist Jason Brooks wrote:

"Health care in Ontario is free, but so is eating lunch from a trash can."

In the column, Brooks discussed his decision to visit a Baltimore, Maryland-based eye specialist in order to avoid a two-month wait in Toronto and "the indignity of being treated like a head of cattle." Brooks said that his $1,000 U.S. medical bill was a small price to be paid "to avoid being sworn at by Toronto nurses." That $1,000, according to Brooks, bought "something you can’t buy [in Canada]: civility."

The absence of choice combined with the economic rationing of new medical technology that Americans take for granted is endemic in Canada. Those who claim that the skyrocketing price of this nation’s health care can be contained by the discipline of a single payer health system are right…but the price to be paid must be recognized, described and understood. Civility and access have a price tag.

Now that the Wisconsin state budget has been put to bed, at least for a few months, the Wisconsin legislature will begin to focus on a variety of other issues. Health care is likely to be on that agenda with GOP leaders targeting "market-based" solutions while at least a handful of Democrats (and their champions within organized labor) promote some form of single payer health care. In that regard, we owe it to our patients and communities to explore the unintended consequences of such systems with real life anecdotes such as the one described earlier in this column.

WHA’s health reform principles promote an agenda that enables consumerism, improves coverage and access, and promotes community accountability. Focusing on reforming the marketplace also must entail a commitment to real solutions and engaging public and private purchasers who are frustrated by soaring health care costs. Failure to do that will lead at least some to cozy up to the seductive sound bites of single payer health care system.

The Centers for Medicare & Medicaid Services will release its proposed rule in the August 12 Federal Register outlining its changes to the Medicare outpatient prospective payment system for calendar year 2004. The final rule, to be published around November 1, would take effect January 1, 2004.

The proposed rule provides for an outpatient PPS rate increase of 3.8%--the estimated full market basket rate of inflation of 3.5% mandated by law, plus 0.3% for changes to the new technology pool. It also extends the "dampening rule" put in place in 2003, meaning that certain ambulatory payment classifications (APCs) that would decrease by more than 15% in 2004 would be shielded from significant losses. The target for total outlier payments would remain at 2.0% of total outpatient spending, but two separate outlier thresholds would be created--one for hospitals and one for community mental health centers. On transitional pass-through payments, CMS said it was not yet sure whether an across-the-board (pro rata) reduction in payments for new technology, drugs, devices and biologicals would be necessary in 2004 to meet the 2.0% of total outpatient spending target set by law.

WHA will provide comments to CMS on the proposed rule. We welcome any member input on this issue.

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In recent weeks WHA has received a number of questions recently concerning CRNA practice in Wisconsin. In Wisconsin, the Medicare Conditions of Participation (COP) require CRNAs to administer anesthesia only under the supervision of a physician. (It is important to note that the Medicare COP do not require CRNAs to be supervised by an anesthesiologist.)

In November 2001, HHS issued a rule that confirmed the general Medicare requirement that CRNAs administer anesthesia only under the supervision of a physician. The rule, however, permits the governor of a state to "opt-out" of the requirement by requesting an exemption from CMS. Before requesting an exemption, the governor must consult with the state’s medical and nursing examining boards and attest that the opt-out is consistent with state law. In other words, the governor may request an exemption from the Medicare supervision requirements only if state law does not require CRNAs to be supervised by a physician. Wisconsin has not opted out of this Medicare requirement.

If you have questions, contact Judy Warmuth at 608-274-1820.

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Tim Size, executive director, Rural Wisconsin Health Cooperative, was named to a national committee that will study the delivery of health services. The Office of Rural Health Policy, Department of Health and Human Services, requested that the Institute of Medicine establish the committee to provide an independent, unbiased assessment of the quality of health care in rural America. The committee will develop a conceptual framework for a core set of services and the essential infrastructure necessary to deliver those services to rural communities. The committee will also recommend priority objectives, identify the changes in policies and programs including, but not limited to, payment policies and the necessary information and communication technology infrastructure needed to advance the identified objectives. In the entire analysis, the committee will consider implications for federal programs and policy. The study will make recommendations on an agenda for quality improvement in rural settings, identifying the performance characteristics that model 21st century community rural health systems should meet.

As a major part of the study, the committee will convene a large day-and-a-half workshop in addition to three committee meetings. The discussions at the workshop will focus on the key characteristics that are unique to rural environments and map out the characteristics that a model rural community health system should meet in terms of care delivery, payment, quality monitoring, reporting, IT infrastructure, and other relevant areas.

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Congressman Dave Obey (D-7th District), and ranking member of the Appropriations Committee, brought leaders from the National Institutes of Health to share their knowledge on the state of medicine in the U.S. on August 1 at the Wisconsin Indianhead Technical College. Founded in 1887, NIH is one of the world’s foremost medical research centers, and the Federal focal point for medical research in the United States.

"The National Institutes of Health is one of our best investments. NIH is largely responsible for the increase in knowledge for virtually every physician in this country as they treat their patients," Obey told the capacity crowd in Rice Lake as he introduced NIH Director Elias Zerhouni, MD. "Today, we bring to Northern Wisconsin some of the most eminent scientists in this country."

Zerhouni said 75% of our health care dollars are spent on chronic diseases. "One thing that worries me is how can we provide the best care at an affordable cost? If you look at our expenditures, we spend 14% of our gross domestic product (GDP) on health care and the cost is accelerating," according to Zerhouni. "What are we are going to do about this increase in cost? This is a challenge we need to face."

Zerhouni said 30% of the U.S. population is obese, which is generating other health problems, like heart and renal disease. "Wisconsin’s state ranking in obesity has actually fallen to 14th, but that isn’t because Wisconsinites are thinner, it is because other parts of the country have accelerated their rates of obesity," he said.

"The NIH budget has increased as the burden of disease has become greater in our country," according to Zerhouni. "Congressman Obey is a leader and strong supporter of NIH, and he understands the importance of investing in research."

"The change in the landscape of disease requires us to adopt new approaches and accelerate the pace of our discoveries. We are directing our research in a way that centers on the individual. We no longer believe that you do research in a lab. At the end of the day, the research has to have had an impact on your life," Zerhouni concluded.

Dana Richardson, WHA vice president of quality, asked the NIH leaders how the research they do could be more quickly incorporated at the point of service. Zerhouni said the true manager of chronic disease is the person, and that knowledge must be conveyed to the person, who in turn, helps the physician increase their understanding of the disease or the condition.

Francis Collins, MD, Ph.D. and director of the National Human Genome Research Institute, strongly agreed with Zerhouni. "Clearly, in this modern era, people get information themselves and at times, know more about the condition than their provider. In Wisconsin, you have a wonderful medical care network of providers who are well informed and are meaningful and significant participants in medical research. At NIH, we want to get information to the public and providers as fast as we can," Collins said.

Break out sessions were held on specific conditions, including, Alzheimers, diabetes, hypertension, and cancer. NIH also showcased their Web site (www.nih.gov), which offers a host of information to both clinicians and patients. Following the presentations in Rice Lake, Obey and the NIH leaders traveled to Superior and repeated the sessions.

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Hospitals Enrolled

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Sharon Whelan, president of River Falls Area Hospital (RFAH), has resigned after 38 years of service to Allina and its predecessor organizations with the past 11 years spent at RFAH.

"Sharon has had a very successful career at Allina and in particular at River Falls Area Hospital," said Rickie Ressler, executive vice president, regional and specialty care services. "She will undoubtedly be missed in Allina and in the River Falls community where she has been involved in several civic leadership positions."

Whelan will join the Riverland Community College (Minn.) nursing faculty this fall.

"I’m looking forward to the career change," said Whelan. "I’m at a point in my life and with my family where I sincerely have two passions — my family and my commitment to making a difference in the education and direction of future health care leaders.

Whelan’s final day with Allina’s River Falls Area Hospital is August 8. Mary Ellen Wells has been named interim president until the position is filled. Wells also serves as the president of Allina’s Buffalo Hospital in Buffalo, Minnesota.

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The Wisconsin Office of the Commissioner of Insurance is hosting a teleconference with the Centers for Medicare and Medicaid Services (CMS) to discuss implementation issues concerning the HIPAA electronic transaction and code set regulation. The teleconference also will cover certain Privacy Rule issues. The teleconference will be on September 24 from 1 to 2:30 p.m. More information will be provided in the near future through The Valued Voice and on the WHA Web site.

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On August 5, the Speaker’s Task Force on the Wisconsin Technical College System held its third meeting. Task Force members which include Philip Stuart, CEO of Tomah Memorial Hospital heard first from Harry Peterson. Peterson was an administrator with the Minnesota State Colleges and Universities (MnSCU) during the time that that system was being consolidated between 1991 and 1995. He spoke both about the difficult part of changing cultures and working with individuals whose jobs are threatened and the positive aspects of a single body making uniform decisions regarding programming and the benefit to students of a ‘seamless’ higher education system.

His advice to the group was: 1) Focus on the ends, not the means. 2) Know that it takes a lot of years to achieve optimal functioning of a new organization. 3) Try to begin with legislative consensus. It will make the process go much more smoothly. He also suggested that four years between legislation and implementation is too long. In that merger, 20 co-located institutions were merged (for example both a technical college and a four-year campus in the same town). He encouraged the group not to consider consolidation solely for financial savings, as they may not be achieved.

Rolfe Wegenke, President of the Wisconsin Association of Independent Colleges and Universities (WAICU) presented to the group on behalf of the Wisconsin PK16 Council. The Council, sponsored by DPI, UW System, WTCS and WAICU, is working on a voluntary basis to foster collaboration among education, business, industry and government. He described issues that the group is currently addressing and answered questions about a voluntary approach to problems the task force is investigating.

Janice Mueller, state auditor, presented an overview of the recent audit of the Milwaukee Area Technical District by the Legislative Audit Bureau. The audit focused on the financial status of the college, not programming. Mueller’s findings included: Charges for specialized programming do not cover costs, which is a violation of MATC’s own policies. Enterprise activities such as the cafeteria do not cover their own costs. MATC utilizes consultants when employees with above-market salaries have the same responsibilities. The maximum instructor salary is $78, 271. Sixty four percent of faculty earn more than the maximum and 12% of faculty earn over $100,000. Faculty bargaining agreements regarding health care may cause financial hardships in coming years. Administration has not always provided their board with complete and accurate information, and they have not consistently complied with state statutes.

The group also received follow-up information on the 2003-2004 Budget and vetoes.

The next meeting is August 19, 2003.