Over 110 case managers, coding, compliance, finance and other hospital staff attended the WHA seminar, Minimizing Compliance and Financial Risk While Preparing for a RAC Audit on August 6. Featured presenter, Dr. Robert Corrato, president/CEO of Executive Health Resources, provided strategies and insights derived from his day-to-day experience as a physician as well as his experience in representing hospitals already impacted by the Medicare Recovery Audit Contractors (RAC) program. The seminar is one of a series of actionable steps recommended by the multi-disciplinary WHA RAC Task Force, chaired by Divine Savior Hospital CEO Mike Decker and being implemented by WHA.

In assessing the RAC demonstration program to date, the two main areas of RAC audits for all providers have been medical necessity determinations and coding errors, 40 percent and 35 percent respectively. However, when looking only at inpatient hospitals, medical necessity determinations comprised 62 percent of all audit errors. As a physician and expert in representing hospitals during RAC appeals, a strong focus of Corrato’s presentation was medical necessity determinations.

Corrato walked attendees through detailed questions such as: who decides medical necessity, who is at risk from those decisions, what are the risks, and how can the risks be managed? He focused in-depth on several corollary areas, including the importance of an appropriate utilization review plan and criteria for admission evaluation. Corrato also described the RAC appeals process, providing practical tips on how to and what to do when appealing.

The final segment of the day-long seminar featured John Bartell from Bay Area Healthcare Consulting, who focused his presentation on the processes that result in a compliant claim being created. His discussion targeted on accurate charge description masters, charge capture procedures and claim generation processes that are key components to producing compliant claims.

WHA will offer a two-part audiconference series in October focused on the issues surrounding the RAC initiative. Part one will be offered October 1 and will touch on the history of the initial three-state findings. Significant time and specific emphasis will be placed on practical strategies for multi-department integration, defensive audits focusing on known issues, and ideas for ongoing education and prevention.

The demand for nurses continues to accelerate, according to Sally Lundeen, Ph.D., Dean, University of Wisconsin-Milwaukee College of Nursing. Speaking at the WHA Workforce Council meeting in Madison August 7, Lundeen said nursing schools are turning away qualified nursing students because they cannot find enough faculty to meet student demand for classes.

Lundeen, who heads the largest nursing program in Wisconsin, provided background on the current and future nursing workforce and enumerated the factors that she believes must be addressed in Wisconsin to build an adequate nursing workforce. The factors included:

• Address nursing shortage

• Understand knowledge explosion

• Recognize sites of care are changing

• Realize the need for evidence-based practice

• Relearn how to teach and learn

• Gain access to what we need to know (data)

• Teach nurses how to work in teams and successfully supervise others

Lundeen reminded the group that the demand for nurses in all aspects of health care (today, only about 50 percent of RNs work in hospitals) continues to increase. It is essential there be qualified registered professional and other licensed nurses to meet the needs of patients. Competition for new graduates and experienced nurses is intense as new positions and opportunities outside of clinical settings are becoming available for nursing graduates.

In the face of existing and future significant shortages, the nursing schools and colleges are directing resources to one of their most critical shortages: nurse faculty. Lundeen cited the following as contributors to the faculty shortage:

• Faculty are required to be educated at the masters and doctoral levels.

• Large number of faculty are reaching retirement age.

• Nursing faculty salaries are not competitive with the administrative and practice salaries for nurses with graduate degrees in the health care service sector.

• The current nurse workforce and nurse educators do not reflect the diversity of the state.

• The lack of funding for nursing scholarships and traineeships limits the number of nurses who are able to attend graduate programs full time.

• The time it takes to earn a degree for graduate students in nursing is much longer than for other graduate students because many nursing graduate students attend graduate school on a part-time basis and continue to work in order to pay for school, support families and maintain access to health insurance.

Additional funding is necessary to fund nurse educator positions if the supply of nurses is ever going to meet the demand, according to Lundeen. A strong working relationship among the Wisconsin Hospital Association, the University System, and collaborative work with both the Wisconsin Technical College System and Wisconsin Private Colleges and Universities, is one of the strengths that Lundeen cited as Wisconsin attempts to avert the crises that other states currently are experiencing. Lundeen also talked about the many ways in which Wisconsin is working to address the need for nurses.

"Even when the discussions are difficult, these groups continue to address the bigger issues," she said.

WHA’s Judy Warmuth was chosen to attend a National Summit on Nursing Capacity held in Washington, DC recently that brought nurse experts and leaders from Wisconsin together over two days in June to develop a plan to increase capacity and ensure that the state’s future nurse workforce needs will be met. Warmuth said during the Summit, the Wisconsin constituents determined that accurate data useful for workforce planning surfaced as one of the most pressing needs.

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The Towers Perrin report confirms other recent analyses that show that historically high Wisconsin costs, as compared to the rest of the nation, have moderated significantly over the past few years. In fact there is now only a 7 percent differential, and that gap may be whittled down again in 2008 if projected cost increases are realized (Wisconsin costs are estimated to increase at levels lower than the national average).

The report concludes that the lower cost trending is due to: 1) Improved negotiations with provider networks; 2) Proactive management of employee and dependent health status (a relatively recent phenomena for many organizations); and 3) Encouraging a "consumer focus" by creating new plan designs that encourage personal involvement in decisions about health care usage.

In alignment with this positive trending, the Wisconsin Manufacturers and Commerce (WMC) has produced a series of "best practice" papers (http://www.wmc.org/healthcare/index.php?page=68) that highlight specific efforts being taken by Wisconsin employers to reduce their own health care costs. Organizations being profiled include: West Bend-based Serigraph, Inc.; Fort Atkinson-based Highsmith; and Bellin Health, Green Bay. The common denominator? These progressive organizations determined that they absolutely can reduce their health care costs by engaging their employees….and it’s working!!

Some might suggest that this is REAL (and SUSTAINABLE) HEALTH CARE REFORM. And the efforts are fully consistent with WHA Access and Coverage Principles and issue priorities identified during recent WHA Board discussions.

Steve Brenton
President

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Final cut-off for hotel reservations: August 22
Conference registrations due: September 3

Health services and education are projected to add nearly 92,600 new jobs over the next 10 years, the greatest number of new jobs of any industry sector, according to the most recent Job Outlook Report released by Wisconsin’s Office of Economic Advisors (OEA). The report gave top billing to the fact that nearly one million jobs will open in Wisconsin between 2006 and 2016. One third of those jobs will be new, while two thirds will be replacement positions for retiring baby-boomers.

The report indicates that aging baby-boomers will drive up the demand for health care and assistive services, which will create 81,400 new jobs over the next decade. In addition, workers will be needed to fill replacement job openings as existing health care practitioners retire.

Health care support occupations will be the fastest growing job category with an anticipated 22 percent increase over the 10 year period. Registered nurse is the only top-ten occupation where new jobs outpace replacement openings with an anticipated 21,820 new RN positions created within the next decade.

WHA’s Judy Warmuth described the report as containing both "good news and bad news" for Wisconsin.

"While some industries are declining and offer fewer opportunities for employment, health care will continue to add jobs and lend strength to the employment market," Warmuth said. "The bad news is that hospitals will be challenged to find an adequate number of prepared applicants to fill the large number of projected positions in our industry."

Want to learn more about a specific topic, but just can’t get away from your hospital for the day? Need to educate several members of your staff but the budget is tight? Then one of the many Webinar and audioconferences offered by WHA over the next few weeks may be for you. A variety of topics are available, with more to come, and you can gather numerous staff members in one room to "attend" for one economical price of $295.00 per phone line. Prior to the event, you will receive dial-in information and supporting materials, which you can then distribute to all of your participants.

The Webinars and audioconferences available in the next six weeks include:

Chargemaster: Understanding Revenue Codes
Date: August 12 Time: 8:30 – 10 a.m.

New Models for Hospital-Physician Partnership
Date: August 12 Time: 11 a.m. – 1 p.m.

How to Protect Your Hospital From the Anesthesia Shortage
Date: August 13 Time: 10 - 11:30 a.m.

Creating an Operational Early Warning System
Date: August 14 Time: 1:30 – 3 p.m.

Disruptive Behavior Impacting Quality & Safety: What Hospitals Need to Know About New Joint Commission Standards
Date: August 14 Time: 9:30 – 10:30 a.m.

Hospital Discharge Planning: Best Practices to Reduce Preventable Re-admissions
Date: August 21 Time: 9 – 10 a.m.

Creating Service Excellence and Patient Relations
Date: August 19 Time: 9 – 10:30 a.m.

Conducting a DRG Audit
Date: August 28 Time: 10 – 11:30 a.m.

The Challenges of Providing Psychiatric Services
Date: September 9 Time: 10 – 11:30 a.m.

Preventing Patient Movement-Related Injuries at the Bedside
Date: September 11 Time: 12 – 1 p.m.

The Immigration Crisis Continues: Is Your Hospital Ready for 2009 and Beyond?
Date September 11 Time: 1 – 2:30 p.m.

Diversity and Inclusiveness: One Organization’s Journey
Date: September 16 Time: 12 – 1 p.m.

Researching Coding and Billing Compliance Issues
Date: September 16 Time: 8:30 – 10 a.m. (CST)

Strategies on How to Ask Patients for Money
Date: September 18 Time: 1:30 – 3 p.m.

For more information about any of the sessions or to register on-line, visit the education section of WHA’s Web site at www.wha.org. Advance registration is required to ensure delivery of instructional materials and call-in instructions, which will be distributed prior to the event date. For registration questions, contact Lisa Geishirt at 608-274-1820 or email lgeishirt@wha.org.

If you are interested in a quick monthly reminder of upcoming WHA education offerings right to your e-mail box, you can subscribe to WHA’s e-newsletter, Education Insider, by contacting Lisa Geishirt at lgeishirt@wha.org.

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The IPPS final rule for FFY 2009 includes quality provisions that will significantly change Medicare payment and reporting requirements over the next several years. In addition, the final rule incorporates mandates contained in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), which was enacted on July 15, 2008. Due to the timing of this legislation, CMS was unable to recalculate the FFY 2009 wage index values and rates in time for publication of the final rule. Therefore, CMS has indicated that they will re-issue the final FFY 2009 wage index values and other related tables in a separate Federal Register notice. This will affect wage index values, standardized amounts, relative weights, offsets, the outlier threshold, and budget neutrality adjustments.

- Marketbasket Update: Although CMS is providing a full marketbasket update of 3.6 percent for FFY 2009, the standard rate will only increase by 2.7 percent due to a legislatively mandated 0.9 percent reduction to account for anticipated coding improvements under the new Medical Severity Diagnosis-Related Groups (MS-DRGs) and adjustments for budget neutrality. In addition, a 2.0 percentage point reduction will be applied for hospitals that do not submit quality data as required by the Deficit Reduction Act of 2005 (DRA).

- Quality Measures: Hospitals will be required to report 30 measures in order to receive the full marketbasket update in FFY 2009, compared to 27 measures in FFY 2008. The three additional measures, which were endorsed by the National Quality Forum (NQF), include Pneumonia 30-day mortality, SCIP Infection 4: Cardiac Surgery Patients with Controlled 6 a.m. Postoperative Serum Glucose, and SCIP Infection 6: Surgery Patients with Appropriate Hair Removal. For FFY 2010 Medicare payment determination, CMS will expand the number of required inpatient quality measures to 42. CMS had proposed an increase to 72 measures.

- Hospital Acquired Conditions (HACs): CMS, in the proposed rule, solicited comments on nine additional HACs that could affect payment in FFY 2009. Based on the comments received, CMS added four conditions in the final rule, increasing the number of HACs from 8 to 12. Therefore, effective October 1, 2008, hospital claims with one of 12 selected hospital-acquired conditions may be reimbursed at a reduced MS-DRG level if the condition was acquired in the hospital.

- Section 508 Reclassifications: Per MIPPA, Section 508 reclassifications, which were due to expire on September 30, 2008, will be extended through September 30, 2009.

- Wage Index Reclassifications: CMS has adopted its proposal to revise the average hourly wage (AHW) comparison criteria used in determining whether a hospital is eligible for reclassification to another geographic location. However, CMS will provide a two-year transition period for this revision, beginning in FFY 2010. For FFY 2010, CMS will restrict reclassifications by increasing the comparison benchmarks to 86 percent for urban hospitals and to 84 percent for rural hospitals. The group reclassification test will increase from 85 to 86 percent. For reclassifications beginning in FFY 2011, the new average hourly wage comparison criteria will be fully phased-in, increasing the benchmarks to 88 percent for urban hospitals and to 86 percent for rural hospitals. The group reclassification test will increase to 88 percent. These changes affect new reclassifications beginning with the FFY 2010 wage index and will not affect existing reclassifications.

- Indirect Medical Education for Capital: Last year, CMS adopted a policy to eliminate the capital teaching adjustment over a three-year period beginning October 1, 2007. CMS maintained the current adjustment in FFY 2008. In the final rule, CMS confirms that they will reduce the teaching adjustment by 50 percent in FFY 2009 and eliminate the teaching adjustment completely in FFY 2010. WHA has been working with our congressional delegation on this issue and comment letters opposing this provision have been sent to CMS from both the House and the Senate.

- Sole Community Hospitals (SCHs): Per MIPPA, SCHs with cost reporting periods beginning on or after January 1, 2009 will be paid based on their FFY 2006 hospital specific rate if it yields the highest payment compared to using the Federal rate or to their hospital-specific rate based on 1982, 1987, or 1996 costs.

- Post-Acute Transfers to Home Health Services: Based on comments from WHA and others, CMS rejected a proposal that would have extended the time period for when the post-acute transfer policy would apply to an acute care discharge to a home health care provider from three days to seven seven days. However, CMS has stated that they will continue to monitor this issue and could address it in future years.

- Rural Floor and Imputed Floor Budget Neutrality: CMS will change their policy as proposed and begin to apply the rural floor budget neutrality adjustment at the state level instead of the national level. This will decrease payments to those states that have the most hospitals receiving the rural floor and increase payments to other states. CMS will provide a three-year transition for the new policy. In FFY 2009, hospitals will receive a blended wage index of 20 percent of a wage index with the State level budget neutrality adjustment and 80 percent of a wage index with the national budget neutrality adjustment. For FFY 2010, the blended wage index will reflect a 50 State level adjustment and 50 percent national adjustment. In FFY 2011, the adjustment will be based entirely on 100 percent of the State level methodology.

- Cost Report Changes: CMS will revise the Medicare cost report to help improve the data CMS uses to determine DRG weights. In the final rule, CMS is adopting a proposal to split the current cost center for Medical Supplies Charged to Patients into one line for "Medical Supplies Charged to Patients" and another line for "Implantable Devices Charged to Patients." However, CMS rejected proposed criteria that would have established complex rules for determining the devices that could be reported on the new line. Instead, CMS accepted recommendations that the determination be done through use of existing revenue codes.

Based on comments received from WHA and others, CMS in the SNF PPS final rule for FFY 2009, has postponed a rate recalibration that would have reduced payments by 3.3 percent.

In its proposed rule, CMS indicated the expanded Resource Utilization Groups (RUGs) (implemented in FFY 2006) resulted in an unexpected and inappropriate increase to SNF payments because more patients were classified into the newly created RUGs than CMS had originally estimated. CMS further stated that much of the increase was due to coding behavior changes and not actual changes in SNF patient acuity. As a result, CMS had proposed to apply a 3.3 percent reduction to FFY 2009 SNF payments. Under the final rule, this reduction will not be implemented in FFY 2009.

- Marketbasket Update: CMS will apply a full marketbasket update of 3.4 percent for FFY 2009.

The IRF PPS final rule for FFY 2009 includes a series of payment policy changes to implement provisions of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). Most important, MMSEA rolled back the phase-in of the "75 percent rule," a requirement that at least 75 percent of admissions to an IRF be for one of 13 specified conditions. WHA, the American Hospital Association (AHA), the American Medical Rehabilitation Providers Association, and the allied associations had worked for several years to see Congress address this.

- Compliance Threshold: CMS will set a 60 percent compliance threshold (60 percent of patients must need treatment for specified conditions) for cost reporting periods beginning on or after July 1, 2006.

- Patient Comorbidities: CMS will allow the inclusion of patient co-morbidities as qualifying conditions toward the compliance threshold for cost reporting periods beginning on or after July 1, 2007.

- Marketbasket Update: CMS will apply a zero percent marketbasket update beginning April 1, 2008 through September 30, 2009 as required by MMSEA.

- Patient Classification System: CMS will update the Case-Mix Group (CMG) weights and average lengths of stay (ALOS) using claims data from FFY 2007 replacing the FFY 2003 data that i currently used.

U.S. residents made 1.1 billion visits to physician offices and hospital outpatient and emergency departments in 2006, a 26 percent increase over 1996, the Centers for Disease Control and Prevention reported recently. According to the CDC, in 2006 approximately half of all non-obstetrical hospital inpatient admissions occurred through the emergency department, up from 36 percent in 1996. Most ED visits occurred after regular business hours, defined as between 8 a.m. and 5 p.m. weekdays, and the average wait time to see a physician in the ED was nearly 56 minutes.

The data come from various components of CDC’s National Center for Health Statistics National Health Care Survey and are featured in a series of new National Health Statistics Reports. Some of the findings include:

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Jadea Mack’s childhood ended early – stopped in its tracks by a still-unknown gunman who shot her in the right calf for no apparent reason when she was only 10 years of age. Her ability to run away from him may well have saved her life.

Jadea was haunted afterward by sleeplessness and fear, all punctuated by the thought that the criminal might return.

But Jadea was not alone. While still hospitalized, she received a visit from a member of Project Ujima. Unbeknownst to her at the time, Project Ujima was about to have a major influence in her life.

In the beginning, none of it was easy. There were many visits from therapists and counselors, but in the words of Andrea Mack, Jadea’s mother, Project Ujima "got right on it," helping Jadea come to terms with the violence that entered her life.

How? By involving her with others who had been victims of violence, by taking her on field trips, providing gifts at holidays, and being available to her when the pressure was too much to bear. "They were wonderful with a consistent schedule of contacts with Jadea and our family," said Andrea.

Founded in 1996, Project Ujima is the only program of its kind in the state. With a commitment to help those who have been victims of violent crime, Project Ujima works to reduce the number of violent crimes by providing hospital, home-based and community services to approximately 300 youth and 500 adult victims of crime in southeastern Wisconsin each year. It is the result of a collaborative effort of Children’s Hospital of Wisconsin, the Medical College of Wisconsin and Children’s Service Society of Wisconsin. It was initiated after nurses at Children’s Hospital saw a young man repeatedly brought to the emergency department. On separate occasions, he had been stabbed and shot, and eventually died from his injuries. Their concerns about repeat violence led to the creation of Project Ujima.

Since 1996, more than 2,000 adolescents with violent injuries have been treated in the Emergency Department at Children’s Hospital. The link between violence and psychological trauma, poor school performance, criminal detention and repeat violence literally cried out for services such as Project Ujima – a network that assists with physical, psychological and social recovery.

For Jadea, her relationship with Project Ujima has been strong throughout the years since the unknown gunman took away her sense of security. Working with Project Ujima has helped her regain her self-esteem, has given her a place to meet with others who understand what she has been through, and the opportunity to help others coping with the many effects of violence. A Project Ujima liaison even worked closely with her to resolve a conflict with one of her teachers at school. She attends regular meetings with peers and also has participated in leadership conferences where such issues as HIV, teen pregnancy and STIs are discussed.

Today, Jadea plays a more significant role in Project Ujima as a project spokesperson who goes into the community to "tell her story," explaining to others the value of a program that has stood by her as she moved from childhood through adolescence. Jadea now is poised to graduate from the Milwaukee High School of the Arts and head off to college.

While she enjoys the support of a loving mother and three siblings, Jadea has never underestimated the importance of Project Ujima in her life. "They’re my second family," she says, "and I love them all."

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"The Governing Board, administration and staff of Hayward Area Memorial Hospital and Hayward Nursing Home have always strongly believed in, and promoted, education," said Barbara Peickert, CEO of the local health care facility. "Their commitment to learning is strong and is evidenced by the number of students that have come to us for work experience or to shadow," she said.

Hayward Area Memorial has a supervised student program. Students are accepted from high schools, vocational/technical schools and colleges/universities. Individuals who are accepted by the hospital or nursing home go through a complete orientation that includes facility policies, codes, HIPAA instruction and more. Health records are checked and each receives a tour of the buildings. They are supervised by a qualified staff member in each department they are placed in. Everyone who enters the program is expected to complete an exit interview at the completion of their allotted time.

At the first level, the student program coordinator accepts young people from Hayward High School and other area high schools through educational offerings such as Education for Employment (E for E) class and the Work Experience Program. Students in the E for E course are placed in each clinical department for one-two weeks. They "shadow" the staff in their assigned department for one hour each day for a full semester of school. In the Work Experience program, they are placed in one department—normally a non-clinical area—for the semester. Some students are hired while they are in high school after their work/shadow sessions are completed. One special needs student is in her sixth year of work in the laundry department.

Post high school students are accepted for job shadowing experience, EMS work experience, preceptorships and internships. Graduate students and medical students have also come to Hayward Area Memorial to learn.

At times, the small, rural facility may have as many as five or more students on different schedules in different departments. Schedules are arranged so patients are not overwhelmed with too many people providing/observing their care.

"We feel as if the time and dollars we put into this program benefit our community greatly," said Peickert. "We’ve had students in almost every department including administration, and many of these bright young people have come back here to work after completing their education," she said. "Our employees are great instructors and understand the need to teach those that will become the caregivers in the future."

Thanks to the cranked-up volume of modern life and a maturing population, hearing loss is becoming a major health problem. Hearing loss afflicts more than 30 million adults, children, and infants in the United States. According to conservative estimates, the number is expected to top 50 million by year 2050.

More than 20 million working adults ages 18-64 endure hearing loss. If unrecognized and untreated, it affects their quality of life, and their ability to communicate and interact effectively with customers and coworkers.

A hearing problem can hinder a child’s self-esteem, language development, and ability to learn. Studies indicate more than five million kids have hearing damage from amplified sounds.

In addition to noise exposure, common causes of hearing loss include disease, unintended affects of certain prescription drugs, and aging.

In addition to the obvious culprits – portable media players, cell phone ear pieces, gaming headsets – here’s a look at common noises that affect hearing, and the amount of time it can take for damage to occur:

Rock concert – 9 seconds
Leaf blower – 90 seconds
Snowmobile – 15 minutes
Hand drill – 23 minutes

Employers know the value of competitive benefits that demonstrate concern for employees and their families. A hearing benefit is not only an inexpensive way to enhance your benefits package, it also helps people develop proactive habits for hearing health, prevent future problems, and receive needed treatment.