At a February 11 news conference, Governor Jim Doyle and legislative leaders announced a package of proposals, including a hospital assessment, which would help ease the state’s $600 million budget shortfall for the current biennium (ending 6/30/09). The hospital assessment will bring more federal dollars back to Wisconsin, improve Medicaid payments to hospitals and provide funding for essential health care programs during one of the most challenging economic times in Wisconsin history.

The hospital assessment was just one of many proposals included in the Governor’s package. In a letter to legislators, Doyle said his plan also includes adoption of the national Streamlined Sales and Use Tax project, authorizing combined reporting of corporate income, both of which will generate additional revenue for the state. The package also includes $125 million in cuts to state operations, tax credits for high tech and agriculture industries, and several other provisions.

Wisconsin hospitals have been hit hard by the recent economic downturn. Charity care and bad debt increased by 20 percent over the past year (equaling $85 million at cost), and reports from the field suggest this trend is worsening. Medicaid utilization is also increasing and the combination of these factors, left unaddressed, will jeopardize access to important health care programs in communities all across the state. Importantly, a portion of the assessment will be used to implement statewide health coverage for low-income, uninsured childless adults, a key addition to the Wisconsin health care safety net during these difficult times.

The hospital assessment would provide hospitals with the first increase in Medicaid reimbursement in more than a dozen years. The near complete absence of payment increases over that time means today hospitals are paid less than half of what it costs to serve Medicaid patients. That has fueled a $600+ million annual shortfall between what it costs to treat patients and what the Medicaid program pays hospitals. These losses are being passed on to everyone else, resulting in higher health care costs. The hospital assessment and the matching federal dollars it will bring will result in higher payments that will begin to reduce that burden. Twenty-two other states use this mechanism to bring federal tax dollars back to their states.

According to WHA Executive Vice President Eric Borgerding, "Governor Doyle and Legislative Leaders are taking an important and necessary step forward with this proposal. It will bring Wisconsin’s fair share of federal health care dollars back to the state and use them to better fund necessary health services for hundreds of thousands of patients and families. The Wisconsin Hospital Association is committed to working with the Doyle Administration and the Legislature to advance this necessary initiative."

Due to the retroactive nature of the proposal, time is of the essence.

"WHA is urging legislators to act quickly on the plan so it can be applied retroactively beginning fiscal year 2009, which started July 1, 2008," according to WHA Executive Vice President Eric Borgerding. "If too much time passes, the proposal would be too disruptive to cash flows if it were applied to fiscal 2009," he said.

Congressional conferees reached a deal on the American Recovery and Reinvestment Act this week. Detailed language of the bill—including language on provisions of priority concern to WHA—was unavailable at time of The Valued Voice printing. The following are the broad highlights of the negotiated compromise.

• $86.7 billion in temporary Federal Medical Assistance Percentage increase
• Funding distributed to states for a 27-month period through 2010
• Across-the-board increase to states of 6.2 percent
• Additional bonus based on state’s increase in the unemployment rate
• $19 billion for Health Information Technology (HIT)
• Provides for HIT incentive payments for Prospective Payment System and Critical Access Hospitals (CAHs). WHA advocated strongly that CAHs have access to the same incentive payments as their PPS counterparts. WHA thanks Wisconsin’s Congressional Members for their support of this provision.
• Phases in Medicare payment penalties for physicians and hospitals not using electronic health records starting in 2014.
• Establishes process led by Office of the National Coordinator for Health Information Technology to develop national standards.
• Provides $2 billion in immediate funding for HIT infrastructure, training, dissemination of best practices, telemedicine, inclusion of health IT in clinical education and state grants to promote health IT.
• Moratoria on Medicaid regulations (through 06/30/09)
• targeted case management
• provider taxes
• school-based administration and transportation service
• hospital outpatient services
• Indirect Medical Education Capital Payments. Blocks FY 09 Medicare payment reduction to teaching hospitals related to capital payments for IME.
• Tax-exempt Bonds. Proposal allows banks to deduct 80 percent of the cost of buying and carrying tax-exempt bonds issued in 2009 and 2010, up to $30 million per borrower.
• 60 percent, nine-month COBRA premium subsidy for eligible workers
• Administered by Treasury; allows employers (or health plans if they administer COBRA benefits) to receive a credit against payroll taxes.
• Incomes above $125,000 (single) or $250,000 (couples) not eligible.

This week Governor Doyle estimated that the federal stimulus package would result in a total of $3.5 billion for Wisconsin, including $2 billion for health care, education and other state government. In late January, Doyle also created the Office of Recovery and Reinvestment in anticipation of federal dollars. That office is preparing to move the money out the door quickly for worthy projects that immediately jumpstart job creation, maintain jobs and invest in long-term economic growth in Wisconsin. The Web site allows individuals to submit ideas for worthwhile projects for federal stimulus dollars.

Access information on the Office of Recovery and Reinvestment at www.recovery.wisconsin.gov.

Advocacy Day is on April 1 (just over six weeks away) and falls right during action on the state budget. Make sure you are assembling your contingent of hospital staff, trustees and volunteers today for this important event.

With so much happening at the state and national level, you cannot miss this day. Hear from keynote speaker Rick Pollack, executive vice president of the American Hospital Association, on what President Obama and Congress are proposing for health care. Then learn from Governor Doyle (invited) and state legislators about health care issues pending in Madison.

You will be able to use this information and the WHA legislative issues briefing when you meet personally with your legislators or their staff later that afternoon. Having hundreds of hospital employees, trustees and volunteers take what they’ve learned during the day and put it into action by meeting with their legislators that afternoon is essential to having the voice of hospitals heard.

Register today and plan to join 600 of your peers from across the state in Madison at Advocacy Day 2009 on April 1. Online registration and full details are available at www.wha.org/governmentRelations/advocacy_day.aspx.

It may be hard to believe but it was just two years ago almost to the day (February 13, 2007), that Governor Doyle’s 2008-09 Biennial Budget proposed an assessment on hospitals. That initiative was strongly opposed by WHA. Twenty-four months later, we are just days away from seeing the passage of a significantly reworked assessment initiative supported by WHA and by major business organizations with a track record of vigorously opposing "tax" increases. The world changed.

Wisconsin hospitals opposed the original assessment initiative for many reasons, not the least of which was the fact that it had been cobbled together absent necessary discussions with WHA. Additionally, aspects of the legislation were unapprovable by CMS, thus undermining important features of the proposal and creating a huge list of hospital "losers." Perhaps most importantly, we believed lawmakers would support payment increases with dollars generated by higher tobacco taxes. We were proved wrong on the last point. It’s been well over a decade since hospitals received a Medicaid payment increase financed by general revenue, and the potential for that fact to change anytime soon is nil.

As mentioned earlier, the world changed. Today, we stand as partners with the Doyle Administration and are urging prompt passage of a measure that represents a rare WIN—WIN—WIN for WISCONSIN.

The hospital assessment initiative currently included in the Wisconsin Economic Stimulus bill aligns with all aspects of WHA Board-approved principles that have been previously discussed on this page. Wisconsin hospitals will see a net Medicaid payment increase of $200 million annually—new dollars from Washington that can help backfill recent losses caused by skyrocketing charity care and bad debt that are occurring in the most difficult economic environment seen in a generation. The increased funding will also modestly reduce cost shifting Medicaid losses, provide necessary support for the growing Medicaid budget deficit, and help pay for early statewide implementation of the important Medicaid Childless Adults expansion. Forty thousand chronically-uninsured citizens will soon have coverage.

Now, it’s time to get it done. The legislation is being fast tracked, in part, because the logistics of collecting 12 months worth of assessment in just four months while making supplemental payments for fee-for-service and HMO claims retroactive to July 1, 2008 is a daunting task. But it is doable and plans to cash flow the supplemental payments and the assessments are in place and ready to go.

It’s also time to remove the politics from the hospital assessment/tax discussion and recognize the fact that this WIN—WIN—WIN for WISCONSIN is a rare opportunity that comes at a most challenging time for all Wisconsin stakeholders.

Steve Brenton
President

On Friday, February 6, the Centers for Medicare & Medicaid Services (CMS) announced the two companies that unsuccessfully bid to become Medicare recovery audit contractors (RACs) had withdrawn their bid protests, allowing the Medicare RAC program to proceed. CMS is now moving forward with a two-stage implementation of the program nationwide.

As we alerted WHA members last November, the protests filed by two companies (PRG Schultz and Viant) had placed a temporary hold on all RAC-related activities. In resolving the bid challenge, CMS announced that these two companies will now serve as subcontractors to the four permanent RACs which were named last year. The four permanent RACs are (Wisconsin is in Region B):

Region A: Diversified Collection Services (DCS)

Region B: CGI

Region C: Connolly Consulting, Inc.

Region D: HealthDataInsights, Inc.

CMS announced that PRG-Schultz will serve as a subcontractor for the RACs in Regions A, B and D and Viant will subcontract with the Region C RAC. PRG Schultz will act as sub-contractor to CGI in reviewing Part A and B claims for Wisconsin. In addition, they will also be the sub-contractor reviewing Home Health and DME claims for Region B.

RAC Two-Stage Rollout

Due to the bid challenge and accompanying delay in implementation, CMS has decided to condense the RAC rollout into two stages. RAC audits are slated to come to Wisconsin August 1 or later.

Prior to RAC activity, CMS and state hospital associations will host RAC educational sessions for hospitals, and RACs will be required to complete several administrative actions. These include: receiving and processing CMS claims data; entering into joint operating agreements with the claims processing contractors in each state, such as CMS-contracted fiscal intermediaries and Medicare administrative contractors (MACs); and requesting CMS approval through the "new issue review process," which grants authority for widespread automated or medical necessity review, on a per RAC basis and for each type of claim to be targeted for review.

WHA continues to offer a variety of education options focused on preparing for RAC audits and the issues surrounding them. On February 26, an audio conference will be offered entitled "Utilizing Observation to Reduce Exposure with One-Day Stays." On March 19, a second audio conference is scheduled, entitled "An Operational Guide to the RAC Appeal Process." You can learn more about these sessions or register online at www.wha.org/education/RAC2-2009.aspx.

For more information on the RAC program, visit www.aha.org/rac.

Marc Edwards, MD, principle, Wilson-Edwards Consulting, presented the findings of the National Peer Review Practices Survey to the Medical and Professional Affairs Council at their February 12 meeting in Madison. The survey was completed by 339 hospitals in six states including 59 hospitals in Wisconsin. The goal of the survey is to begin to systematically document hospital-based peer review structures, processes and governance and evaluate the influence these elements have on the quality of care and provider satisfaction.

"Despite the fact that all hospitals support peer review programs, there has been very little research done to evaluate the influence of these programs on the quality of care," Edwards acknowledged.

The study identified wide variation in peer review programs nationwide with more robust programs having a greater perceived impact on quality and safety. In addition, the study points toward the emergence of a quality improvement model for peer review, as opposed to a punitive model, as a new frontier for quality improvement.

"The national survey suggested that more than 35 percent of physicians in the survey sample view their hospital’s peer review process as less than satisfactory," according to Charles Shabino, MD, WHA senior medical consultant. "There seems to be a higher level of satisfaction when the process recognizes outstanding clinical performance and not just sub-standard care. Unfortunately, less than five percent of reporting hospitals recognize exceptional care as part of their peer review process," he added.

The Council also heard from Dana Richardson, WHA vice president, quality, about improvement projects that Wisconsin hospitals are currently participating in including the "Color of Safety: color-coded alert standardization project," the Wisconsin Pressure Ulcer Reduction and Prevention Project and the Rural Hospital Stroke Improvement project. In addition, Richardson outlined an upcoming national improvement collaborative called STOP BSI (blood stream infections) that hospitals with intensive care units will have the opportunity to participate in through WHA. The STOP BSI collaborative will begin in June 2009, and is co-lead by Johns Hopkins University Quality and Safety Research Group in partnership with the Michigan Health & Hospital Association Keystone Center. The aim of this project is to eliminate central line associated blood stream infection across the United States.

The Concordia School of Pharmacy is on on-track to admit their first class in September 2010 and they continue to fill academic positions. The dean position has been filled by two individuals: Former State Representative Curt Gielow serves as executive dean and assistant professor of pharmacy practice; and Dean Arneson, PharmD, PhD, is the academic dean and associate professor of pharmacy administration. Currently, the program advisory committee is interviewing candidates for two chair positions; pharmaceutical sciences and pharmacy practice. Gielow said they have attracted exceptional candidates for both positions.

Fundraising for a School of Pharmacy building is progressing, but the timeline for admission and opening the program will be maintained regardless of the building’s status.

The Pharmacy Program Advisory Committee continues to be enthusiastic and supportive of the program. WHA’s Judy Warmuth serves on the advisory committee along with representatives from Aurora, ProHealth, and Ministry, as well as representatives from the retail pharmacy industry.

"We are pleased that Concordia continues to make progress in creating another School of Pharmacy in Wisconsin considering that pharmacists are among the most difficult positions to fill in Wisconsin hospitals," Warmuth said.

Hospital representatives traveled to Madison for 2009 Business Day, the same day Governor Doyle announced that his proposed economic stimulus package would include a WHA-backed hospital assessment.

The WHA government relations team provided hospital attendees an issues briefing on the hospital assessment, community benefits, transparency initiatives and nursing workforce issues. Attendees like CEO Dave Fish and Division Manager Skip Gjolberg of St. Joseph’s Hospital in Chippewa Falls used the opportunity to then walk up to the State Capitol and meet personally with their newly-elected legislator, Rep. Kristen Dexter, to discuss these important issues.

Hospitals are vital to the Wisconsin economy and to the economic stability of their communities. As such, WHA participates in Business Day each year.

Representatives from the following hospitals attended Business Day 2009: Children’s Hospital of Wisconsin, Fort HealthCare, Franciscan Skemp Healthcare, Gundersen Lutheran, Holy Family Memorial Medical Center, Meriter Hospital, Ministry Healthcare, Saint Joseph’s Hospital—Marshfield, St. Joseph’s Hospital—Chippewa Falls, St. Nicholas Hospital, Sacred Heart Hospital and UW Health Partners Watertown Regional Medical Center.

Take advantage of nationally-recognized, CME-qualifying education offered in-state for your new or seasoned physician leaders—great education at a fraction of the travel and registration costs of out-of-state events.

Reminder: Deadline for the group rate at The American Club: February 20

At a Milwaukee County Board of Supervisors meeting this week, WHA was one of four organizations recognized for energetic advocacy on behalf of the General Assistance Medical Program (GAMP).WHA has been actively involved on several fronts in helping to sustain the program since its inception over a decade ago. As of 1/1/09, all 12,400 GAMP patients have been transitioned into the new BadgerCare Plus for Childless Adults program.

Since GAMP’s inception in 1997, WHA has played a leadership role over the years in crafting three intergovernmental transfers that saved millions of dollars of county revenue by drawing down additional federal funds to sustain the program.

"As the only true safety net program for a very vulnerable population, GAMP’s capacity to stay afloat was enhanced with the work of WHA and Association staff," said Bill Bazan, vice president, Metro Milwaukee for WHA. "At one time or another, we were able to provide needed interventions with the state and the county board in order to sustain GAMP in very tight economic times."

In addition to WHA’s recognition, Joy Tapper and the Milwaukee Health Care Partnership were recognized for their work in transitioning GAMP patients into the BadgerCare Plus program.

The Wisconsin Society of Healthcare Human Resource Administration (WSHHRA) will host its annual conference for human resource professionals from April 22-24, at The Abbey Resort in Fontana. The conference will open with a keynote session focused on accountability and turning limited resources into results, presented by Liz Jazwiec, a nationally-renowned presenter and faculty speaker for The Studer Group. A variety of timely concurrent session topics will be offered, as well as the important annual legislative and legal updates.

Anyone who has human resource responsibilities in a health care organization will benefit from the educational agenda and is welcome to attend. Attendance is not limited to current WSHHRA members. An ‘early bird’ discount is available for registrations received by March 6, and group discounts for three or more from the same facility are also available. In addition, the program will be submitted to HRCI for continuing education/recertification credit.

Nurse anesthetist positions are difficult to fill in Wisconsin hospitals, especially in rural areas. The Franciscan Skemp Healthcare School of Anesthesia, which has an academic affiliate agreement with the University of Wisconsin-La Crosse, has added Sauk Prairie Hospital as its sole rural clinical experience. Traditionally, clinical experiences for this program have been completed at large hospitals, while the major place where CRNAs practice is in small, rural hospitals. By adding Sauk Prairie as a clinical site, the students can now complete their clinical in a location that more closely matches the environment where they will eventually practice.

At Sauk Prairie Hospital, the CRNA students will:

• Practice in a smaller and rural setting
• Experience supervision by CRNAs, rather than physicians
• Experience the full scope of CNRA practice, including a variety of pain management interventions
• Be more likely to set up practice in a rural area upon graduation

Judy Warmuth, WHA vice president, workforce, praised the arrangement.

"We know these professionals will be more likely to locate their practice in a rural area if they have first-hand experience working in that setting before they graduate. This program is a good example of how rural hospitals can support students and schools by providing clinical practice sites in exchange it is hoped that many of these students will stay in rural areas after they complete training," according to Warmuth.

Congratulations to the Franciscan Skemp School for seeking this new clinical arrangement for their students.

Your risk management staff has been working hard to implement risk prevention and patient safety solutions, and to promptly deal with adverse events, serious patient complaints, and perhaps pending claims. In addition, you want to adhere to the CMS "never event" reimbursement rules. Furthermore, your next State/CMS/Joint Commission survey is only six months away.

How will you react if your risk management director becomes ill or decides to leave the position? Meeting ongoing demands requires a capable leader who can promptly step in and juggle complex responsibilities.

In this challenging situation, it may be your best strategy to consider an accelerated training program for a new risk manager and/or engage an interim senior risk professional who keeps your organization moving in the right direction. An experienced interim risk professional can serve as mentor for new staff while ensuring that your risk and patient safety program stays fully operational without potential adverse consequences of a temporary vacancy.

For more information regarding vacancy management solutions, contact The Risk Management and Patient Safety Institute at 888-466-4272 or Matt Wahoske with FinCor Solutions at 608-469-8590.

Ministry Health Care, Saint Mary’s Hospital and Ministry Medical Group hosted their second annual Community Health and Wellness Fair Saturday, April 26 from 8 a.m. to 1 p.m. at the Saint Mary’s Hospital campus in Rhinelander. One hundred fifty-seven health care professionals, volunteers and community partners came together to share health related information and to offer FREE screenings for the community. Ministry Health Care, Saint Mary’s Hospital, Saint Mary’s Hospital Foundation and Ministry Medical Group were the sponsors for this event.

More than 700 community members and visitors attended. One hundred eighty-three blood sugar tests were done, 190 cholesterol panels and 89 PSA Prostate screens; 48 people participated in the skin cancer checks, 69 throat and 50 hearing screens were completed, 28 breast health exams were given, 28 pints of blood were donated to the Community Blood Center, 62 pounds of pharmaceuticals and containers were collected for disposal and multiple boxes of non-perishable food items were donated to the Rhinelander Area Food Pantry.

Planning is underway for the third annual Community Health and Wellness Fair scheduled for Saturday, April 25, 2009.

"I think many students have been inspired to look into nursing and/or surgical technician jobs as a result of this program," said Jean Pirkey, Instructor, Alverno College Nursing program. Jean’s comment follows a series of presentations at Riverside University High School by Sherie Ponting, RN, director of surgery for The Wisconsin Heart Hospital.

Ponting was invited to do an all-day series of presentations at the school’s annual Health Fair in March. Assisted by Diane Coolidge, RN from the Wheaton Franciscan Healthcare Community Health, Wellness and Education, the two presented several hour-long programs throughout the day. The highlight of the presentation was the interactive demonstration of the use of scalpel and suturing techniques and look at a life-size swine heart with an implanted mitral valve repair. The swine heart is much like a human heart.

"One of my seniors made a comment about how proud she was of herself that she ‘didn’t fall apart’ when she visited your booth!" said Karen Lustig, Wellness Services Program Director/Family & Consumer Education, at Riverside." She wants to go into nursing, but wasn’t certain if she could tolerate the tough stuff!"

Probably most memorable is Ponting’s presentation to two different special needs classes. The Alverno College Nursing Department representatives had tears in their eyes as they watched the joy of the students as Sherie interacted with them.

"I was especially touched by the extra attention that your group gave to students with disabilities and cognitive challenges. They were able to participate and feel a part of the demonstration. I am sure they will be talking about this experience for a long time," Pirkey said.

"There is such a need for nurses and others who care about teens at this school. I truly believe that we can make a difference in their lives." Pirkey said.

Margaret Hahn recently joined the Caregiver Support Group, a new support network sponsored by Red Cedar Medical Center and the Dunn County Office on Aging. She enjoys the camaraderie of being surrounded by people who are caring for their aging parents.

"It’s been very educational—learning tricks that other caregivers have found helpful and hearing other people’s stories," says Hahn. "It’s beneficial to be a part of a community."

For the next 18 months or so, Hahn, who lives in Iowa, will live in Menomonie. Her 93-year-old mother, Margaret Bark, has Alzheimer’s disease and needs full-time care. When Hahn’s sister, Linda, reaches retirement age in a year and a half, she will move from Alaska to Menomonie to take care of their mother, allowing Hahn to return home to Iowa.

Bark had been in an assisted-living facility. When she began wandering away from the facility, the decision was made that she needed a different environment.

"The next step would’ve been the county care center or a nursing home," says Hahn. "My husband, Allen, and I knew that if Mom went to a place like that, despite the good care, she would probably go downhill quickly."

Hahn has rented an apartment, where she and her mother will live. Hahn handles everything from budgeting and grocery shopping to planning meals and scheduling outings and visits. "It’s pretty much like I remember being a mother to young children," she says. Hahn has two grown children of her own. "It’s rewarding, challenging and, at times, demanding, but I wouldn’t trade it for anything. One of the things that really surprised me about doing this is learning how many people have made this same decision."

Hahn looks forward to the monthly support group meetings and says being part of a group that shares her values means a lot. "It strengthens my ability to keep doing what I know is the right thing by caring for your loved one," says Hahn.

Jane Mahoney, caregiver coordinator for the Dunn County Office on Aging and facilitator of the support group, says the group’s goals are to offer participants a sense of unity, provide information about community resources and support services, and serve as an outlet to express feelings and struggles. "It’s a very stressful thing to be a caregiver for someone," Jane says, noting that many caregivers are also raising children and have existing obligations and commitments.

Nationwide, more than 22 million Americans are characterized as informal caregivers—providing unpaid help to older people who have at least one limitation on their daily living activities (U.S. Department of Health and Human Services, Administration on Aging).

Mahoney says the support group already fills a need in the community. "Caregivers have a place to get the support they need, and local medical professionals have a place to refer caregivers who accompany loved ones to medical appointments," she says. "Participants in the group are grateful for the support. It’s humbling to see how much time, effort and love there is for vulnerable adults in our communities."