June 17, 2016
Volume 60, Issue 24

WHA Meets with CMS’s Slavitt on Physician Payment Reform
Chicago listening session gathers stakeholder input on MACRA

On June 13, WHA participated in an invitation-only meeting with CMS Acting Administrator Andy Slavitt and members of his team to provide input into the development and implementation of the physician payment reforms included in the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). CMS hosted the meeting at its Chicago office with some 20 attendees representing health systems, physicians and clinicians from CMS Region 5. Monroe Clinic Chief Medical Officer Mark Thompson, MD, joined WHA President/CEO Eric Borgerding at the meeting. 

“WHA has received feedback and input about MACRA from a broad spectrum of Wisconsin’s health care system, and we were pleased to carry that feedback to the meeting with CMS Administrator Slavitt,” Borgerding said. “It was a great opportunity for Wisconsin to weigh in directly with CMS, but there is still much work to be done.”

Slavitt opened the meeting by describing CMS’s extensive outreach strategy, emphasizing the need for input and to “get it right” while continuing to move ahead. CMS is in the process of developing rules to implement the payment reforms—known as Alternative Payment Models (APMs) and Merit-Based Incentive Payment System (MIPS)—and is seeking comments through June 27. The rules are expected to be finalized in November, with the program slated to measure performance based on care delivered in 2017—just two months later.

At the Chicago meeting, the tight implementation timeline and steep learning curve was a top concern. Borgerding stated that despite MACRA being a top-of-mind issue for the past several months, it is clear there is still a significant knowledge gap among physicians, clinicians and hospital and health system leaders. With implementation just around the corner, he encouraged CMS to be mindful of the need for even more education and outreach. He noted that Wisconsin is highly integrated and home to innovative local and regional health systems, and that concerns about timing and implementation should not be construed as holding on for the status quo. 

Thompson thanked Slavitt for his commitment to deliver flexibility in the final rule making in addition to assuring alignment around current CMS programs. Thompson suggested this approach to flexibility and alignment be applied to the Comprehensive Care for Joint Replacement demonstration project that many organizations have been mandated to participate in: He stated, “ As we are knee deep in this mandate, it would make sense to add the EHR requirement to this demonstration project which functionally would lead to an on-ramp for an Advanced Alternative Payment Model.”

Borgerding also noted the inherent challenges faced by low-volume and rural providers in satisfying various elements and measures proposed within MACRA. He encouraged CMS to adopt measures that are relevant to rural, low-volume providers and adjusted for their population and geographical characteristics. He pointed to work of the National Quality Forum’s Rural Health Committee (co-chaired by WHA Chief Quality Officer Kelly Court) and its report on Performance Measurement for Rural Low-Volume Providers as a resource CMS should rely on for this purpose. (See the report

Thompson and Borgerding were well prepared to offer comments based on feedback received from WHA members and others over the past several months, including extensive discussion at the WHA Board June 9 (see www.wha.org/pubarchive/valued_voice/WHA-Newsletter-6-10-2016.htm#1) and the WHA Physician Leaders Council in May (www.wha.org/pubarchive/valued_voice/WHA-Newsletter-5-20-2016.htm#10). 

Development and implementation of the new payment models included in MACRA are a top WHA priority in 2016 (see www.wha.org/pubarchive/valued_voice/WHA-Newsletter-5-6-2016.htm#5). In addition to providing input directly to CMS in Chicago this week, WHA provided comments to CMS in November (see www.wha.org/pubarchive/valued_voice/WHA-Newsletter-11-20-2015.htm#4). WHA will also submit comments as a part of the final rulemaking process now underway. Several webinars and other informational sharing opportunities are also in the works as a part of WHA’s comprehensive MACRA strategy (see www.wha.org/pubarchive/valued_voice/WHA-Newsletter-5-20-2016.pdf.) Visit the MACRA section of WHA’s website at www.wha.org/macra.aspx to learn more.

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WHA Comments on DSH, Quality Programs Proposed Changes
CMS FY 2017 Prospective Payment System 

The Wisconsin Hospital Association submitted comments June 15 on the Centers for Medicare & Medicaid Service’s (CMS) proposed FY 2017 Inpatient Prospective Payment System rule. Those comments focused largely on the Medicare Disproportionate Share Hospital (DSH) and Medicare quality programs. 

With respect to DSH payments, WHA highlighted concerns with the accuracy and consistency of the Worksheet S-10 data, which CMS will use. While WHA believes the Worksheet S-10 can provide a more exact measure of hospital uncompensated care costs, it will only do so if reported accurately, consistently and is improved upon. 

To that end, WHA urged the agency to take additional steps to ensure the accuracy, consistency and completeness of these data prior to their use, including auditing and making necessary modifications. One such modification is to adopt a broad definition of uncompensated care costs to include all unreimbursed and uncompensated care costs, such as Medicaid shortfalls and discounts for uninsured.

With respect to quality programs, WHA expressed its support for the movement to a more efficient system for data collection of measures for inpatient quality. WHA also expressed its appreciation that CMS did not propose any new measures that will require manual data abstraction. However, WHA pointed out several issues that needed CMS attention. WHA asked CMS to reevaluate its Sepsis Bundle Measure and expressed caution about the number of electronic submissions of eCQMs that CMS proposed. 

Read WHA’s full comment letter.

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Medical Examining Board Considers New Opioid Rule and Guideline

At the June 15 meeting, the Medical Examining Board (MEB) considered the adoption of two directives based on recent HOPE (Heroin, Opioid Prevention and Education) legislation. The first action is the proposed requirement for physicians to complete two CEs (continuing education) per the licensing renewal period of two years on the responsible administration of controlled substances. The MEB discussed limiting the requirement to physicians who are registered by the DEA (Drug Enforcement Administration) as an authorized prescriber. Additionally this CE requirement would be for licensees who are renewing their license, and not for first time licensees. 

Finally, the MEB acknowledged that clinical and practice priorities change over time and the requirement for CEs focused on controlled substances should have a limited timeframe. Therefore, the MEB discussed limiting this requirement to two licensing renewal dates, 2019 and 2021. The MEB plans to present a first draft for review by the board at their next meeting, July 20, 2016.

The MEB also began discussion about the writing of opioid and controlled substances guidelines for providers. As guidelines these recommendations would not be binding but are meant to assist physicians in addressing the opioid abuse and misuse here in Wisconsin. Referring to opioid abuse and misuse in Wisconsin, Tim Westlake, MD, stated, “I would be remiss if I didn’t say we have a real problem.” He continued to stress the importance of guidelines, but also said they must be relatively simple, and not overly complicated. Westlake and the rest of the Board agreed to use the recently published CDC guidelines (http://www.cdc.gov/drugoverdose/prescribing/guideline.html) on opioids as the beginning framework for the Wisconsin guidelines. 

The MEB plans to present a draft of these guidelines first to Wisconsin’s Controlled Substances Board at their July 13, 2016 meeting before bringing them back to the July 20 MEB meeting. For more information, contact Steven Rush, WHA VP workforce and clinical practice, at srush@wha.org  or 608-274-1820.

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WHA Compiles Wisconsin-specific Exchange Enrollment Data Tables 
239,000 Select Exchange Health Plan, 84% Eligible for Premium Assistance


At the June 9 WHA Board meeting, WHA staff shared the final state-level open enrollment data released by the federal Department of Health and Human Services (HHS). Just over 239,000 people in Wisconsin have chosen a health plan through the federally-facilitated insurance exchange. Nationwide, 85 percent of all enrollees are eligible for financial assistance. In Wisconsin, 84 percent of enrollees are eligible for financial assistance in 2016, compared to about 90 percent in 2015. The average tax credit received in 2016 is $330 per month.

About 70 percent of enrollees in Wisconsin chose the silver level plan, while 23 percent chose the bronze plan. Nationwide, 71 percent chose the silver plan and 21 percent chose the bronze plan. The bronze plan typically has a lower premium, but higher cost sharing in the forms of deductibles, copayments and coinsurance. 

It is important to note that the number of people who have enrolled in a plan may be quite different than the number who “effectuate enrollment” or in the end pay their premiums and maintain their coverage. In 2015, for example, HHS reported about 206,000 people had originally enrolled in coverage, and a later report in September 2015 showed about 175,000 had maintained that coverage, about 85 percent of those who had selected a plan. 

As in past years HHS has provided data at the county and zip code level. WHA has prepared a map showing the data by county

To view the Wisconsin-specific summary reports prepared by WHA staff, go to this link
For the latest HHS reports, go to this link

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Variety of Legal and Regulatory Hot Topics Focus of Webinar Series

In July, WHA will launch a monthly WHA Member Forum webinar series focused on current legal and regulatory hot topics. There is no fee for these webinars, which are intended for WHA hospital and corporate members as a member benefit, but pre-registration is required. The series will include a range of topics, each presented by a representative of a WHA corporate member law firm. 

The first few sessions will include:

July 13: A Practical Approach to Complying with EMTALA
July 19: Examining The DOL’s Final White Collar Exemption Regulations
August 31: Managing Risk in Telemedicine Platforms
September 20: Alterative Payment Programs: What Can Hospitals Do To Succeed?

Registration is now open for all of these sessions, as well as topic descriptions of these and more, here.  

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WCMEW and AHEC to Jointly Sponsor Conference 
Seeking Presentation Proposals

The Wisconsin Council on Medical Education and Workforce (WCMEW) and the Wisconsin Area Health Education Council (AHEC) are jointly planning a conference on Inter-professional Education and Clinical Practice, scheduled November 10 and 11 at the Madison Marriott West in Middleton. The goals of the conference are to foster collaboration, innovation, and momentum around Interprofessional Education and Interprofessional Collaborative Practice in Wisconsin.

The conference seeks presentation proposals featuring best practices, showcasing theoretical models, highlighting evidence-based outcomes and lessons learned. Presentation sessions will be 45 minutes long with an additional 15 minutes for a question and answer session. Presentations should meet at least one of the conference objectives. Interprofessional teams of presenters are encouraged.

For WCMEW, this conference will complement its efforts to explore and promote team-based care, while at the same time provide opportunities to dialogue with academicians working to further inter-professional education. The half-day session November 11 will allow for discussion and problem solving involving educators and clinicians. 

Conference objectives:
Engage with colleagues practicing in health and education interested in IPE and IPCP. 
Develop and build on knowledge and skills across the spectrum of IPE and IPCP program development. 
Learn the current state of IPE and IPCP, theory-based best practices, and lessons learned in the field. 
Advance and sustain IPE and IPCP to facilitate effective and patient-centered health care education and practice. 

The deadline for submissions is July 15, 2016. Submit proposals to George Quinn, WCMEW executive director, at gquinn@wcmew.org. If you have questions, email Quinn or call 608-516-5189.

Conference registration information will be made available in the next several weeks.

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Rusk County Memorial Hospital to Host Upcoming H2H Meeting
WHA VP Steven Rush to Join Expert Panel

The sustainability of rural hospitals can never be taken for granted. Rusk County Memorial Hospital, Ladysmith, a very successful century old hospital by many measures, especially financially, found itself at eminent risk of closure. The unexpected loss of six primary care providers left the sole provider group with four primary care physicians who were taxed to continue call coverage, including obstetrical services for the hospital. This caused the closure of the OB program. The lack of call coverage was cited as the primary reason for inability to recruit replacement providers, potentially devastating access to care. 

According to Charisse Oland, Rusk County Memorial CEO, “A quick response was required to secure the future. At the heart of a four-point plan for change was the creation of an all-Advanced Practice Nurse Prescriber Hospitalist program to eliminate call coverage.” The program, launched in 2014 has proven to be very successful, but has not been without challenges. Oland states, “Because the APNP hospitalist profession is relatively new in rural hospitals and professionals are in high demand, the pathway was filled with many challenges and risks, from practice to regulatory issues. Yet the undaunted team forged ahead and learned along the way by its failures and achievements.”

The intent of the H2H program scheduled July 22 is to explore how various models of APNP (or mixed with MDs) hospitalist programs could work within the context of individual rural environments and cultures. Two panels of experts consisting of CMOs/collaborating physicians, APNP hospitalists, nursing executives, and statewide leaders who will help participants understand the role of hospitalists and collaborators, and the impact this type of program has on patient care processes and outcomes. Hospital models that could enhance a rural hospital’s current program and could help advance the field of APNP hospitalists in rural communities will be explored. The afternoon panel will discuss the opportunity to expand the APNP hospitalist workforce and develop the profession through scope of practice and potential legislation. 

Panelists include:

Session 1 Expert Panelists:
Dr. John Almquist, Medical Director, Collaborator, Eagle River Memorial Hospital- telemedicine program
Dr. Estaban Miller, CMO, Collaborator, Black River Memorial Hospital, Black River Falls
Dr. Linda Klein, CMO, Collaborator, Rusk County Memorial Hospital, Ladysmith
Dr. Kim Moldenhauer, APNP Hospitalist, Rusk County Memorial Hospital, Ladysmith
Jenifer Deziel, APNP Hospitalist, Black River Falls

Session 2 Expert Panelists:
Dr. Steven Rush, PhD, APNP, Vice President for Workforce and Clinical Practice, Wisconsin Hospital Association
Dr. Jeff Miller, DNP, ACRN, APNP, Assistant Professor, Medical College of Wisconsin / Clinical Director of Outpatient Care at Tosa Center
Clint Miller, DON Spooner Health System
Amanda Shimko, RN, Interim Director of Nursing, Rusk County Memorial Hospital, Ladysmith
Jennifer Friday, APNP Hospitalist, Rusk County Memorial Hospital, Ladysmith
Theresa Hutzler, APNP Hospitalist, Spooner (invited)

Space is limited for this meeting. For more information on how to register, email Tim Size, Rural Wisconsin Health Cooperative executive director at timsize@rwhc.com.

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Reminder: Meaningful Use Hardship Exception Deadline Is July 1

As previously reported in The Valued Voice, the Centers for Medicare and Medicaid Services (CMS) has extended to July 1, 2016, the deadline for hospitals and physicians to apply for a hardship exception for the 2015 meaningful use requirements of the Medicare EHR Incentive Program.

Under the Medicare EHR Incentive Program, CMS may exempt providers who are not meaningful EHR users from application of Medicare payment adjustments if CMS determines that compliance with the meaningful use requirements would result in a significant hardship. The categories for which CMS may grant a hardship exception are as follows:

Insufficient internet connectivity,
Extreme and uncontrollable circumstances,
Lack of control over the availability of EHR technology (available for physicians only); and,
Lack of face-to-face patient interaction (available for physicians only).

CMS application forms and instructions may be found here.   

For additional information, contact Andrew Brenton, WHA assistant general counsel, at 
abrenton@wha.org or 608-274-1820.


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Workshop to Focus on Fall and Injury Prevention Practices, August 17

On August 17, WHA is offering the workshop “Re-Energizing Fall and Injury Prevention Practices,” focusing on the state of science specific to fall and injury prevention, shifts in regulatory guidelines, and best practice approaches to fall risk and injury reduction. Registration is now open here.

This one-day workshop will be led by Patricia Quigley, PhD, nationally renowned expert in clinical practice innovations in patient safety, nursing and rehabilitation designed to promote independence and safety. Quigley has a legacy of leadership in health care outcomes related to functional improvement, rehabilitation outcomes and continuum of care. 

Encourage your quality and patient safety leaders, managers, front-line nursing staff, and nursing leaders to participate in this workshop. Hospital staff are encouraged to attend as a team, as attendees will engage in group commitment discussions of changes that can be made quickly and those requiring added infrastructure and capacity. In addition, post-acute providers who partner with hospitals, including staff from assisted living facilities, skilled nursing facilities and home health providers, should consider attending this important event as well.

The workshop is scheduled August 17 at Glacier Canyon Lodge at The Wilderness Resort in Wisconsin Dells. There is a minimal registration fee to attend this workshop, thanks to funding provided by the Wisconsin Office of Rural Health. For questions about the workshop’s content, contact Beth Dibbert at bdibbert@wha.org or at 608-274-1820.

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Fast Facts from the WHA Information Center

Over 30,000 ER Visits in Wisconsin are Related to Migraines
June is National Migraine and Headache Awareness Month


Migraine is an extraordinarily common disease that affects 36 million men, women and children in the United States. Almost everyone either knows someone who has suffered from migraine, or has struggled with migraine themselves. American employers lose more than 
$13 billion each year as a result of 113 million lost work days due to migraine.

According to the WHA Information Center, in 2015 there were 11,256 inpatient discharges, 11,313 outpatient surgery records, 30,438 emergency department visits, 3,097 observation care visits and 36,049 hospital outpatient clinic and ancillary services visits for the primary or secondary treatment of migraines. 

There were 18,690 emergency department visits to Wisconsin hospitals where migraines were the primary diagnosis. Of the 18,690 emergency department visits 10, 231 (54.7 percent) were between the ages 25-44. And, of those visits, 83.8 percent were women.

Data provided by the WHAIC (www.whainfocenter.com)

The WHA Information Center is dedicated to collecting, analyzing and disseminating complete, accurate and timely data and reports about charges, utilization, quality and efficiency provided by Wisconsin hospitals, ambulatory surgery centers and other health care providers.

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AHA Releases Tool for Assessing and Improving Community Health

A powerful tool for hospitals to address priority health needs of their patient population and the community at large is the community health needs assessment. A new AHA guide, “Engaging Patients and Communities in the Community Health Needs Assessment Process,” describes an eight-step assessment and implementation pathway, with many additional resources. The CHNA process, if conducted systematically and with the active participation of patients, their families, community members and community organizations, provides a clear understanding of the community’s health needs and priorities. This ongoing process leads to implementing community health improvement plans and increases a sense of ownership and shared commitment among the hospital, community organizations and populations served. The guide includes an asset-mapping tool for identifying and utilizing resources in the community for the CHNA; best practices for conducting community surveys, key stakeholder interviews and focus groups during the CHNA process; information about using electronic health records for CHNAs; and many other resources and links to resources. The guide is a collaboration of the AHA’s Association for Community Health Improvement and the Health Research & Educational Trust, with support from the Patient-Centered Outcomes Research Institute.

Visit the Hospitals in Pursuit of Excellence website at HPOE.org  to download a free copy of the guide 
(http://www.hpoe.org/resources/hpoehretaha-guides/2846).

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DHS and Partners Conduct Large-Scale Anthrax Response
Readiness exercise is one of the largest drills of its kind in the nation

On June 13-14, the Wisconsin Department of Health Services (DHS) and more than 40 federal, state, local and private partners jointly tested emergency plans in the second largest full-scale exercise of its kind in the country this year. The exercise involved the simulated delivery and distribution of antibiotics to treat those who may have been exposed to Bacillus anthracis, most commonly referred to as anthrax.

The two-day exercise executed June 13-14 tested more than a decade of local, state, and federal planning in response to a scenario involving the release of aerosolized anthrax in southeastern Wisconsin. The drill began with the escorted shipment of empty pill bottles, simulating antibiotics, to a confidential central location. These bottles were then distributed to more than 1,500 volunteers participating across 14 dispensing sites around southeastern Wisconsin, including the Waukesha Expo Center.

Hospitals that participated in the response include:

Children’s Hospital of Wisconsin, Milwaukee
Columbia St. Mary’s Hospital, Milwaukee
Columbia St. Mary’s Hospital Ozaukee, Mequon
Post Acute Medical Specialty Hospital of Milwaukee, Greenfield
St. Agnes Hospital, Fond du Lac
Waukesha Memorial Hospital, Waukesha

The exercise is part of the Cities Readiness Initiative, a national program out of the Centers for Disease Control and Prevention (CDC). DHS facilitated the planning and conduct of this exercise with several federal, state, local and private partners.

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