The Supreme Court ruling on the Patient Protection and Affordable Care Act (PPACA) on June 28 garnered much attention and was a focus of discussion at the Wisconsin Rural Health Conference this week, but health leaders here agreed that reform is not new in Wisconsin. Wisconsin hospitals have been quietly transforming health care by focusing on quality improvement and making innovative changes in both the delivery of, and payment for, health care here, according to the Wisconsin Hospital Association (WHA).

“Health reform is already well underway in Wisconsin, and our journey down this path will continue, and would have continued, regardless of how the Court ruled,” said WHA President Steve Brenton. “Health care leaders have been reforming care in our state to improve quality, moderate costs, expand access and raise the value of health care in Wisconsin.”

For example, Wisconsin providers are already developing new systems of care that improve quality and reduce cost. Hospitals here are working with insurers to develop new payment models in health care, moving away from volume-driven, unit pricing toward outcomes/total cost of care. In fact, health systems, insurers and physicians are actively involved in the Wisconsin Partnership for Healthcare Payment Reform that is moving away from fee-for-service payments in favor of bundled payments that are tied to outcomes. A focus on performance-based outcomes where payment metrics are tied to outcomes is the better way to go, especially for Wisconsin.

The Court ruled that the federal government could not eliminate a state’s full Medicaid funding if a state chooses not to implement the new Medicaid expansion requirements in the law. Under PPACA, all individuals under the age of 65 with income below 133 percent of the federal poverty line ($30,650 for a family of four) would become eligible for Medicaid in all states.  If a state did not expand its eligibility as required under the law, a state would lose all of its Medicaid funding for its entire Medicaid population – a significant amount of funding for most state budgets.   

Since the Court upheld the remainder of the law, all states will be required to have a health insurance exchange. It is yet unclear if Wisconsin will have a state-run exchange, a federally-run exchange, or something in between (under what is called the “partnership” model). Governor Walker said that Wisconsin will not take any action to implement the law. He has indicated he is awaiting the results of the November election. Thus, it is too early to tell which model will be implemented in Wisconsin. 

“Our commitment to improving health care quality, access and value continues forward,” Brenton said. “Few other states are as well positioned to succeed, if not thrive, in the emerging reform dynamic—a strength WHA believes can be transformed into a competitive advantage for Wisconsin.”

Since the health reform bill was signed into law in 2010, WHA has been working with a national coalition comprised of health systems, hospital associations and hospitals to work with policymakers on both sides of the aisle in Washington DC to help reform the health care delivery system in a way that rewards states that provide high-quality, low-cost health care.

“WHA said it five years ago and it is even truer today—improving health care quality and value is health care reform,” according to Brenton.

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What can Wisconsin’s medical schools, hospitals and health systems do to attract and keep physicians in the state?  That was the question before the medical residency program directors and the Deans of Wisconsin’s two medical schools at a WHA-sponsored meeting held in Madison June 25.

“We turn over more than 900 physicians every year, so we have a significant task ahead of us in recruiting and keeping physicians in Wisconsin,” according to Chuck Shabino, MD, WHA senior medical advisor, who chaired the meeting. 

Shabino explained that the purpose of the meeting was to discuss how to improve the transition between Wisconsin’s medical school graduates and their residency training, with a goal of connecting them to an in-state graduate medical education experience.

The WHA 2011 physician workforce report entitled, “100 More Physicians a Year: An Imperative for Wisconsin” stated that about 86 percent of the Wisconsin students that attend medical school here, and complete a residency in Wisconsin, will stay here and practice. 

Dean Robert Golden, MD, from the University of Wisconsin School of Medicine and Public Health and Dean Joseph Kerschner, MD, from the Medical College of Wisconsin, were both in attendance. The Deans took an opportunity to thank WHA for its leadership in the area of physician workforce. 

Golden said UWSMPH will welcome 175 students into the medical school this fall—the largest class in the school’s history.  He noted that 25 of the students are in the Wisconsin Academy of Rural Medicine (WARM).  UWSMPH also has a program that runs parallel to WARM, which is the Training in Urban Medicine and Public Health Program (TRIUMP), that draws students who are interested in practicing medicine in urban underserved communities.

“We clearly need more physicians, but creating more GME in the wrong locations or in the less necessary locations is not going to help us,” according to Golden.  “If more and more of the financing for GME is falling on the health care systems, they are going to want to invest in those service lines that they need now. We also need to have really strong residency programs that attract strong students.” 

One model that Golden likes is that of locally-led partnerships among academic institutions, hospitals, physicians and communities. He recognized WHA for its work in establishing state funding through the Wisconsin Rural Physician Residency Assistance Program which provides grants for the expansion, or creation of new rural resident rotations and training tracks.

“GME is extremely important.  We need to continually come up with new models that meet the needs of the physician and the community,” Golden said. 

Kerschner echoed Golden’s praise for WHA’s physician workforce efforts. He noted that Wisconsin is competing on a national scale to attract the best and brightest students to their residency programs. Kerschner said new ideas must be brought forward to address the physician shortage. MCW’s announcement June 25 to expand their medical school campus to two communities -- central Wisconsin and Green Bay – with a focus on a more rural medical practice, is one example.  (See MCW story on page 2.) 

“We are encouraging students from Wisconsin to apply to our medical school and to set up a practice here when they complete their residency,” Kerschner said. 

Program directors representing many areas of Wisconsin shared their challenges and suggested steps that could be taken to create more opportunities for Wisconsin residencies.  In addition, strategies to increase the proportion of Wisconsin medical school graduates choosing residency training in Wisconsin were discussed. 

Employers play an important role in supporting GME and in attracting physicians to the community.  A strong economy, built by a vital employer community, plays a critical role in creating a community that a physician would want to live, work and play in. 

The next steps according to Shabino are to coordinate the efforts of medical schools and residency programs to increase the proportion of graduates that stay in Wisconsin for residency training with the objective being the recruitment of more than 80 percent of these new physicians to practice in Wisconsin.

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The Wisconsin Supreme Court issued its decision this week in Weborg v. Jenny, a medical liability case in which the plaintiffs sought a new trial because, according to the plaintiffs, the circuit court erroneously admitted evidence of life insurance proceeds and social security benefits and erroneously modified the standard jury instruction on expert testimony. The Supreme Court found that any error on the part of the circuit court was harmless error and rejected the plaintiffs’ claim for a new trial.

The Weborgs brought a medical liability claim against three physicians, alleging that the physicians were negligent in their medical treatment of Weborg. During the trial, the court admitted evidence of collateral source payments, proceeds of a life insurance policy and social security benefits, on the issue of damages. The trial court also agreed to modify the standard jury instructions on expert testimony.

After the trial, during which the parties stipulated to the amount of the damages, the jury returned a verdict in favor of the physicians, finding that the physicians were not negligent in their care of Weborg. The plaintiffs appealed. The plaintiffs argued that the circuit court erroneously admitted evidence of life insurance proceeds and social security benefits and erroneously modified the standard jury instruction on expert testimony. The Court of Appeals concluded that both errors were harmless and affirmed the jury’s verdict that the physicians were not negligent.

The Supreme Court agreed with the Court of Appeals. Justice Annette Ziegler wrote for the five member majority, “In this case, considering the trial as a whole, we agree with the physicians that the circuit court’s error in admitting the evidence of life insurance proceeds and social security benefits did not affect the Weborg’s substantial rights. That is, the admission of evidence of collateral source payments does not undermine our confidence in the jury’s determination that [the physicians were not] negligent in the care and treatment of [their patient].” The Court also concluded that the circuit court’s error in modifying the standard jury instruction on expert testimony did not affect the Weborg’s substantial rights and was therefore harmless.

WHA and the Wisconsin Medical Society filed an amicus brief in this case in support of the physicians’ position. A copy of the Court’s decision is available here: http://www.wicourts.gov/sc/opinion/DisplayDocument.pdf?content=pdf&seqNo=84217

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The Medical College of Wisconsin’s (MCW) Board of Trustees has authorized MCW’s leadership to enter into the development phase of establishing two community-based medical education campuses in Wisconsin. Sites selected for development are Green Bay and Central Wisconsin with a goal of admitting the first group of medical students to the new campuses as early as the summer of 2015. The Trustees identified milestones that must be achieved before student recruitment will begin on the selected campuses.

Milestones to be achieved are relevant to accreditation, funding, faculty recruitment and development, formalized agreements with local health care systems and academic institutions, MCW faculty approvals, and the creation of local residency programs.

Wisconsin Hospital Association President Steve Brenton praised the Medical College’s announcement, which he said has the full support of the Association. 

By MCW’s move to expand their campus to educate medical students in Central Wisconsin and Green Bay, students will have an opportunity to receive a superb education and then stay in their home state and practice medicine,” according to Brenton. “There is much work to be done to ensure that when these students complete medical school, there are enough slots open in residency programs for them to complete their training in Wisconsin. We are confident Wisconsin hospitals and systems in partnership with the Medical College of Wisconsin, communities, business, and government--all working together--will make this happen.”

MCW is launching the community-based medical education initiative to address the shortage of physicians and other health care providers in Wisconsin, especially in underserved rural and urban areas.

John R. Raymond, Sr., MD, MCW president and CEO, said, “Factors that led to our determination that Central Wisconsin and Green Bay are appropriate sites for the development of plans for a community-based medical education program are:  strong health systems with outstanding physicians and established programs for student-focused clinical experiences, quality academic institutions with a scientific program infrastructure, and civic and business engagement and enthusiastic support. These communities also expressed a strong readiness to proceed.”

Raymond added, “The Medical College of Wisconsin is committed to developing multiple community-based medical education sites throughout Wisconsin. In addition to Green Bay and Central Wisconsin, we received enthusiastic responses from several other communities who want to be considered at a later date. We will continue to engage in discussions with communities across the state with the hope that other sites could be developed. We will continue discussions with potential partners in multiple regions of Wisconsin; no sites have been ruled out.”

Regional health systems, academic institutions and civic and business leaders in Central Wisconsin and Green Bay will partner with MCW in the development phase. Raymond said, “Our shared goal is to partner in developing Medical College of Wisconsin medical school campuses that reflect the community’s values and address community needs.”

Green Bay academic and health care institutions involved to-date in the discussions are (in alpha order):  Aurora BayCare Medical Center, Bellin College, Bellin Health, Hospital Sisters Health System – Northeast Division, Northeast Wisconsin Technical College, Prevea Health, St. Norbert College, and the University of Wisconsin-Green Bay.

In addition, MCW has engaged the following Central Wisconsin health care and academic institutions to-date in discussions (in alpha order):  Aspirus Health System, Marshfield Clinic, Mid-State Technical College, Ministry Health System, Nicolet College, Northcentral Technical College, Riverview Hospital, University of Wisconsin - Marathon County, University of Wisconsin - Marshfield/Wood County, and the University of Wisconsin - Stevens Point.

A next step in the development phase will be to engage physician practices, county medical societies, and academic and health system leaders in the planning of the two community-based medical education campuses.

“We believe that there is a rich pool of potential Wisconsin-based medical school applicants for our community-based medical education program,” said Joseph E. Kerschner, MD, Dean of the Medical School and executive vice president of the Medical College of Wisconsin. “On average, 625 Wisconsin residents apply annually to MCW’s medical education program. A substantial number of these applicants reside in underserved rural or urban areas of the state.”

"The Medical College of Wisconsin has had ongoing discussions about our community-based medical education initiative with the University of Wisconsin School of Medicine and Public Health,” Dr. Kerschner said. “We share a commitment to coordinate statewide medical education outreach programs and explore opportunities for collaborative efforts.”

The initial plans to be reviewed in the development phase call for an immersive model in which students will receive their medical school education in either Central Wisconsin or Green Bay.  Students will have the opportunity to take elective courses at MCW’s Milwaukee campus or at other campuses.

The first class of medical students at both campuses will target a minimum of 15 students per class.  In subsequent years, the class size will target 25 students per class. The class size could increase in the future if determined by community needs and resources.

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On June 25, WHA submitted comments to the Centers for Medicaid and Medicare Services (CMS) in response to the 2013 notice of proposed rulemaking on the Medicare hospital inpatient prospective payment system (IPPS) for acute care hospitals and the long-term care hospital prospective payment system.  

WHA provided detailed comments on several flawed policies. The primary example of this is the wage index rural floor.  In the proposed rule, CMS continues to apply a nationwide rural floor budget neutrality adjustment. The conversion of a single facility in Massachusetts from a critical access hospital (CAH) to an IPPS hospital is indicative of why this policy is inappropriate. As a result of this one change, Medicare payments are estimated to be reduced to thousands of hospitals across the nation by $3.5 billion over a decade while benefitting a few dozen hospitals in one state. CMS provides an impact table showing that Massachusetts hospitals will reap a $182.7 million windfall in IPPS payments alone for FY 2013 under this manipulation of wage index policy.

“In this fiscal environment, CMS must target scarce federal resources towards paying for outcomes like increased quality and safety,” said WHA President Steve Brenton. “Taking billions of dollars from 49 states through a policy sleight of hand should not be tolerated by CMS.”

WHA also provided comments on several quality-related programs including the readmissions reduction program, the inpatient quality reporting system, and the value-based purchasing program. With respect to the latter, for the first time the Medicare program proposes to include an efficiency measure—Medicare spending per beneficiary—in the value-based purchasing program. Although there are some concerns about the reliability of this measure initially, WHA supports the inclusion of efficiency measures in the program to show the true value both in quality and in cost. 

Graduate medical education is another high priority area for WHA, and CMS’ proposal to increase the cap-building period for new teaching hospitals from three years to five years is welcome. However,  WHA points out hospitals wishing to expand their residency programs as a result of the new medical school capacity should be given special consideration and exemption from the cap. As was announced Monday (June 25), the Medical College of Wisconsin is moving forward with community-based medical education campuses in Green Bay and Central Wisconsin (see related story on page 2). Any hospitals that may have had a low number of rotations in the past are capped at an artificially low Medicare GME reimbursement, hampering their ability to increase their residency capacity as a result. WHA asks CMS to relieve these hospitals of this artificial limit.

WHA also commented on the flawed methodology CMS uses to determine the coding adjustment; issues for sole community and Medicare dependent hospitals; hospital services furnished “under arrangements” with another hospital; and long-term care hospital payments.    

To see the full WHA comment letter, go to: www.wha.org/Data/Sites/1/medicare/WHAcommentNPRMIPPS6-25-12.pdf

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This week WHA submitted comments to the United States Senate Committee on Finance regarding the federal government’s efforts to reduce “waste, fraud and abuse” in the Medicare and Medicaid programs. The Committee solicited comments and ideas from interested stakeholders in the health care community.

“WHA believes this opportunity to comment is important in order to advocate on behalf of hospitals over growing concerns with the duplicative nature of Medicare and Medicaid audit programs,” said WHA’s Jenny Boese. “We hear regularly from our hospitals about the costly impact these programs have on otherwise scarce health care dollars.”

WHA’s comments focused on “Payment Integrity Reforms To Ensure Accuracy, Efficiency and Value” and highlighted problems encountered with the Recovery Audit Contractor program. Major areas of concern with the RAC program include the administrative burden on providers, a convoluted RAC process and the increasing use of medical necessity denials.

The WHA also provided several recommendations such as ensuring the accuracy of published audit data and improper payment statistics, which are the driving force behind much of the Centers for Medicare and Medicaid’s (CMS) audit activity as well as streamlining audit processes and programs.

As stated in the letter, “WHA and our providers support fighting waste, fraud and abuse in government health care programs, but we believe it is important to understand that there is a cost borne by the health care delivery system with having complex and oftentimes redundant programs. In this time of scare federal and health care dollars, we strongly urge the Congress and CMS to reevaluate audit efforts to target them more appropriately and effectively.”

On a related note, this week a group of Members of Congress who serve on the committees of jurisdiction for Medicare requested that the Government Accountability Office study the coordination of various Medicare audits being conducted. WHA supports this effort as a means to understanding how audit programs are administered and whether contractors are using audit methodologies that are valid, clear and consistent among other questions.

Read WHA’s full letter at www.wha.org/Data/Sites/1/medicare/WHA-USsenateCommFinance.pdf

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On June 21, Flambeau Hospital CEO Dave Grundstrom was joined by Senator Bob Jauch (D-Poplar), Representative Mary Williams (R-Medford), Mary Willett from the office of Representative Sean Duffy, Marge Bunce from the office of Senator Herb Kohl, other local officials and hospital staff for the ribbon cutting on their hospital remodel.

With the redistricting changes, the event provided a perfect opportunity for legislative relationship building with Sen. Jauch as Flambeau Hospital is now in his district, as well as somewhat of a farewell to Rep. Williams who no longer represents the area, which is now represented by Rep. Janet Bewley (D-Ashland).

Most of the group was able to stay for a hospital tour and afterwards discussed several key issues including the value hospitals bring to their communities and their importance to local economic development, Medicare and Medicaid, looming federal payment cuts, and Wisconsin’s shortage of physicians.

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Beginning July 1, hospitals will have two options for arranging for ambulance transport of most Medicaid enrollees. Under a policy update published in Forward Health Update #2012-23, if a hospital is discharging a Medicaid enrollee eligible for Logisticare transportation services and if the individual needs non-emergency ambulance transportation with life support services, the hospital may arrange for such transportation either through Logisticare or directly with the ambulance provider. In either case, transportation from a hospital with life support by ambulance or stretcher vehicle must be prescribed by a physician, physician assistant or nurse practitioner.

Additional details can be found in the full Forward Health Update #2012-23 at:  https://www.forwardhealth.wi.gov/kw/pdf/2012-23.pdf . Additional information can also be found at WHA’s website at: http://www.wha.org/logisticare.aspx .

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The Transforming Care at the Bedside (TCAB) team from 8SW St. Mary’s Hospital in Madison hosted Judy Warmuth, WHA vice president of workforce and TCAB clinical leader June 18 for their 2012 site visit. Data collection and graphs from their falls reduction project have helped the team find the best interventions, and a sign on the nursing station sign keeps everyone apprised of their progress. The group is designing a meeting room environment that encourages participation and involvement in daily patient rounds. They are also developing a new strategy for involving all of the RNs in this large nursing staff by including TCAB activities as part of unit meetings. Safe patient handling has been a project for the TCAB team with very positive outcomes including no staff injuries or days lost. As part of ongoing work on hourly rounds, new patient room clocks have been trialed with a rollout planned for August.  The group has been working on both sustaining the energy and progress on 8SW and spreading the TCAB processes and improvements to other St. Mary’s nursing units.

Warmuth visited The Monroe Clinic Hospital TCAB team June 19 for a site visit. This team moved into the new hospital in March, which offered great new opportunities with space and resources, but also provided challenging changes to processes already in place. The team demonstrated the hospital’s TCAB Intranet site, which updates all hospital employees about the project. New initiatives for the team include patient call backs making use of functionality in the electronic medical record, daily interdisciplinary rounding at the bedside and recruiting a patient member for the team. This group will also refocus on hourly rounding. They also had suggestions for improving the TCAB implementation for the next cohort to kick off in September. 

Warmuth will conduct site visits for all TCAB teams this summer, and a new cohort of hospitals will be invited to join the program this fall. 

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Wisconsin hospitals share a common mission to improve their community’s health status, which includes oral health care, an area often neglected because people cannot afford dental work.  Lack of proper dental care can lead to a myriad of other health problems.  Those with severe tooth pain often end up in hospital emergency rooms for pain relief.  By increasing access to dental services for those who cannot afford it, hospitals are not only improving the overall health of their communities, but also decreasing the burden on their emergency departments.

New dental center helps address oral health care disparities

Children’s Hospital of Wisconsin opened a Primary Care and Dental Center in Milwaukee’s central city in May to help fulfill a critical oral health care need in the city and ensure that a child’s first dental experience is not in an emergency department. Located in one of the most underserved areas of the city, the new center will provide dental care for approximately 1,500 neighborhood children annually.

      “More than 70 percent of Wisconsin’s low-income children go without oral health care, and poor oral health has a significant impact on a child’s overall health, well-being and ability to learn,” said Peggy Troy, MSN, RN, president and CEO of Children’s Hospital and Health System.

      In less than three months, the Primary Care and Dental Center has provided oral health care services to more than 300 children. Families already have shared relief that this service is available in their neighborhood. One grateful parent said the care is “changing lives,” because her child finally can sleep at night after receiving dental care.

      Although children should have their first oral exam before the age of two, most children in Milwaukee’s central city first go to the dentist when they are school age or older. By this time, many already have significant and multiple areas of dental decay.

      Pediatric and general dentists, hygienists and dental assistants, who are dedicated to meeting the special and unique oral health care needs of children and adolescents, staff the dental center. They specialize in oral and facial growth and development, restorative dentistry, preventive dental care and dental injury. Advanced training allows them to provide the most up-to-date treatment available and care for children in a kind and compassionate way.

      Children’s Medical Group-Next Door Pediatrics, a member of Children’s Hospital and Health System, has provided medical care to children in the Metcalfe Park neighborhood since 1999. Primary medical and dental care are now housed together in the 7,700-square-foot center.

      Funding for the new center was provided in part through generous private donations from Delta Dental of Wisconsin, The Harley-Davidson Foundation, Briggs & Stratton Corporation Foundation, Greater Milwaukee Foundation, KBS Construction and N.J. Staunt Larson.

Children’s Hospital of Wisconsin, Milwaukee

Monroe Clinic partnership helps meet prescription needs of young dental patients

In 2009, Fowler Memorial Free Dental Clinic began serving patients in Green County, offering free dental care for children, ages 3-12, who may otherwise go without due to lack of dental coverage and financial resources.

      Because Fowler is an important local resource which helps promote a healthier community, Monroe Clinic Pharmacy partnered with the organization to expand the support of its patients by offering a prescription program.  This special service allows Fowler patients needing antibiotics or pain medication to have their prescription filled at Monroe Clinic Pharmacy free-of-charge. Through partnerships such as this, there are fewer barriers between children of lower-income families and essential dental care.

Monroe Clinic

Submit community benefit stories to Mary Kay Grasmick, editor, at mgrasmick@wha.org.

Read more about hospitals connecting with their communities at www.WiServePoint.org .

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