November 21, 2014
Volume 57, Issue 47

·         Sen. Vukmir Tours Milwaukee Safety Net Hospitals

·         U.S. Sen. Baldwin Leads Bipartisan Letter Urging President Not to Cut Rural Hospital Funding

·         Guest Column: Team-Based Care in Wisconsin: Moving it Forward

·         House Ways & Means Release Comprehensive Draft Medicare Hospital Bill

·         Common and Complex ICD-10-PCS Coding Scenarios Focus of WHA Webinars

·         President’s Column: Wisconsin’s Strong, Vibrant High-Performing Rural Health System under Siege

·         Mark Your 2015 Calendar for the Wisconsin Rural Health Conference

·         Quality Residency Hits the Mark



Sen. Vukmir Tours Milwaukee Safety Net Hospitals
Aurora Sinai, Wheaton St. Joseph’s provide frontline perspective

Sen. Leah Vukmir (R-Wauwatosa) recently toured Milwaukee’s two safety net hospitals—Aurora Sinai Medical Center and Wheaton Franciscan-St. Joseph campus—to see firsthand the role these hospitals play in their communities. Vukmir is a certified pediatric nurse practitioner and educator with more than 25 years of nursing and teaching experience.

“We appreciate Sen. Vukmir taking time to visit Aurora Sinai Medical Center to learn about the unique challenges faced by Milwaukee’s last downtown hospital. Aurora Sinai serves a critical role in Milwaukee’s and the state’s health care infrastructure, as Medicaid patients make up nearly 50 percent of our annual volumes. In 2013, Aurora Sinai’s Medicaid shortfall totaled -$28 million and we provided $4.4 million in charity care,” said Carolynn Glocka, president, Aurora Sinai Medical Center. 

“Despite these financial constraints, we remain committed to helping our patients access high-quality and cost-efficient care through medical homes and many unfunded case management and supportive services. We look forward to working with our legislative leadership next session to find ways to further improve the health of our patients while increasing efficiencies within government health programs that support this population,” said Glocka.

During her time at Aurora Sinai, Vukmir was able to see and understand the passion and commitment by the hospital, physicians and nurses for treating the often complex needs of their economically-disadvantaged patients. She was able to hear from several veteran OB nurses about their pride in being able to successfully provided care to an opiate-addicted newborn. It was later relayed to the Senator that the cost of that care was over $400,000, for which Medicaid reimbursed the hospital $40,000. Vukmir was also able to learn about the mental health care-related problems in the Milwaukee area. In fact, she was told there were three behavioral health patients with posted security each waiting for a bed to open or for the arrival of the Milwaukee County crisis team.

hile visiting Wheaton Franciscan St. Joseph campus, Vukmir heard similar examples of the role the hospital played in their community. In order to address the medical and even socio-economic needs of their patients, the hospital has taken a comprehensive, multi-faceted approach. This approach includes case managers, social workers and a primary care clinic at the hospital among other strategies. All of this work has led to what is known as a 52 percent “stick rate,” which is the rate that individuals without a primary care doctor then establish one and receive follow-up care there.

Deb Standridge, Wheaton’s North Market CEO, had this to say about this complex problem:

“Wheaton Franciscan - St. Joseph has the busiest single hospital emergency department in Wisconsin, on track to experience a record 90,000 patient visits this year. We attribute the increase in part to newly-insured childless adults now eligible for Medicaid. Because an estimated 50 percent of our emergency department visits could take place in a primary care setting at a lower cost with better continuity of care, we work hard to link patients to a medical home in the community or on our St. Joseph campus.”

The overarching goal at both Aurora Sinai and Wheaton Franciscan - St. Joseph is to help patients access the appropriate level of health care and better manage chronic conditions, avoiding emergency visits and hospitalizations. The biggest challenge is that current Medicaid reimbursement doesn’t cover the full cost of delivering the care, or the cost of additional case management support. That shortfall on every single Medicaid patient combined with the increase in volumes is unsustainable in the long term.

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U.S. Sen. Baldwin Leads Bipartisan Letter Urging President Not to Cut Rural Hospital Funding
Green Bay Press Gazette Editorial: Rural hospitals play important role

U.S. Sen. Tammy Baldwin (D-WI) led a bipartisan group of 27 senators, with Sen. Mike Crapo (R-ID), in support of rural hospitals and the value they provide to communities across the country. Baldwin and 26 other senators expressed opposition to provisions the President has previously included in his budgets. Those include reducing Medicare reimbursement levels for critical access hospitals (CAHs) and removing the “critical access” designation for any hospital within 10 miles of another hospital.

“I am deeply concerned by this proposal from the Obama Administration. If enacted, these policies would compromise access to health care and weaken rural economies in Wisconsin and across the country. I fear these proposals could even force many rural Wisconsin hospitals to shut their doors—causing a ripple effect on our economy and leaving many without access to care,” Baldwin said. “Critical access hospitals play a vital role providing access to medical services, as well as economic security and jobs to rural communities. That is why I am leading a bipartisan effort to stand up for rural hospitals, their patients, and the local economies they help support.”

The Wisconsin Hospital Association (WHA) and Rural Wisconsin Health Cooperative (RWHC) both expressed appreciation to Sen. Baldwin for her efforts and her long-standing commitment to Wisconsin’s rural hospitals.

The Wisconsin Hospital Association greatly appreciates Sen. Baldwin’s efforts on behalf of rural Wisconsin hospitals,” said WHA President Steve Brenton. “Rural and critical access hospitals provide essential access to care across much of our state and the nation. We are grateful for those in Congress who continue to stand up for our rural providers against ill-advised policy proposals.” 

“Rural Wisconsin hospitals are very appreciative of the senators for their efforts in opposing unnecessary and arbitrary efforts by the Administration that would jeopardize rural access to critical health services,” said Tim Size, RWHC executive director. “Wisconsin has a number of critical access hospitals that would likely be affected by the Administration’s plans. These hospitals are critical in the services they provide to their communities and deserve our country’s support.”

The Green Bay Press Gazette editorialized on the joint Senate letter, expressing strong support for the role rural hospitals play in their communities.

“We agree with the senators’ sentiment because we believe these rural hospitals play an important role in their communities, both medically and economically. If this sounds familiar, it’s because it is. Just over a year ago we urged Congress to defeat a similar proposal…Each [hospital] faces challenges in accessibility, lack of health care providers, and a growing number of underinsured residents, according to the National Organization of State Offices of Rural Health…We’re all for saving money in Medicare, but not at the expense of health care for those who live outside of urban areas.”

Read the signed Senate letter.

Read Sen. Baldwin’s press release.

Read the Green Bay Press Gazette editorial.

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Guest Column: Team-Based Care in Wisconsin: Moving it Forward
By George Quinn, WCMEW executive director, and Chuck Shabino, MD, WHA Chief Medical Officer

In the WHA 2011 report, “100 New Physicians a Year: an Imperative for Wisconsin,” the projected shortage of physicians in 2030 was based, in part, on the assumption that team-based care would leverage physician resources by involving other caregivers in health care delivery, therefore limiting the projected shortage. One recommendation in the report was to have stakeholders in Wisconsin’s health care workforce investigate team-based care to better understand how it will impact the future of care delivery.

Acting on that recommendation, the Wisconsin Council on Medical Education and Workforce (WCMEW) earlier this year established a workgroup on team-based care.  Their first goal was to create a forum that would showcase existing team-based care teams and provide a foundation for understanding the culture necessary to make these teams successful. That idea grew into the “Building a Culture for Patient-Centered Team-Based Care” conference held November 12, 2014, which drew 200 attendees and attracted 30 team presentations.

The workgroup outlined five critical questions that were addressed at the conference:

Q.   What is the state of team-based care in Wisconsin?

A.   It is important to note that team-based care is not limited to ambulatory/clinic-based care. Teams range from population-targeted teams such as those that target the unmet needs of veterans in rural Wisconsin, to specific clinical processes such as coordinated coagulation therapy. There is great diversity in how the team-based approach is applied. In addition, there is a desire to connect with others interested in team-based care. Future meetings could be structured around this idea. Finally, there is an increasing body of knowledge suggesting that team-based care is a critical element of success in the quality and effectiveness in care delivery. This knowledge needs to be widely disseminated.

Q.   Why are teams formed?

A.   The most often-mentioned reasons for creating teams were to improve quality of care and patient safety while making better use of resources; in other words, enhancing the value of care being provided to patients. Team-based care also has benefits to those providing the care. It enhances professional satisfaction and minimizes burnout. It provides a more even sharing of workload, and it builds cohesion across work groups.

Q.  What are the key ingredients needed for teams to be successful?

A.  A shared vision of the mission, roles and responsibilities is critical to the team’s success. In addition, organizational support and leadership are necessary for teams to have staying power. Leadership is demonstrated by a clear indication of caring; a willingness to listen in a non-defensive way and seek input by encouraging team members to speak up about issues that concern them and take action on those concerns; a facilitation of communication and teamwork; and, by enhancing information sharing.

The right skill sets, attitudes and knowledge base are also keys to success. Skills mean how to do a certain task, attitudes are represented when individual team members know why a task is important and they are willing to carry it out, and knowledge is understanding what to do in the appropriate circumstance.

Finally, team members display characteristics such as adaptability, situational awareness, good interpersonal relationships, coordination and communication, and good decision-making. These skills and characteristics can be built through training and experience.

Q.   What are the barriers to team-based care?

A.   Organizational culture, while a key ingredient for success, can also be a barrier if the culture does not provide the leadership, empowerment and encouragement of self-learning and autonomy necessary for teams to thrive.

Limited time and resources were also repeatedly mentioned as barriers, as well as the regulatory and payment environment.

Q.   How do we as a state move team-based care forward?

A. The next step will be to continue sharing best practices in team-based patient care. WCMEW is helping to create the educational resources and networking opportunities that will be helpful to hospitals and health systems as they implement new models of care.

The WCMEW workgroup will continue to analyze data on team-based care outcomes, including quality measures, the cost of care and patient and team-member satisfaction, and make the information available.

Finally, WCMEW will follow this first conference with others that will involve more networking and sharing of best practices, showcasing innovative models and skill building in areas such as coaching and mentorship.

Top of page (11/21/14)

House Ways & Means Release Comprehensive Draft Medicare Hospital Bill
Draft proposal includes “Bay State Boondoggle” fix, RAC fixes, 96 hour fix

This week the U.S. House Committee on Ways & Means released a 150-page draft proposal, known as the Hospital Improvements for Payment (HIP) Act of 2014, which would make multiple changes to the Medicare system for hospitals. The Wisconsin Hospital Association continues to analyze the provisions and will provide comments to Wisconsin’s Congressional Delegation and the Committee.

Several very positive provisions included in the bill have been the focus of WHA’s advocacy, including:

·         “Bay State Boondoggle” – to correct a provision included in the health reform law that provides Massachusetts hospitals hundreds of millions of dollars in bonus payments—at the expense of nearly every other state in the country. Close to two dozen state hospital associations, including WHA, have come together seeking to reverse this manipulation of the Medicare payment system.

·         “96 Hour Fix” for critical access hospitals (CAHs) – to harmonize Medicare’s Conditions of Payment with its Condition of Participation. The two have differing 96-hour requirements, believed to be a drafting error dating back to the enactment of the CAH designation itself.

·         Medicare Data – allowing for entities like the Wisconsin Health Information Organization (WHIO) to have access to Medicare data

In addition, the proposal includes multiple provisions to address problems with the Medicare Recovery Audit Contractor (RAC) program. Those provisions include:

·         Creation of a new Hospital Prospective Payment System to deal with shorter stays. (Short stays have been a target of the RACs and have resulted in an overwhelming backlog in the federal Medicare appeals process.)

·         Additional six-month extension of RAC audit moratorium (through September 2015)

·         RAC provisions, including limits on RAC reviews, allows for rebilling, and more RAC monitoring

·         Requires notice to be provided to Medicare beneficiaries if in observation 24 hours or more

A few other provisions included in the bill are:

·         Requires hospitals, including CAHs, to report “assessment data” on conditions, functionality, cognitive function, living situations/access to family, etc.

·         Makes some adjustment to the readmissions program related to dual-eligibles, socio-economic factors.

There are also provisions related to price transparency, among others. To read the full draft log onto:

Watch for more information in The Valued Voice in the coming weeks.

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Common and Complex ICD-10-PCS Coding Scenarios Focus of WHA Webinars

The October 1, 2015, deadline for ICD-10 implementation allows Wisconsin hospitals and health systems the opportunity to take full advantage of the additional time to prepare for the ICD-10 transition. In early December, WHA is offering two webinars featuring well-known coding expert Lynn Kuehn. Kuehn will focus on helping coders, coding managers, and members of a hospital or health system’s ICD-10 implementation team better understand how to work through common and more complex ICD-10-PCS coding scenarios, to be better prepared for on-time and efficient implementation.

On December 2, Kuehn will lead a webinar focused on making root operations selections and assigning all characters for the codes included in 10 common ICD-10-PCS cases encountered at hospitals and health systems of all sizes. This interactive webinar will be a great way to work through some of the most common cases you’ll encounter after October 1, 2015.

On December 9, Kuehn will focus on teaching participants to improve critical thinking skills by tackling more complex ICD-10-PCS cases. Kuehn will provide tips on how to differentiate between root operations groups and similar individual root operations. Intended as the capstone for the webinar series, this session will assist attendees in making decisions to code 10 common but more complex ICD-10-PCS cases.

Full information on both sessions and online registration are available at: Encourage your team to gather for this webinar series and learn together through one, low-cost registration.

Top of page (11/21/14)

President’s Column: Wisconsin’s Strong, Vibrant High-Performing Rural Health System under Siege

Twenty years ago a small group of rural, upper Midwestern lawmakers led by Iowa Sen. Chuck Grassley and former Iowa Congressman Jim Nussel championed legislation that transformed rural health care and saved hundreds of rural hospitals from closure. They convinced colleagues to allow individual states to define small rural hospitals as “necessary providers”—organizations deserving slightly higher Medicare payments because of their “necessary” function of providing accessible health care services to their communities.

Today Wisconsin has 58 critical access hospitals (CAHs), nearly all of which owe their designation to the “necessary provider” criteria. Every one of these hospitals has strengthened local health delivery. And as a group, these hospitals have ensured access to hundreds of thousands of individuals and families all across Wisconsin at a marginal additional cost that amounts to “erasure dust” in the context of the larger Medicare program.

Other supplemental payment programs like Low Volume Adjustment, Sole Community Provider and Medicare Dependent Hospital each provide a few extra dollars to slightly larger rural hospitals that serve a disproportionate number of older and often times sicker patient populations.

Unfortunately, the CAH program in particular has been under siege recently via Obama Administration budget proposals and OIG reports that attack the “necessary provider” criteria and instead suggest mileage requirements. Similarly, CMS last year announced a new rule that undermines a 20-year precedent related to length of stay in a CAH bed. If a patient stays longer than 96 hours, payment is denied. This is an astounding and baffling example of regulatory fiat usurping clinical decisions.

It is particularly fitting as we celebrate Rural Health Day to recognize Wisconsin’s strong rural delivery system and remind lawmakers to not tamper with low cost, essential payment programs that are foundational to achieving rural health care excellence—a situation in which Wisconsin rural residents today receive health care from organizations whose clinical infrastructure and performance is equal to that in more urban settings. Special thanks to Sen. Baldwin (see for standing up for rural health care!

Steve Brenton,

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Mark Your 2015 Calendar for the Wisconsin Rural Health Conference
Glacier Canyon Lodge at the Wilderness Resort in Wisconsin Dells *** June 17-19, 2015

More information will be available in spring 2015 at

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Quality Residency Hits the Mark

The quality residency program formed by Wisconsin Hospital Association (WHA) and the Rural Wisconsin Health Cooperative (RWHC) is a big success with new quality managers. The program is designed to engage new and novice hospital quality improvement directors in a two-year track of education, leadership training and networking. The program was enhanced in September to accommodate additional residents and allow veteran residents to attend individual program sessions. Thirty-six residents recently completed the fourth session of their ten-session program. The modular format of the program is designed to allow new applicants to join at any time.

Each session begins with a learning needs assessment and then content is designed to the needs of the current residents. Faculty for the program includes a combination of staff from WHA, RWHC and external quality experts.

”The residency is a very rewarding experience for both the residents and instructors. The high level of resident participation and collaboration, and the value of customized curriculum has exceeded everyone’s expectations,” said Kelly Court, WHA chief quality officer.

Jerene Managan, RN, case management coordinator at Riverside Medical Center who participated in the program, said, “Thank you for giving me the tools I needed. Your classes have helped me tremendously in my new job role.”

The WHA Foundation and Wisconsin Office of Rural Health are helping fund the program to keep it affordable for participants. Contact Kelly Court at or Beth Dibbert at for an application package and additional information.

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