December 4, 2015
Volume 59, Issue 48
Wisconsin Hospitals Generate $26 Billion in Economic Activity
Wisconsin hospitals generate $26 billion annually in economic activity and directly employ more than 107,000 people in communities throughout the state, according to a new report released December 3 by the University of Wisconsin/UW Extension and the Wisconsin Hospital Association. The report also looks at the impact patients from outside of Wisconsin who receive their health care here have on the state’s economy.
"Hospitals are major economic drivers in their communities and in our state," according to Professor Steve Deller, an economist at the University of Wisconsin/UW-Extension and a co-author of the report. "Wisconsin’s high-quality health care, combined with health care providers who are well-respected for their excellent patient care, are also attracting patients from other states to seek care here. In addition, hospitals and health systems are advancing medical science and technology, and as such, are providing therapies that may not be available in other states."
Over a 12-month period, non-Wisconsin residents had over 545,000 hospital admissions or medical visits here. Residents of Illinois and Minnesota accounted for more than two-thirds of these visits, according to data from the WHA Information Center.
According to the report, the services associated with providing care to out-of-state patients supported more than 6,400 jobs in hospitals alone. Payments to hospitals from out-of-state patients totaled about $1.0 billion, but when economic multipliers are applied that account for indirect effects, such as the hospital’s purchase of goods and services within the region or in other parts of the state, the total impact to the state’s economy is estimated at $1.3 billion.
Hospitals comprise about one-third of total health care spending per capita in Wisconsin. This means other health care services, such as physician office visits, prescription drugs, rehabilitation and long-term care, etc., account for about two-thirds of the total health care spend. When estimates for these services and purchases are included, the impact of out-of-state patients on the state’s economy is well over $3 billion.
Health care is often viewed as being only very local. However, Wisconsin’s national reputation for high-quality health care and the breadth of specialized services available here are likely among the key factors that attract out-of-state patients.
Community Hospitals Help Drive Local Economic Development
When a new industry or business is considering a relocation or expansion, the quality, accessibility and cost of health care factors into the decision on where they will locate. Baby boomers looking to retire also rank "a good nearby hospital" as an important factor in their decision.
"Wisconsin hospitals and health systems play an important role in our state’s economic health," according to WHA President/CEO Eric Borgerding. "The hospitals in our state are ‘job creators’ and they are among the state’s largest employers. This study shows that health care is much more to Wisconsin than hospitals, doctors and clinics. The ripple effect of the health care sector in employment numbers and on our state’s economy is enormous. Hospitals are not only tied to the physical health of our communities, they are also directly connected to the state’s economic health."
Hospitals are Among Largest Employers in Most Communities
Nearly nine out of every ten counties have at least one hospital, and in many communities, particularly in the rural areas of the state, the hospital is one of the largest employers. Deller said for every job created in a hospital, there are an additional 0.878 jobs created in the state. When the multiplier effect is considered, hospitals contribute a total of 201,187 jobs to the Wisconsin economy.
Almost every business and industry located in Wisconsin is affected in some way by the operation of a hospital. The study calculated economic multipliers and estimated that hospitals indirectly account for nearly 115,000 additional jobs statewide because hospitals and their employees purchase goods, services and "bricks and mortar" from other businesses in their communities.
"Wisconsin hospitals represent a significant and growing source of higher-paying employment opportunities in the future," Deller noted. "A hospital also has positions that attract college-educated professionals, which helps avert a ‘brain drain’ and keeps graduates in our state."
Hospitals and health systems in nearly every area of the state participate in economic development activities through local Chambers of Commerce and on regional boards.
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Wisconsin has historically been ahead of the curve on hospital price transparency through the development and advancement of the PricePoint website, but regulatory changes and health care market changes mean we must continue to lead and play a proactive role in advancing policy in this area. WHA convened the Transparency Task Force to focus on developing best practices in the provision of price and quality information to consumers. As patients face increased exposure to health care costs, they have a need for meaningful and transparent price and quality information.
As one of the first deliverables, the taskforce has created a toolkit, located on the WHA website at www.wha.org/transparency.aspx, to help hospitals improve their price transparency while complying with two new and separate regulatory transparency issues, the ACA hospital charges requirement, and the IRS 501(r) rule as it relates to financial assistance and billing and collections.
The ACA section contains rationale and a sample policy for one way to approach complying with the ACA hospital charge posting requirement and making it easier for patients to find charge information. The 501(r) section contains several checklists to help improve the financial assistance and billing and collection processes and communication with patients as outlined as part of the 501(r) regulations. There is also a sample billing and collection policy.
A special thank you goes out to the WHA Transparency Task Force for their work on this document. There is more to be done, however, and the Task Force will continue through 2016 to work on other policy and process initiatives that can help improve health care transparency for the citizens of Wisconsin.
WHA Transparency Task Force Members:
Steve Little, CEO, Agnesian HealthCare – CHAIR
Dave Breitbach, CFO, Crossing Rivers Health Medical Center
Dan DeGroot, CEO, HSHS St. Clare Memorial Hospital
Coreen Dicus Johnson, President, Wheaton Franciscan Healthcare, St. Francis
Rich Donkle, Director of Finance, Rural Wisconsin Health Cooperative
Jane Jerzak, Partner, Wipfli
Mark LePage, CMO, Security Health Plan
Gordy Lewis, CEO, Burnett Medical Center
Megan Mulholland, Public and Media Relations, ThedaCare
Geri Murphy, VP, Revenue Cycle, UW Hospitals & Clinics
Jim Nelson, VP, Fiscal Services, Fort Healthcare
Randy Schubring, Manager, Public Affairs, Mayo Clinic Health System
Brian Stephens, CFO, Ministry Door County Medical Center
Lori Wink, Attorney, Hall Render, Killian Heath & Lyman
Special Contribution: Shawn Gretz, Americollect
WHA Staff: Eric Borgerding, Brian Potter, Joanne Alig
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WHA to Congress: Site Neutral Needs Immediate Fix
WHA meets with every office of Wisconsin Delegation on amendment
The Wisconsin Hospital Association was in Washington, DC this week to meet with every office of Wisconsin’s Congressional Delegation about the immediate need to fix the recently-enacted policy on "site neutral" payments. The provision was included in the rushed enactment of the larger Bipartisan Budget Act of 2015 (BBA 2015) and took effect immediately on November 2.
"WHA is very disappointed with the last-minute inclusion of the site neutral policy, and strongly objects to having the long-term strategy and operational decisions of our providers upended within the span of a week by this surprise Congressional action," said WHA President/CEO Eric Borgerding in a November letter to Wisconsin’s Congressional Delegation. "We are aware of multiple projects in process in Wisconsin that are negatively impacted under the law’s prohibition."
The site neutral policy inappropriately restricts hospitals’ ability to use a Medicare reimbursement system known as the Outpatient Prospective Payment System (OPPS), particularly in cases where organizations have already invested significant amounts of time and money on planning, developing or constructing hospital outpatient departments (HOPDs). This means years of planning, time and financial resources have been upended by this surprise Congressional action.
While on Capitol Hill, WHA stressed the need to fix this policy for those HOPDs under development or that will need to relocate in the future, as contained in an amendment proposed by the American Hospital Association and under discussion in Congress. WHA urged support and quick action on the amendment.
"WHA strongly believes delaying action on this amendment is an untenable position for Wisconsin hospitals and health systems," said Jenny Boese, WHA vice president, federal affairs and advocacy, during meetings in Washington, DC. "Our providers need stability and certainty as they move forward into the new year. An immediate fix is necessary."
WHA met with the offices of Speaker Paul Ryan, Sens. Johnson and Baldwin, and U.S. Reps. Duffy, Grothman, Kind, Moore, Pocan, Ribble and Sensenbrenner. Also participating in meetings was Aurora Health Care.
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Debra Standridge, Wheaton Franciscan – St. Joseph’s, Milwaukee, is president of an urban safety-net hospital, but when she discusses charity care and Medicaid underpayments to hospitals, she speaks for all hospitals in the state.
Standridge participated along with Rep. Joe Sanfelippo (R-West Allis); Kathleen Falk, Region 5 director, Health and Human Services (HHS); and John Peacock, research director, Wisconsin Council on Children and Families, on a panel discussion December 1 focused on "The State of Health Reform in Wisconsin" sponsored by Wisconsin Health News.
The amount of charity care in 2014 was slightly lower than the amount reported by hospitals to WHA in 2013, (see www.wha.org/pubarchive/special_reports/2015cbReport.pdf). Standridge explained that even with increased coverage, there is still a need for charity care.
"More people have coverage, but our hospitals still provide charity care for a large number of people," according to Standridge. "People are getting into the right setting now. Previously, they were coming in through the ER for primary care. That is an expensive setting and it is where we had the highest incidence of charity care. Now we are using our own resources to connect these patients with a medical home and a primary care physician, where they can be treated properly and at less cost."
Another reason charity care and Medicaid shortfalls decreased over the past year, according to Standridge, is providers are reducing their costs and increasing efficiency.
"This fact is not put forward often enough, but we know based on a study by the UW-Whitewater, Wisconsin’s health care system ranks third in the nation in terms of efficiency, and second based on the quality of our care," Standridge said. "That reflects in the data reported on charity care and Medicaid shortfalls. There is less cost, and you are actually seeing the results of high-efficiency, high-quality care in terms of our great outcomes."
Falk applauded Wheaton and all Wisconsin hospitals for the work they are doing to enroll patients in coverage and coordinate their care. Many consumers in the health exchange have coverage for the first time and are novices in navigating the health care system.
"We have learned that simply having the insurance card did not help people understand how to use it," according to Falk. "They thought they were supposed to go to the ER because that is where they always went. Our goal (at HHS) is to get that next piece of education in place so consumers use health care resources more efficiently."
When asked whether Wisconsin will expand Medicaid, Sanfelippo said that is not going to happen.
"Wisconsin was ahead of the game," according to Sanfelippo. "Before the ACA, we had a lower uninsured rate than just about any other state in the country. We were already doing a good job insuring people."
Peacock said historically, Wisconsin has been a leader in covering kids. As recently as 2009, Wisconsin had the sixth lowest percentage of uninsured kids. Some ground was lost when parents did not qualify for Medicaid coverage. The best way to cover kids, he said, is to enroll their parents in coverage.
"We need to reduce the churning during enrollment," Peacock added.
Standridge said the biggest change in enrollment has been in childless adults in both urban and rural settings. When they gained coverage, they presented in the ER and were very sick. Hospitals, including St. Joseph’s, mobilized their own resources at their own expense to ensure that these patients received the right care in the right setting. Care coordination experts "parachute" in, according to Standridge, to help ensure that care is coordinated and that patients are connected with a primary care physician so they receive the care they need to stabilize their health.
"It is a transformational time. You are all part of making it happen," according to Falk. "We are making progress together even though change is not easy."
Watch the program on WisEye.
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Damond Boatwright, CEO of hospital operations and regional president of hospital operations for SSM Healthcare of Wisconsin, has been selected as a Section for Metropolitan Hospitals alternate delegate and member of the AHA Regional Policy Board (RPB) 5 for a term effective immediately and expiring December 31, 2016. In RPB 5, alternates attend when substituting for a delegate who cannot attend a meeting.
There are nine RPBs that meet three times a year to foster communication between the AHA, its members and state hospital associations. The RPBs provide input on public policy issues considered by the Board of Trustees, serve as an ad hoc policy development committee when appropriate, and identify needs unique to a region and assist in developing programs to meet those needs.
Boatwright currently serves on the WHA Board of Directors.
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In four short years, the WHA Partners for Patients Collaborative has helped Wisconsin hospitals work toward reducing hospital acquired harm by 40 percent and decreasing readmissions by 20 percent.
The hard work and collaboration among hospitals working with WHA has averted more than $87 million in health care costs in the state, and more importantly, avoided nearly 9,400 hospital-acquired harms to Wisconsin patients.
Considering these outstanding results are reflective of Wisconsin hospitals’ historical commitment to provide high-quality, high-value care, more than 85 hospitals have committed to continuing the hard work in the fifth year of the WHA Partners for Patients Collaborative.
"The results we have achieved together over the past four years are impressive, but there is room to improve as we strive to reach the national goals to reduce harm by 40 percent and readmissions by 20 percent," said WHA Chief Quality Officer Kelly Court. "WHA will be taking a more targeted approach with hospitals this year. We will be working with each hospital to develop a custom approach for those conditions that have not yet met the improvement goals. Wisconsin is a leader state in quality health care, and I am confident that together, we can reach our goals."
To prepare hospitals for year five, the WHA quality team held a series of orientation webinars in November, designed to help all levels of organizations prepare and support the improvement work in the coming months. One of the events, "From Boardroom to Bedside: Getting the most from an improvement collaborative" provided a framework on how hospital executive leaders can be engaged in and support the improvement efforts at their hospitals. The event was kicked off by WHA President/CEO Eric Borgerding and widely attended by executive leaders throughout the state.
"The top-down commitment from hospital leaders has been a crucial element to the success of our WHA Partners for Patients work to date, and will be even more essential as we work to meet the CMS improvement goals by the end of 2016," Borgerding said. "It is this ‘whole house engagement’ that supports improvement efforts and keeps Wisconsin hospitals ‘ahead of the curve’."
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The WHA Physician Leaders Council met December 2. It discussed a range of issues including draft telemedicine rulemaking, the development of WHA’s Health Care Leader Opioid Initiative, physical therapist authority to order x-rays, and advanced practice nurse prescribers
(APNPs) scope of practice rulemaking. The Council also had a discussion with the chair of the Medical Examining Board, Ken Simons, MD.
MED 24 telemedicine practice proposed rule
The Council led off with a detailed review of a new proposed rule—MED 24—on physician use of telemedicine that was advanced by the Medical Examining Board at its October 22 meeting. The Council considered the need for a parallel set of rules governing physician practice and use of telemedicine, and was skeptical of the need for broad new rules governing physician use of telemedicine.
Members viewed practice issues regarding the use of telemedicine vs. "face-to-face" medicine as only "very narrowly different," and said that Wisconsin’s existing physician practice rules generally adequately address physician use of telemedicine. Council members said the proposed rule needs to be much more narrowly tailored to address identified, material concerns with specific uses of telemedicine, and that as currently written, Wisconsin’s proactive uses of telemedicine to increase access, reduce cost and improve quality could be unnecessarily and negatively impacted.
"By specifically and broadly regulating physicians’ use of telemedicine technologies, WHA is concerned Wisconsin would be sending the wrong message to patients and the public that telemedicine should be viewed with skepticism and as a fundamentally different practice of medicine," said Steven Rush, WHA vice president for workforce and clinical practice.
The Council also discussed the breadth of the proposed rule, as it would not only regulate so-called "e-visits" but would also create new, redundant "one-size-fits-all" regulations on long established telemedicine solutions such as teleradiology, telepathology, and eICU. Additional concerns were raised that the rule goes beyond regulating physician practice and instead regulates telemedicine technology with the physician’s license at risk for standards not met by a telemedicine technology vendor.
As noted in the October 23 Valued Voice, the proposed rule was unexpectedly approved in October after a few minutes of discussion. WHA was the only organization that commented at that October meeting regarding the approval of the language for the proposed rule, and expressed concern that the language had little stakeholder review or opportunity to provide input before being further advanced in the rulemaking process, as the language was released only a few days before the MEB’s approval.
The proposed rule will have a public hearing on January 20. With input from the WHA Telemedicine Task Force and the Physician Leaders Council, WHA is preparing written comment and testimony, and will be sharing that with interested members as they consider their own written comments for the
PT x-ray orders and APNP collaboration
The Council also reviewed proposed scope of practice changes regarding physical therapists and APNPs. Under a draft bill being circulated in the Legislature, Wisconsin law would explicitly add physical therapists to the list of individuals under ch. 462 who may order x-rays. The Council reviewed and discussed the elements of that bill.
Members also reviewed and discussed a draft proposed rule being considered by the Board of Nursing that would modify the physician collaboration requirements for APNPs. The Board of Nursing is targeting a hearing for that proposed rule in late winter. WHA will have further discussions with the Physician Leaders Council and others on that draft proposed rule in the coming weeks.
Special Guest – Ken Simons, MD, chair, Wisconsin Medical Examining Board
Ken Simons, MD, spoke to the Council regarding the make-up and operations of the Wisconsin Medical Examining Board (MEB), and discussed board activity on some of the "hot topics" at the MEB.
Implementing the Interstate Medical Licensure Compact is one thing that Simons expects the MEB will be involved with in 2016 (pending the Governor’s signature on the bill). Although the MEB has taken steps to speed up physician licensure processing time by ramping up staffing during peak times of the year, Simons said that much of the delay is a result of delays in receiving verification materials from a physician’s past employers, educational institutions, etc. He said that by enacting the Interstate Compact, those delays will be significantly shortened for physicians processing a license under the Compact.
To provide physicians with easy-to-find resources for opioid prescribing practices, Simons said that getting approval to put such resources on the MEB website has been an initiative of the Board. Rush shared WHA’s Health Care Leader Opioid Initiative with Simons, and it was noted that WHA has on its website some of the same physician resources the MEB is seeking to put on its website.
Simons also talked about the MEB’s work on the MED 24 physician use of telemedicine rule. Because the rule is currently open, he couldn’t comment specifically on the rule, but he did say the MEB views telemedicine as "just another tool in the quiver." He said addressing physician identification concerns and what should happen in the case of an emergency were two key issues the MEB intended to address in the rulemaking. The MEB will be holding a hearing on the MED 24 rule January 20, according to Simons.
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In April 2016, the Centers for Medicare & Medicaid Services (CMS) will implement a mandatory bundled payment pilot across 67 geographies nationwide. Hospitals will be required to accept bundled payment for hip and knee replacements starting with a hospital admission and extending for 90 days. This new model presents significant financial implications for hospitals.
On December 15, WHA will offer a webinar providing members an important overview of the CMS Comprehensive Care for Joint Replacement (CJR) model, along with critical success factors to help hospitals prepare for its implementation. The presenters will review case studies with tangible examples that will assist participants in evaluating their hospital’s current resources. Although not all hospitals may be directly impacted by the initial pilot, CMS may expand this initiative beyond the pilot in the near future, and this webinar may help Wisconsin hospitals prepare for what’s ahead.
The webinar, titled "Implications of CMS’s Comprehensive Care for Joint Replacement (CJR) Bundled Payment Model: What You Need to Know to Prepare Your Hospital," is scheduled December 15 from 9-10 a.m., and pre-registration is required. For more information or to register, visit:https://www.signup4.net/public/ap.aspx?EID=15WD11E&OID=161.
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Physician Leadership Development Conference, March 11-12, 2016
Early bird discount available; register today
Start gathering your team of new and seasoned physician leaders and register them for the 11th annual WHA Physician Leadership Development Conference. The 2016 event is scheduled March 11-12, 2016, at The American Club in Kohler. The full conference brochure is included in this week’s packet. Online registration is available at http://events.SignUp4.net/16PLD, and discounted registration is available to those registering by January 15.
This year’s conference will include a full-day session with Stacy Nelson, MEd, EdD, offering both the "Crucial Conversations in Medical Management" session and the "Influencer: The New Science of Leading Change" session, focusing on the tools needed to tackle conflict and challenges and the strategies to change culture, thoughts and actions in your organization. Michael Guthrie, MD, MBA, FACPE, will offer the half-day session "Medical Staff Leadership: Meetings and Organizational Politics," focusing on ways to run an effective meeting, use group dynamics to build support and deal with disruptive personalities effectively.
Both Nelson and Guthrie are nationally-recognized faculty from the American Association for Physician Leadership (AAPL), formerly the American College of Physician Executives, and both will discuss important and practical leadership skills that help physician leaders move beyond their clinical training and take a new approach to managerial decision-making and problem solving.
For questions about the Physician Leadership Development Conference, contact Jennifer Frank at email@example.com or 608-274-1820.
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Make plans now to head to Madison on March 30 for WHA’s 2016 Advocacy Day. Join peers from hospitals all across the state for a day of learning and leading on important health care issues. Registration is now open at http://events.SignUp4.net/16AdvocacyDay0330.
As always, Advocacy Day 2016 will have a great lineup of speakers, including morning keynote Rick Pollack, president and CEO of the American Hospital Association (AHA). He’s been a member of AHA’s advocacy team for the past 33 years and will share his Washington DC insider’s view of federal political activities during this presidential election year.
The legislative panel discussion will round out the morning session, followed by a luncheon keynote address from Governor Scott Walker (invited).
Attendees will have an issues briefing before heading to the State Capitol for their scheduled legislative meetings. Our goal? Advocating for policies that keep Wisconsin hospitals and health systems strong so they can continue to provide high-quality, high-value care.
Make sure you are assembling your hospital contingent for 2016 Advocacy Day, set for March 30, 2016, at the Monona Terrace in Madison. Registration is now open at: http://events.SignUp4.net/16AdvocacyDay0330.
For Advocacy Day questions, contact Jenny Boese at 608-268-1816 or firstname.lastname@example.org. For registration questions, contact Jenna Hanson at email@example.com or 608-274-1820.
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Health care hotspotting is the strategic use of data to focus resources on a small subset of high-need, high-cost patients.
A small number of individuals drives much of the cost in the American health care system. The system is designed to work for the average patient, and like many large systems, it struggles to help extreme patients, or outliers—the small number of patients with complex, hard-to-manage needs and chronic conditions. These outliers are known as super-utilizers.
Hotspotting uses data to discover the outliers, understand the problem, dedicate resources and design effective interventions. It is a movement for a new system of multi-disciplinary, coordinated care that treats the whole patient and attends to the non-medical needs that affect health: housing, mental health, substance abuse and emotional support.
The Evidence-Based Health Policy Project (EBHPP) in collaboration with Health Innovation Program (HIP) will be holding a morning briefing at the Wisconsin State Capitol December 10 from 8:30-11 a.m., as well as an afternoon training for providers and payers at Monona Terrace from 1-4 p.m. The morning briefing will be moderated by Rep. Debra Kolste, (D-Janesville). Guest speakers include Carter Wilson, senior program manager at the Camden Coalition, who will describe how the innovative coalition developed and the lessons they have learned; Wisconsin Medicaid Director Kevin Moore, who will provide an update on the state’s Complex Care Management Program in Milwaukee; and Carolyn Krause, recently retired from iCare, who will offer a payer’s perspective on hotspotting. The afternoon training session at Monona Terrace will be conducted by Brian Akers, also of the Camden Coalition, and will focus on the development and implementation of a hotspotting program.
Registration for this free event is now open online here. If you are unable to attend or are outside of the Madison area, watch live coverage of the event online at www.wiseye.org/Programming/CoverageSchedule.aspx.
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