December 21, 2012
Volume 56, Issue 51

Federal Funding Cuts Threaten GME, but Wisconsin Takes Steps to Expand Medical School Capacity, Build New Residency Opportunities

Four health care leaders shared their perspectives on physician workforce-related issues at a Wisconsin Health News luncheon sponsored by the Wisconsin Hospital Association at the Madison Club December 18.

WHA President Steve Brenton participated in a panel discussion along with Kathryn Kuhn, vice president of government and community affairs at the Medical College of Wisconsin (MCW), Robert Golden, MD, dean, University of Wisconsin School of Medicine and Public Health (UWSMPH), and Medical Society of Wisconsin CEO Rick Abrams. Karen Timberlake, director of the Population Health Institute at UWSMPH, moderated.

Brenton noted that in 2013, the emphasis will be on expanding the capacity to educate in-state medical students in one of Wisconsin’s two medical schools. The WHA report, "100 Physicians a Year: An Imperative for Wisconsin," cautions, however, that if more residency positions are not created in Wisconsin, the physicians who are educated here are likely to complete their graduate training in another state. When graduates of a Wisconsin medical school finish their residency training in a Wisconsin program, there is a 70 percent chance that they will practice here.

The residency issue is the least understood component of the pipeline, even among WHA members, according to Brenton. WHA is currently developing resources that will help educate its members on the issue. GME support, however, requires adequate funding. One of Brenton’s concerns is that fiscal issues in Washington will trigger a reduction in GME funding at the federal level.

"The cuts are significant because they come at a time when we are facing huge challenges," Brenton said. "The rationale of these cuts is not there, and it will require us to engage our Congressional Delegation if we want to try to mitigate the impact."

On the positive side, MCW’s announcement to expand their campus to central Wisconsin and Green Bay received an enthusiastic welcome from key stakeholders. Kuhn said when MCW asked the Wisconsin health systems for their help to create a medical education program in partnership with their local communities, the answer was a resounding "yes" from every corner of the state.

"You can imagine the difficulty of bringing health systems to the table when they compete for patients," recounted Kathryn Kuhn, MCW vice president of government and community affairs. "But, they put their competitive hats aside and talked about how we can all work together to increase the number of medical students and physicians in Wisconsin. "

Kuhn said the Medical College is committed to helping health systems open residency programs and are doing whatever they can to encourage the health systems that have never had a residency program before to open a new one, thus avoiding the issue of restrictions on the number of slots the Center for Medicare and Medicaid Services (CMS) will fund.

"The Medical College wants to do whatever we can to open new residency programs, to have our new graduates in these programs, and then keep these new physicians in Wisconsin when they complete their graduate training," according to Kuhn.

Golden said UWSMPH has taken a strategic approach as they expanded the medical school class size, which is "paying off" in terms of training students that are most likely to serve at-risk populations.

"We created a pipeline for rural and urban students in the Wisconsin Academy of Rural Medicine (WARM) and the Training in Urban Medicine and Public Health (TRIUMPH) programs," Golden said. "Medical schools no longer produce physicians, we produce residents, and that has become a rate-limiting step. It is going to get ‘terrible’ sooner than we thought."

Golden said if you look at the current cohort of medical students, there will not be enough residency programs and the students will be unable to go on and practice medicine. "We really need to create residency training capacity where it is needed geographically and in family medicine and other areas of family care," according to Golden.

"We are heading for a disaster. With all the hard work we’ve done to expand medical school, there will not be residencies and they will smack up against a wall because there will be nowhere for these graduates to go," Golden said.

Abrams applauded WHA’s role in bringing stakeholders together on the GME issue. He pointed to the Wisconsin Council on Medical Education and Workforce (WCMEW) as a "perfect example" of a group that has brought stakeholders to the table.

While the focus has been on physicians, Brenton said the WHA physician report emphasizes the importance of the evolving role of advanced practice professionals. He pointed to the fact that MCW’s approach to physician education aligns with the medical practice model that supports all health care professionals practicing "at the top of their license."

"All health care professionals need to be allowed to practice at the height of their abilities and license, but that requires a leader," Brenton stated. "Physicians must be the ones at the forefront of this movement."

The panel discussion is posted on Wisconsin Eye at:

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Commentary: Medicare Needs to Pay for Quality, not Quantity

High quality, high value health care is a competitive advantage for Wisconsin. Hospital systems are improving quality, increasing efficiency and delivering value to employers and residents in their communities. The following editorial is reprinted with permission from the Appleton Post Crescent.

By Dr. Dean Gruner, President/CEO, ThedaCare
For The Post-Crescent, December 14, 2012

As Americans, we pride ourselves on being leaders in innovation. That is, unless we’re talking about Medicare.

Pushing the half century mark, Medicare pays for health care in much the same way it did in1965. This continues, despite decades of warnings that the system, known as "fee for service," is antiquated, doesn’t benefit patients and is on the fast track to financial ruin.

In a nation where we flock to buy the latest technologies every six months, when it comes to Medicare, we face a dangerous and false mindset that innovation will leave seniors with reduced benefits and limited access to care.

The reality—which we are rapidly approaching—tells us that if we don’t innovate, Medicare will not be viable much longer.

Over the years, reams of reports and countless hearings have looked at how to make the program sustainable. After tinkering on the edges, it’s time to face the realization that recycled Band-Aids shrouded as reforms aren’t cutting it. We need to innovate. The good news? We know how.

As the CEO of a large health system, I understand the dire financial situation the country is facing and the consequences of the fiscal cliff. I understand more tax dollars for Medicare will likely not be an option. I accept this reality. What is hard to accept is the federal government’s reluctance to reward the quality of services rather than the quantity.

Every Medicare dollar wasted is a tax dollar wasted. Every preventable readmission, unnecessary test, hospital-borne infection and preventable fall is paid for by taxpayers. This reality isn’t an indictment of those who use Medicare. It’s a comment on the archaic and inefficient fee-for-service Medicare reimbursement scheme.

If private businesses adopted Medicare’s status-quo approach to paying for supplies and services, they would be bankrupt. A manufacturer looks for the best supplier with the fewest defects per unit and the best price. Manufacturers that settle for less incur higher error rates, longer delays, higher costs, and unsatisfied—and potentially injured—customers.

Manufacturers want high quality and low cost. They search for the best available supplier. Shouldn’t taxpayers and Medicare recipients demand the same?

In recent years, Medicare has launched pilot and demonstration projects that strive to better coordinate care, reduce unnecessary procedures and costs, and improve health outcomes. Some states have also aggressively pursued similar reforms.

While these actions are commendable, they’re too slow and too modest to drive the systemic change Medicare needs right now. ThedaCare, which is a member of the Healthcare Quality Coalition, knows that more rapid transformation is possible. Along with other like-minded health care providers, we have worked for years to deliver more effective care—despite Medicare’s failing fee-for-service payment system—to ensure every procedure is clinically necessary, every encounter of the highest quality and every patient is at the center of care.

We have made significant progress, and even though there are more opportunities to improve, our efforts are paying dividends.

Our organizations operate in regions of the nation with the lowest per-capita Medicare costs and the highest levels of quality. High-quality, lower-cost care is possible. We’re proving it.

Encourage your federal legislators and the President to do something truly innovative for Medicare. Tell them to quickly act to move toward a system that prompts high-quality, lower-cost care.

We’re Americans. Innovation is what we do.

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2013 WHA Physician Leadership Conference Focus on ACA Impact on Physicians
Register soon for this popular session this year March 8 – 9, The American Club

The WHA 2013 WHA Physician Leadership Development Conference will focus on the impact that the Affordable Care Act (AHA) will have on physicians. Sarah Freymann Fontenot, professor for legal aspects of health care administration for Trinity University’s Department of Health Care Administration in San Antonio, will present a session that will explore how the ACA will affect physicians as practitioners and as participants in larger organizations committed to delivering quality health care.

Fontenot, a well-known expert in hospital and public health law, has taught at Yale Medical School, Auburn University, for the American College of Physician Executives (ACPE) and for the American College of Healthcare Executives (ACHE) annual Congress on Healthcare Leadership.

This year’s conference will be held at the American Club March 8 - 9. Learn more about the conference, including the March 8 session which focuses on practical strategies for physician leaders to engage their colleagues, online at: Registration is now open, and discounted early bird pricing is available through January 18.

Attendance at this conference is an opportunity to expose physician leaders to the important leadership skills that help them move beyond their clinical training and take a new approach to managerial decision-making and problem solving. Consider attending this event with physician leaders—a ‘host’ registration option is available to those who do not need CME credit.

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Gov. Walker Carries WI Health Care Value Message in Economic Summits
"We have a world-class system of health care in Wisconsin"

In regional economic summits held in cities across Wisconsin, Governor Scott Walker touted Wisconsin’s high-quality, high-value health care as an economic advantage that can attract and keep employers in the Badger State.

"One thing we should not lose sight of is the fact that a good, solid health care system in the state is a benefit...a strength. Not just because of the thousands of people they employ and that they are the biggest employers, but because of the added value they bring to employers in our state," Walker told business and economic development leaders who participated in the Summits. "Whether you are a large or small business, one of the benefits of living in this state, particularly when you are trying to attract talent, is we have a world-class system of health care in Wisconsin."

Walker noted that as state budget talks start, his goal is to ensure that "our decisions do not undermine that system." In the last state budget, Walker said he put $1.2 billion more into the Medicaid program to help the most vulnerable citizens, but also because it helps reduce the cost-shift "so providers do not have to pass along the cost of uncompensated care, at the same level, as a ‘hidden tax’ on our employers."

"I did it because it has a direct link to economic development, which includes investments in health care in our state," according to Walker.

WHA Executive Vice President Eric Borgerding agreed that Wisconsin’s high value care is an asset to the state in attracting economic development. It’s a message that WHA is heavily promoting that is being picked up in state and local media channels, as well as many other venues. (See

"The message that our hospitals and health systems are providing high quality, high value care is catching fire across the state, and we’re certainly pleased that our Governor is promoting it as being just as important as good roads, clean water, and all the other great assets that our state has to offer employers," Borgerding said.

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President’s Column: Business Journal Editor Mark Kass Interviews Borgerding

Next year will be pivotal for health care in Wisconsin.

With the implementation of the federal Affordable Care Act and other major changes on the way, the Wisconsin Hospital Association and its members will have a lot of work on their hands.

Eric Borgerding, executive vice president at the Wisconsin Hospital Association, recently answered questions from The Business Journal about the group’s top legislative issues, the Affordable Care Act and the introduction of accountable care organizations. The interview was published in The Business Journal December 21, 2012 at

  1. What are the top legislative initiatives or issues for the Association in Madison in 2013?

  2. High-quality, high-value care is a competitive advantage for Wisconsin, and WHA’s 2013 legislative priorities are geared toward enabling superior performance. This means partnering with the Medical College of Wisconsin and legislators to address Wisconsin’s primary care physician shortage—a necessity for better coordinated, more efficient care. Similarly, we must remedy the Wisconsin Supreme Court’s Jandre decision from last summer. Jandre will lead to defensive medicine, unnecessary procedures, inefficiency and higher costs. We’re also committed to modernizing Wisconsin’s antiquated hospital regulations, which are lagging behind our highly-integrated, value-focused health care system. Another priority is our non-physician workforce. Good paying jobs stand vacant at hospitals and clinics because we cannot find trained applicants. We need real-time workforce data so our technical schools and colleges are better informed about tomorrow’s employer needs. And, we have to address cost shifting from Wisconsin Medicaid, which inflates employer health care costs by hundreds of millions. Simply put, Medicaid reimbursement policy makes it more expensive to employ people in Wisconsin.

  3. What do WHA members view as the biggest positives and the biggest negatives in the Affordable Care Act (ACA)?

  4. Some of the biggest positives are steps toward payment reform, including accountable care organizations (ACOs) and other efforts aimed at reimbursing providers based on quality and outcomes. In Wisconsin, we welcome this. In other parts of the country, it is threatening and thwarted. Wisconsin is a high-quality, high-value provider for Medicare. In some states, Medicare spends triple the amount per enrollee that it spends here. Believe it or not, getting Medicare to pay for quality and reward efficiency is controversial and met with stiff resistance. So ACOs and other modest payment reforms included in the ACA are steps in the right direction, but we need to do a lot more a lot faster.

    The biggest negative is the $2.6 billion in Wisconsin hospital Medicare reimbursement cuts to pay for the ACA. Those cuts penalize high-quality, high-value hospitals like we have in Wisconsin. They affect health systems as employers, and will inflate health insurance premiums for everyone. Another negative is the inconsistent approach to ACA implementation. The feds offer flexibility implementing exchanges (which Wisconsin unfortunately did not accept), but take an "our way or no way" approach when implementing coverage expansion. True flexibility is crucial for a leader like Wisconsin.

  5. What is the most understood aspect of the Affordable Care Act?

  6. The federal government is now far more involved in Wisconsin’s health care. For better or worse, it’s fact, and we now must work as much with Washington as with Madison.

    By many measures, Wisconsin’s health care system is doing well, making steady progress, with nearly the best quality, best value care in America. Our uninsured rate is among the lowest. We’ve made quantifiable, exemplary progress, especially in southeast Wisconsin where hospital costs continue to level off. This started well before the ACA.

    So with the ACA now law, Washington says "move over, we’re here to help." That "help" comes with more regulations, heavier hands pulling new purse strings, and national solutions designed toward the lowest common denominator. Wisconsin is not below average or even average, we lead. We set the example in health care. This is a Wisconsin strength that can be underappreciated by technicians in Washington, especially when it comes to designing insurance exchanges.

    Health care is one of Wisconsin’s greatest attributes, and WHA’s primary role is preserving, and hopefully strengthening, our leading edge during ACA implementation. But when policy and politics mix in such a massive undertaking, it produces uncertainty for health systems trying to stay proactive and focused on the future.


  7. How significant a roll will Accountable Care Organizations (ACOs) play for hospitals in 2013 and beyond?

  8. ACOs are a good example of how health care delivery and reimbursement are evolving, and where Wisconsin is excelling. This is happening in the public sector through Medicare ACOs, but also in the private sector as organizations like Aurora and Quality Health Solutions begin putting ACO-like products in the commercial market. ACOs are really a redefining of the "product" in health care—moving away from fees for units of service and instead generating margin based on better health and better outcomes. ACOs, per se, are also redefining the relationship between payer and provider. ACOs shift more risk to providers, which dramatically realigns incentives toward reducing costs associated with poor health and service overutilization. For our members, this means retooling and repurposing delivery and financing for better care coordination via alignment and integration—all key attributes of Wisconsin’s leading health care system. Payment reform is critical to making this work. Health systems are realigning their cost structures to deliver better outcomes, but even with the advent of ACOs, we still have a payment system that’s predominantly fee for service and illness rather than health focused.

  9. What is the trajectory for the costs of charitable, uninsured and bad debts on hospital financial statements?

Uncompensated care remains a challenge. Despite higher Medicaid enrollment, reimbursement shortfalls (at cost) from bad debt and charity have increased from about $780 million in 2006 to about $1.2 billion in 2011. The emergence of high deductible health plans are a part of that. Of equal impact are shortfalls from Wisconsin Medicaid, which reimburses hospitals about nine cents for each dollar in outpatient charges and accounted for an additional $850 million in unreimbursed costs in 2011. Milwaukee hospitals are doing a great job becoming more efficient, moderating their operating costs, and passing those savings on to employers. But payment shortfalls of that magnitude can’t be absorbed; they are recouped from everyone else. A few years back, Wisconsin Manufacturers and Commerce dubbed this Medicaid’s "hidden tax." The good news reported by the Milwaukee Business Journal about moderating hospital costs and prices is tempered by the fact that recouping unpaid costs from Medicare and Medicaid accounts for 23 cents of every commercial dollar paid to southeast Wisconsin hospitals. Just think about that. Unpaid costs from Wisconsin’s Medicaid program alone added $205 million to southeast Wisconsin health care costs in 2011. Those numbers would actually be worse if hospitals weren’t doing a good job of moderating costs.

Top of page (12/21/12)

Mark your 2013 Calendar for These Important WHA Events:

March 8-9: Physician Leadership Development Conference
The American Club, Kohler

April 23: Advocacy Day
Monona Terrace, Madison

June 26-28: Rural Health Conference
Kalahari Resort, Wisconsin Dells

September 19: WHA Leadership Summit
Country Springs, Pewaukee

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Wisconsin Medicaid Receives $23 Million Bonus for Covering Kids

The Wisconsin Medicaid Program received an early Christmas present from the Centers for Medicare and Medicaid Services (CMS) in the form of a $23.3 million performance bonus for enrolling and retaining children.

The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) established performance bonuses, giving states an incentive to cover eligible children in Medicaid and CHIP and to help defray the costs associated with increasing enrollment of the lowest income children. Wisconsin has received a federal bonus for the past three years and this year’s payment is the fourth highest among the 23 states that received the funding boost.

"There are a number of critical improvements in access to care that the state could apply these funds to, such as reopening enrollment in the BadgerCare Core program and improving reimbursement rates for providers," Ken Taylor, executive director of the Wisconsin Council on Children and Families, said in a news release.

To qualify for a performance bonus, states must implement at least five out of eight specific program features aimed at streamlining their enrollment procedures to improve children’s health coverage programs and must increase children’s enrollment in Medicaid above a baseline level for the fiscal year.

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CMS Proposes Details of Insurance Market Rules

Late last month and into the early December, the federal Department of Health and Human Services (HHS) released long-awaited proposed rules on several aspects of insurance coverage and the health insurance exchange provisions of the Patient Protection and Affordable Care Act (ACA). Deadlines for comment are short, and HHS is maintaining the tight timelines for comment despite reported efforts by some—including the U.S. Chamber of Commerce—to extend the comment periods.

The proposed rules contain many complex details that will affect the insurance market in 2014. Some highlights are below. WHA staff has been reviewing the key provisions and is considering comments on several topics.

Essential Health Benefits
. Under PPACA, all health benefit plans in the individual and small group markets will be required to offer a minimum set of benefits. PPACA identified 10 coverage categories that must be included in the essential health benefits, and left it up to the HHS Secretary to determine specifics about what must be included. The proposed federal rules would essentially codify the approach described in previous guidance released by HHS late last year.

The proposed rule requires states to select one of the 10 plans currently existing in the market to set the benchmark for what is included in the essential health benefits. Under the proposed rule, states have until December 26, 2012 to make their selection. Should a state not choose one of the 10 plans, the federal government will default to the largest (by enrollment) small group plan in the state. According to the proposed rule, in Wisconsin this plan is a UnitedHealthcare Choice Plus Definity HSA Plan. It is important to note the benchmark plan is used to set the base benefit package only. Cost sharing is considered separately from the benefit package. Therefore, although this is an HSA plan, insurers will still have to comply with the cost-sharing provisions in the ACA which limit out-of-pocket expenses and deductible amounts for consumers.

The Wisconsin Office of the Commissioner of Insurance (OCI) has indicated that the federal government requested OCI to provide information about the chosen essential health benefits package even before the December 26 deadline included in the proposed rule. The letter ( was sent from Commissioner Ted Nickel to Secretary Sebelius indicating that Wisconsin would not have enough time to gather stakeholder input on the essential health benefits package.

Insurance Market Rules. Insurance market rules in 2014 will change. The HHS proposed rule on these rules includes the new "modified community rating" requirements, guaranteed issue, and allowable state rate regions. The proposed rule also indicates HHS is considering ways in which states might continue their high risk pools beyond 2014. In addition, under the ACA, health insurers are prohibited from using health status in setting premium rates, with the sole exception of tobacco use. The proposed rule requests comment on how to obtain information about tobacco use from consumers, and also contemplates that any premium surcharge related to tobacco use for a small business consumer must be reduced to the extent the consumer participates in a wellness program. A separate proposed rule lays out the requirements for small business providing employee discounts for wellness activities.

Quality Standards in the Exchange. HHS is requesting comments through a Request for Information (RFI) on the appropriate quality standards for the health insurance exchanges. The RFI not only seeks information about quality measures for insurers, but also how commercial insurers currently address quality with their providers and appropriate provider measures such as those related to readmissions. WHA continues to support meaningful quality measures that are consistently applied. That is, WHA does not support new quality standards through the Exchange, but would encourage HHS to use existing outcome measures that are already being reported and part of other payment/penalty programs.

Reinsurance Risk Adjustment. Transparency and accuracy in risk adjustment mechanisms will be an important aspect of the health insurance exchanges to ensure insurers’ ability and willingness to compete in the new market. Under a new proposed rule, rather than a reinsurance program that distributes funds on a state level basis, HHS has determined that insurers must contribute to a national fund and can only become eligible for reinsurance payments when its claims costs exceed the national "attachment point." Thus, contributions to the reinsurance from Wisconsin insurers could be redistributed to other insurers not located in Wisconsin. WHA continues to analyze the potential implications of this new proposal as it relates to our guiding principles around maintaining a pluralistic insurance market in Wisconsin.

Multi-State Plan Program. The Office of Personnel Management (OPM) is charged with administering the ACA provisions for a multi-state plan program for the insurance exchanges. Under the ACA, OPM is required to contract with health insurance issuers to offer at least two multi-state plans through the insurance Exchanges in each state. OPM indicates in its proposed rule that it intends to implement this provision in a phased-in approach, and intends to allow multi-state plans to offer coverage in parts of a state, but not necessarily the entire state. A multi-state plan would have to offer the essential health benefits, but could choose between a national essential health benefits benchmark package selected by OPM, or the benchmark plan in each state in which it operates.

Links to each of the federal proposals and comment period deadlines are below:


Comment due date


Health Insurance Market Rules; Rate Review (CMS-9972-P)


Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation (CMS-9980-P)


Request for Information Regarding Health Care Quality for Exchanges (CMS-9962-NC)


Notice of Benefit and Payment (CMS-9964-P)


Establishment of Multi-State Plan Program for Affordable Insurance Exchanges


Incentives for Nondiscriminatory Wellness Programs in Group Health Plans (CMS-9979-P)



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President, House Leaders Urged to Incent "Value" During Fiscal Cliff Negotiations

Close to two dozen Members of Congress, including five from Wisconsin, co-signed a letter to President Obama, House Speaker John Boehner and Minority Leader Nancy Pelosi urging that federal health care programs like Medicare incent value in payments.

"As negotiations on the fiscal cliff continue, we urge you to address the largest and fastest growing area of federal spending—health care," the letter read. "We believe that we must keep moving away from fee-for-service health care and toward a system that provides better care at a better cost. We urge you to build on delivery system reforms and find further efficiencies through incentivizing the value of care provided instead of the volume of care."

Rep. Ron Kind (D-La Crosse) spearheaded the letter with his House colleagues. The Healthcare Quality Coalition, of which WHA is a founding member, encouraged legislators to sign onto this letter. In addition to Rep. Kind, Wisconsin Members of Congress signing the letter include: Reps. Reid Ribble (R-Green Bay); Gwen Moore (D-Milwaukee); Jim Sensenbrenner (R-Brookfield); and Sean Duffy (R-Wausau).

The letter discussed "indiscriminate" provider cuts and expressed concerns that such cuts would harm high value providers like those in Wisconsin.

"Such across-the-board provider cuts disproportionately harm low-cost, high-quality providers and the patients they serve. Instead, we believe robust, value-based payment and delivery system reforms will not only be better for the Medicare beneficiaries, but they will also put Medicare on a faster track toward efficiencies and better outcomes as seen in the private sector."

Read the letter at:

Read a separate letter value WHA sent to Wisconsin’s Delegation at:

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WHA Quality Team Visits Amery Regional Medical Center

On December 13, Tom Kaster, WHA quality coordinator, visited Amery Regional Medical Center to work with their Partners for Patients improvement teams.

Joanne Jackson, Amery regional’s administrator of human resources, community relations and quality improvement, has been the organizing force behind their well-engaged improvement teams. Jackson was a participant in the 2012 HRET Improvement Leader Fellowship.

"When I visit hospitals that have improvement leaders who participated in the HRET Fellowship, I am very impressed at how organized, engaged and effective their improvement efforts have been," Kaster noted.

Amery was no different. Jackson has done an outstanding job of organizing the teams, keeping them on track and engaged as well as facilitating front line staff involvement, according to Kaster. To ensure top-down engagement, Jackson brought patient safety concepts and goals to Amery’s Board of Directors. In addition, she has leveraged her HR influence and made Partners for Patients initiatives and patient safety core performance competencies for all employees.

Amery Regional Hospital is focusing on three Partners for Patients initiatives: Surgical Site Infections, Readmissions, and in January of 2013, they will be starting the Early Elective Delivery initiative. Below are just a few highlights of their great work.

Readmissions: The Readmissions Team has been focusing on post discharge call backs. They have found early successes and received positive feedback from patients on how helpful the calls have been. In addition, they have been key in developing a county-wide coalition that brings together representatives from area providers in home health care, long term care, community services and hospitals to help improve transitions of care and reduce unnecessary readmissions.

Surgical Site Infections (SSI): The SSI team has taken small test of change to heart. They started with a team that includes front line staff, their infection preventionists as well as a physician champion. Their first small test of change involved trialing new evidence-based methods of cleansing patients prior to surgery. They learned a great deal from their initial tests and are gearing up for future small tests.

OB Early Elective Delivery: The OB Early Elective Delivery team is poised to hit the ground running in January. They already have key staff on the team that includes a physician champion. To get a head start, they have been discussing how they can stratify their data and produce meaningful measures.

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Site Visits Begin for New Group of TCAB Hospitals

The second group of hospitals participating in Transforming Care at the Bedside (TCAB) kicked off in September. This month site visits began to the hospitals and nursing units in this new cohort.

The TCAB team at the William S. Middleton Memorial Veterans Hospital in Madison is measuring interventions to assure that each staff member receives an uninterrupted break. They are working on an hour of quiet time each day on the unit with positive feedback from both patients and staff. A strategy to assure timely turning of patients is also being tried. The team had a relatively slow start but has good ideas and is already working on improvements.

The team at Agnesian HealthCare/St. Agnes Hospital in Fond du Lac quickly learned more about nurse time at the bedside using their location monitoring system. They are doing a small test on change on bedside report using team members only. Collecting data on RN time and steps used helped them obtain a stock of incontinence supplies outside each patient room, which has been a win for the staff. The TCAB group reported to hospital leadership this week on their project and plans.

Stocking of patient care supplies was a quick project for the TCAB team at The Richland Hospital, Richland Center. Data collection about which items and what quantities were needed. This allowed for the right supplies to be available outside of each patient room, which reduced the total amount of supplies on the unit. The team has also measured time at the bedside and is currently working on a buddy system to allow coverage for breaks. This team has yellow cab stickers that they can place on their innovations to remind staff (and the team) of their TCAB improvements.

The Wisconsin TCAB initiative is an 18-month project that will end March 2014. Participants will each be expected to outline a plan to sustain the project after that date. Transforming Care at the Bedside is a WHA project funded through the Wisconsin Collaborative for Healthcare Quality by the Robert Wood Johnson Foundation.

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NGS Hosts Provider Outreach and Education Advisory Group for Wisconsin and Illinois

National Government Services, Inc. (NGS) held their quarterly Provider Outreach and Education Advisory Group meeting in Chicago December 12. Michael Davis, manager, outreach and education, stated the J6 (Wisconsin, Illinois and Minnesota) Medicare Administrative Contractor (MAC) protest will reach its 100th day on January 17. Davis noted that when a decision is made regarding a contractor there will be an aggressive transition schedule to bring both Part A and Part B providers in J6 together under the same management structure. Providers should monitor their email from CMS and the MAC for future communication regarding the transition.

Michael Dorris, congressional outreach liaison, provided an update on the A/B Contractor Comprehensive Error Rate Testing (CERT) Task Force. The purpose of this task force is to work collaboratively to improve the knowledge and performance of the provider community as it relates to the CERT program and to improve on accurate billing of Medicare claims. The A/B Task Force is to be used as a sounding board for CMS CERT tools such as the CERT website and the Medicare Learning Network. NGS encourages providers to take full advantage of these tools.

A couple of topics the A/B CERT Task Force plans to focus on in early 2013 are insufficient physician documentation and appropriate therapy documentation. According to NGS staff, half of the CERT cases providers respond to are submitted with "insufficient documentation" or "no documentation" to substantiate the services on the claim.

During the meeting, there was a review of the new data reporting and collection system for therapy services effective with dates of service on or after January 1, 2013. The requirements, which are outlined in change request 8005, implement a new claims-based data collection requirement for outpatient therapy services by requiring reporting with 42 new non-payable functional G-codes and seven new modifiers on selected claims for physical therapy, occupational therapy and speech-language pathology services. These new codes and modifiers provide information about the patient’s functional status at the outset of the therapy episode of care, specified points during treatment, and the time of discharge. Further instruction will follow regarding the editing required for claims with therapy services furnished on and after July 1, 2013.

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Wisconsin Hospitals Community Benefits: Charity Care

Fear of a bill should never prevent a patient from seeking care at a Wisconsin hospital. Wisconsin hospital charity care programs provided $232 million to more than 700 patients each day last year. The stories that follow illustrate the deep commitment and continuing concern that hospitals have to their patients to ensure they receive the care they need regardless of their ability to pay.

Charity care story

Around Christmas time, Steve Shepard of Appleton felt his health declining quite rapidly to the point where he couldn’t even get out of bed. This feeling lasted for about a week and when he finally decided to go to the hospital, it took him two hours to get down the stairs and out the door.

Before becoming ill, Steve went through a job loss and had heard about the affordable services provided at St. Elizabeth Hospital. Upon arrival at the hospital, Steve was taken right in and immediately diagnosed with severe blood loss due to internal bleeding, which required prompt treatment.

"I knew the people at St. Elizabeth Hospital were very understanding of the situation and that they would help me out," Steve said.

Because of Charity Care, Steve was able to receive six units of blood and was able to recuperate in the hospital over the weekend. He was also provided after-care upon being checked out and set up with food stamps. Charity Care helped with a portion of the $16,000 bill, and a patient financial advocate worked with Steve to set up an affordable monthly payment plan. Not only that, but the quality of care Steve received at St. Elizabeth Hospital renewed his faith in hospital care.

"Of all the times, their care was over-the-top the best I’ve ever received," Steve said. "They never made me feel like a number, but a person. They treated me with a lot of respect."

St. Elizabeth Hospital, Appleton

Unexpected surgery and help

"I’m generally a very healthy person," says Kim Loofboro. "I rarely needed to go to the doctor." And that was a good thing for this self-employed New Auburn resident. She didn’t have health insurance, so her good health kept her medical bills to a minimum.

That all changed in late 2010, when she had an appointment with her primary care provider, John Larson, MD, at Mayo Clinic Health System – Chippewa Valley in Bloomer. At the appointment, she found out she had a prolapsed uterus and, after discussing the options with Dr. Larson, Loofboro decided to have surgery to repair it.

"I didn’t know how I was going to pay for it," says Loofboro. She and husband, Scott, had not budgeted for a surgery and didn’t have the money available to cover the costs. That’s when she learned about Mayo Clinic Health System’s financial assistance program.

If patients need financial assistance, they can apply for it before or after services are given. In some cases, part or all of a medical bill may be forgiven. If treatment extends from one Mayo Clinic Health System location to another, financial assistance information can be transferred along too. This was the case for Loofboro, as she was treated at multiple Mayo Clinic Health System locations. This streamlined process reduces paperwork requirements and anxiety for patients.

"We understand patients aren’t always prepared for medical expenses. That’s why we have this program," says Becca McHugh, patient financial planning supervisor. "Our planners work very hard to help patients."

Loofboro completed the necessary paperwork and, for good measure, included a short note to the approval committee, thanking them for considering her application. A short time later, she was notified that her $22,000 medical bill was forgiven. "I just started crying when I got the letter. I wasn’t expecting that at all. I was so overwhelmed and appreciative!"

Loofboro continues her follow-up care with Dr. Larson and is able enjoy the "simple life" with her husband and Beagle named Moose. And she continues to show her gratitude for the medical and financial care she received. "After this, I sent a nice thank you card to everyone!"

Mayo Clinic Health System – Chippewa Valley, Bloomer

Help during life’s sudden turns

Carolyn vividly remembers the day she learned about Monroe Clinic’s Community Care program. As she arrived for her appointment, she informed the office assistant she was no longer insured.

"I started getting teary-eyed," Carolyn recalls.

Carolyn was a long-time patient at Monroe Clinic, but found herself in an overwhelming and unexpected situation. After experiencing severe pain, Carolyn required emergency spleen removal and a 10-day hospital stay at a different facility. One day after returning home, she lost her insurance coverage. While her previous care was covered, follow-up care and treatment for complications were not.

"I am currently unemployed, and my husband is a disabled veteran. Because my son just turned 19, I was no longer eligible for state assistance. There were no affordable private insurance options, especially in my current situation," explained Carolyn. "I have worked my whole life and always had coverage before, but now I found I was one of those people who fell through the cracks."

Much to Carolyn’s relief, Carrie Peterson, the office assistant, was reassuring and gave her information about Monroe Clinic’s Community Care program.

"Carrie was so kind, and Laurie Seffrood, Monroe Clinic’s patient financial counselor, was so helpful," said Carolyn. "I was wondering, ‘Are we going to lose our home?’ before learning about the Community Care program, but Monroe Clinic has been wonderful."

Carolyn has visited her primary care physician and required hospital visits. She still has not received a bill, though she knows if she does in the future, it will be reduced and can be repaid in affordable installments. In addition to the financial assistance, Carolyn is especially grateful for the compassion and respect offered to her by Monroe Clinic’s medical team and support staff.

"Every time I visit Monroe Clinic, they never bring anything up about my coverage problems. I never feel like a ‘charity case;’ they never made me feel stressed about that. Not once. They were always only focused on my health."

Monroe Clinic, Monroe

Charity care

Spooner Health System’s (SHS) mission is to provide high quality health care. Because SHS values their patients, they provide a sliding-scale discount on charges for medically necessary care to patients who qualify. Susan Johnson* is the primary caregiver for her husband, Larry*. She was very pleased with how SHS worked with her to get her husband’s account to a manageable balance. Larry had received eye surgery for cataracts at SHS, and they did not have the money to pay for the services even after Medicare paid their portions.

Susan met with a financial counselor and applied for charity care at SHS. They qualified for a 75 percent discount after Medicare paid. As the caregiver of the patient, she was very relieved and appreciative for her husband receiving this large discount and she gladly paid the remaining balance that was owed. She’s thankful he was able to receive the care he needed and not end up with a huge medical bill that they would be unable to pay.

*The patient’s and family member’s names in this story have been changed to protect patient confidentiality.

Spooner Health System, Spooner


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