July 13, 2012
Volume 56, Issue 28

Wisconsin Supreme Court: State and Federal Law Permit Hospital Lien
"Tortfeasors and their insurers should bear the burden of the hospital expenses they create, not government payers such as Medicaid and Medicare"

In an important case for the hospital community and the state as a whole, the Wisconsin Supreme Court this week acknowledged the sound statutory scheme in Wisconsin that protects, rather than depletes, valuable Medicaid resources. The Court held that a hospital may pursue payment for the care provided to an injured Medicaid-eligible patient by filing a lien against the settlement between the patient and the insurance company covering the liability of the person responsible for the patient’s injuries.

Writing for the majority, Justice Michael J. Gableman said, "[W]e have harmonized the complex state and federal legal framework surrounding Medicaid with the hospital lien statute. We conclude that the soundest harmonization of the two permits Saint Joseph’s liens[.]" Justice Gableman was joined in his opinion by Justices Roggensack, Ziegler, and Prosser. Justices Bradley and Crooks and Chief Justice Abrahamson dissented.

The patients, the plaintiffs in this case, were injured in an auto accident when the defendant ran a stop sign and crashed into their car. The plaintiffs were taken to Saint Joseph’s Hospital of Marshfield where they were treated for their injuries. The value of the medical care provided to the plaintiffs by Saint Joseph’s totaled $182,799.61. The plaintiffs were all enrolled in Medicaid at the time of the accident. Saint Joseph’s Hospital did not bill Medicaid for the cost of the medical care; instead, Saint Joseph’s filed a lien against the proceeds of any future settlement reached between the plaintiffs and the defendant’s insurer.

Saint Joseph’s Hospital argued that when a third party is liable for the costs of a Medicaid recipient’s health care, federal and state law authorize payment from the liable third-party. Tim Feeley and Sara MacCarthy, attorneys with Hall Render Killian Heath & Lyman, represented Saint Joseph’s Hospital in this case. Explaining the importance of this decision, Feeley said, "If hospitals were precluded from filing liens to recover costs for care rendered to persons injured due to the negligence of another, the burden to pay would be shifted to taxpayers. Wisconsin’s Medicaid program would be depleted not only by having to pay for services that should have been paid by third-party liability, but also by having to shoulder the costs associated with "pay and chase," a result that is clearly contrary to the Legislature’s intent."

Pleased with the Court’s decision, WHA Executive Vice President Eric Borgerding noted, "Tortfeasors and their insurers should bear the burden of the hospital expenses they create, not government payers such as Medicaid and Medicare."

A copy of the Court’s decision in Gister v. American Family Mutual Insurance Company is available at: www.wicourts.gov/sc/opinion/DisplayDocument.pdf?content=pdf&seqNo=84729.

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Health Policy Expert Wynne Headlines WHA Town Hall on Health Reform
Serious issues remain related to Medicaid expansion, insurance exchanges

The long-awaited Supreme Court ruling on the health reform law continues to raise questions and concerns. At WHA’s first Telephone Town Hall Meeting July 12, health policy expert Billy Wynne, senior vice president & principal of Health Policy Source in Washington, DC, guided WHA members through several of the main issues raised by the Court’s decision. (Link to Wynne’s presentation: www.wha.org/healthReform.aspx.)

Wynne identified key issues as those related to the Medicaid expansion and to the health insurance exchanges. While the Court addressed the individual mandate squarely, its Medicaid decision raised many questions for states regarding eligibility levels, payments and subsidies in the insurance exchange.

With respect to the health law’s expansion of Medicaid, the Court found that the requirement that states expand their Medicaid programs or risk losing all federal Medicaid funding as "coercive." In effect, the Court said that a state may choose whether to expand its Medicaid program and receive an enhanced federal Medicaid match rate for the newly-eligible individuals. Should a state choose not to expand, it will not risk losing existing Medicaid funding. Therefore, the decision also raises many questions about the terms for expansion, other Medicaid provisions that still apply, and the process by which a state elects to expand. With respect to the latter, Governors that want to move forward and expand their Medicaid programs may find it difficult to do so without their Legislature’s support, according to Wynne.

An important question also related to Medicaid expansion is whether Wisconsin would qualify for the enhanced federal match for "newly eligibles" given the fact that Wisconsin’s Medicaid eligibility levels are already above those envisioned under the health reform law (ie: 133 percent FPL). Wynne also said states could consider moving Medicaid recipients who are above 133 percent FPL into an exchange.

The exchanges are sometimes referred to as an "Expedia.com" for insurance plans, said Wynne, with premium subsidies available only to those whose income levels qualify and who purchase insurance through an exchange. The interplay between individuals who qualify for Medicaid and those who could receive subsidies in the exchange are key areas each state will need to understand.

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WHA Letter to Hill: Wisconsin Ranks #2 in AHRQ "State Snapshot"

In a letter to Wisconsin’s Congressional Delegation, WHA President Steve Brenton highlighted the recent "State Snapshot" report by the federal Agency for Healthcare Research & Quality (AHRQ), which ranked Wisconsin #2 in the nation for health care quality.

"The Wisconsin Hospital Association is proud to represent Wisconsin hospitals and integrated health care systems that are constantly driven toward delivering better results for our patients and improved health care value for all consumers and payers in Wisconsin," said Brenton in the letter.

Wisconsin ranked #2 in the United States with an aggregate score of 67.2. Minnesota slightly edged Wisconsin out of the top slot with a score of 67.31. The AHRQ looked at a total of 154 measures across a variety of care settings, including hospitals. Wisconsin’s performance across these care settings is strong and has improved since last year.

"As is evidenced by the AHRQ rankings, working together our hospitals and integrated health care systems continue to show the depth and commitment of their efforts to improve quality, patient safety and cost-efficiency in order to provide the highest value care possible. We ask for your continued support as we move Wisconsin’s health care system forward," the letter closed.

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WHA’s Inaugural Leadership Summit, September 21 in Madison

The WHA Leadership Summit, scheduled September 21 at the Marriott Hotel in Madison, is a one-day event focused on learning, networking and peer recognition opportunities for WHA members. This new event, which replaces the traditional WHA annual convention, will highlight examples of innovative and bold leadership, offer actionable strategies, and provide valuable insight on ways to lead in the provision of high quality, affordable and accessible health care services, resulting in a healthier Wisconsin.

The Summit will start with a preview of the upcoming November 2012 elections by nationally-respected political analyst and independent public opinion pollster Scott Rasmussen, founder and president of Rasmussen Reports. In addition, there are two great track options, so you can choose the one that best meets your interests and needs:

Registration is now open for the 2012 WHA Leadership Summit at: http://events.SignUp4.com/12LeadershipSummit0921.

If you need hotel accommodations, a block of rooms is being held at the Marriott Madison West Hotel for the evening of September 20. You can make a reservation in the WHA block by calling 888-745-2032 or 608-831-2000 before August 31.

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President’s Column: Time to Take a Deep Breath

Note to Republican Governors:
Please refrain from declaring your intention to reject ACA enabled Medicaid expansions in 2014. Such a largely political decision today may be regretted in a few months.

Note to Democratic lawmakers and pundits: Please stop baiting Republican Governors to immediately declare their intentions (see above). Ideologically-driven rhetoric may appear foolish once the dust settles in a few months.

Political posturing and hyperbole must be ratcheted back on the Medicaid expansion issue. There are just too many important questions to be answered related to the recent Supreme Court decision which potentially gives states a lot of leeway as to their future Medicaid expansion decisions. And that’s leeway not envisioned by the authors of the ACA who thought they had taken a "do it this way or else" approach.

Earlier this week, the National Association of (State) Medicaid Directors asked CMS officials for answers to about 30 questions that must be answered prior to state-level decision making. Those questions run the gamut from issues that are unique to already high coverage states like Wisconsin, to basic process queries relating to timelines, deadlines and waivers. Realistically, it will take CMS many weeks to provide detailed answers to these questions, and then it will take the states many more weeks to establish their action plans.

For most states—both red and blue—Medicaid is viewed as a budget buster that competes with other popular programs for scarce resources. The fact that under the ACA the feds will pick up most of the early costs of expansion doesn’t answer the question—what happens after that?

As it relates to state-level ACA implementation, WHA has endorsed the need for work to resume on the creation of a state level, market-focused insurance exchange—an unlikely development in the current political environment. That’s unfortunate and creates added uncertainty for the post November 6 environment. But we are pleased that Governor Walker has NOT rushed to judgment on the Medicaid expansion issue.

WHA’s health reform principles support "affordable coverage for everyone’s basic health care needs." The principles also state that government "must play a role in guaranteeing access for our most vulnerable populations." But Medicaid is not the only game in town under the ACA. Armed with tax credits, the new insurance exchanges may be a preferable option to Medicaid for higher income populations. And the Supreme Court decision provides states with flexibility that was absent in the ACA, specifically the ability to fashion "reformed" Medicaid programs that incent personal responsibility and encourage the movement away from Medicaid coverage to private coverage.

States will likely have significant leverage to create innovative approaches because of the recent Supreme Court decision. That’s exactly what many Medicaid critics of a "one size fits all" approach have demanded for years. Let’s take a deep breath and not rush to judgment in the current charged and uncertain environment. There’s plenty of time to develop a sensible approach that works best for Wisconsin.

Steve Brenton

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Extension of Therapy Caps to Outpatient Services

Earlier this year Congress passed and the President enacted the Middle Class Tax Relief and Job Creation Act, which provided a 10-month patch to physician Medicare payments among other provisions. Contained within the law was an extension of therapy caps and exceptions process to outpatient services. The caps affect therapy services provided in hospital outpatient departments (HOPDs), outpatient rehabilitation facilities, comprehensive outpatient rehabilitation facilities, skilled nursing facilities and medical offices. Services provided in critical access hospitals are excluded.

The changes are effective October 1 and will be in place through the end of 2012. Although the therapy caps are only applicable to hospitals for services provided on or after October 1, 2012, claims paid for outpatient therapy services since January 1, 2012 will be included in the patient-specific caps.

The Centers for Medicare & Medicaid Services (CMS) released Transmittal 2457 to provide guidance on these changes regarding affected therapy services—physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP).

The transmittal

Transmittal 2457 does not provide detailed information on how CMS will implement the manual medical review process for claims that exceed $3,700. Access the transmittal at: www.medicarefind.com/searchdetails/Transmittals/Attachments/R2457CP.pdf.

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CMS Releases Three Proposed Rules
Outpatient PPS/ASC, Physician Fee Schedule and Home Health

The Centers for Medicare & Medicaid Services (CMS) on July 6 released three proposed rules for calendar year (CY) 2013—the outpatient prospective payment system (PPS) and ambulatory surgical center (ASC) rule, the physician fee schedule (PFS) rule, and the home health (HH) payment system rule. A few highlights on each of the proposed rules are listed below.

Outpatient PPS/ASC Proposed Rule

Physician Fee Schedule Proposed Rule

Home Health Proposed Rule

Watch for a more detailed analysis in the coming weeks on the WHA website at www.wha.org/medicare.aspx.

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Grassroots Spotlight: Divine Savior Healthcare Hosts Legislators

On July 12, Sen. Jon Erpenbach (D-Middleton) and Rep. Fred Clark (D-Baraboo) met with CEO Mike Decker and several other senior leaders at Divine Savior Healthcare in Portage. The visit was the first for Sen. Erpenbach, as redistricting changes now have Divine Savior Healthcare in his Senate district. Even with the changes, Clark remains the hospital’s Assembly Representative.

Besides being an excellent opportunity for legislative relationship building, the meeting allowed for an in-depth discussion on several hospital and health care issues including Medicaid, the Supreme Court’s decision on PPACA and what it means for Wisconsin, the state’s physician shortage, and the importance of hospitals to their local communities.

Also joining the meeting from Divine Savior Hospital were Craig Telega, Jan Bauman, Jennifer Bieno, and Haley Gilman.

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Three Wisconsin Health Systems Join CMS Shared Savings Program

Three Wisconsin health systems were accepted into the Centers of Medicare and Medicaid Services (CMS) new accountable care programs. Dean Clinic and St. Mary’s Hospital Accountable Care Organization, ProHealth Solutions and Aurora Accountable Care Organization are participating in this program.

CMS defines an ACO as a group of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated, high-quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. According to CMS, when an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

There are three types of accountable care organizations:

Original program
– is what CMS calls the Medicare Shared Savings program. This is a fee-for-service payment, with shared savings/shared losses at the end. Dean Clinic and St. Mary’s Hospital Accountable Care Organization, ProHealth Solutions and Aurora Accountable Care Organization are participating in this program.

Pioneer ACOs
– for organizations with experience offering coordinated, patient-centered care and operating in ACO-like arrangements. In the first two performance years, it is still a FFS payment with higher levels of reward and risk than in the Shared Savings program. In year three, Pioneer ACOs that have shown savings over the first two years are eligible for a "population-based" payment model—essentially a capitated payment. This would replace some or all of the ACO’s FFS payments with a prospective monthly payment. Some Pioneers may have also suggested alternative payment arrangements in their applications. Bellin/Theda Care Healthcare Partners and Allina Health are pioneer ACOs.

Advance Payment program – The third ACO program is an advanced payment model for ACOs that include only hospitals that are critical access hospitals and/or Medicare low-volume rural hospitals and that have less than $80 million in total annual revenue. These ACOs get advanced payments (they have to pay back from savings) to help with up-front costs. In April CMS announced the organizations participating in the Advance Payment Model beginning April 1, 2012. None are in Wisconsin.

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New Discharge Transportation Rules Begin September 1 in SE Wisconsin
Medicaid rules on meals and lodging also updated

On July 9, the Wisconsin Department of Health Services released two new Forward Health Updates relating to non-emergency transportation for Medicaid enrollees.

The first Update – No. 2012-31 announces the expansion of the Logisticare transportation management system to Medicaid HMO enrollees in Milwaukee, Waukesha, Washington, Ozaukee, Kenosha, and Racine Counties, effective September 1. In summary, beginning September 1, hospital discharge planners that arrange for non-emergency medical transportation for southeast Wisconsin Medicaid HMO members should follow the same procedures for arranging for transportation for Medicaid HMO members through Logisticare as they currently do for arranging transportation for fee-for-service Medicaid members. The full Forward Health Update No. 2012-31 can be found at www.forwardhealth.wi.gov/kw/pdf/2012-31.pdf.

The second Update – No. 2012-30 details three Medicaid transportation policies. First, the update sets written policies regarding meals and lodging reimbursement for Medicaid enrollees. Second, the update also restates Wisconsin Medicaid policy regarding parents/guardians’ responsibility to provide their own car seat or booster seat for their children when traveling via non-emergency medical transportation paid for by Medicaid or its contractor, Logisticare. Third, the update restates existing Federal CMS policy that Wisconsin Medicaid/Logisticare cannot provide transportation to persons other than a Medicaid enrollee that has a medical appointment, a medically-required attendant for the Medicaid enrollee with the medical appointment, or a parent or guardian accompanying a minor child to the child’s medical appointment. The full Forward Health Update No. 2012-30 can be found here: www.forwardhealth.wi.gov/kw/pdf/2012-30.pdf.

Additional information about Logisticare and Medicaid transportation policies can be found at WHA’s website at: www.wha.org/logisticare.aspx.

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Wisconsin Academy for Rural Medicine Continues to Grow, Attract Top Students
25 new medical students admitted to WARM; Program total now at 105

The glance through the biographies of the newest class of students admitted to the Wisconsin Academy of Rural Medicine (WARM) reveals that they have one thing in common: A collective desire to serve others. Nearly every profile includes mission or community service, both domestic and abroad, a trait that no doubt reflects their desire to practice medicine in less urban areas.

Since 2007, the WARM program has admitted 80 students. By all measures, the program has been successful in recruiting students that are more likely to establish a rural medicine practice when they complete their training.

According to WARM program director Byron Crouse, MD, "The admissions process used to select the WARM students has been very effective in selecting students committed to rural Wisconsin as reflected in their biographies. More importantly, their commitment to practice in rural Wisconsin remains high when they matriculate, and it is evident throughout their medical school experience. With our first two graduating WARM groups, 70 percent (or about twice the number in the regular program) are staying in Wisconsin for their residency education, and the others are doing their residencies in border states."

WHA Senior Medical Advisor Chuck Shabino, MD, said Wisconsin exports far too many physicians that are trained at one of the in-state medical schools.

"The good news may be that we are able to attract out-of-state physicians to Wisconsin. The bad news is that as the national physician shortage increases, the competition for those physicians will intensify," Shabino said.

Instead, Shabino advocates for a "grow our own" strategy, that is, attract Wisconsin students to medical careers, educate them in Wisconsin and retain them in practices here. This will require an increase in medical school admission numbers, preferential admission of Wisconsin residents who have an interest in practicing in Wisconsin, and establishing training experiences in underserved areas of the state.

"It is important that we connect the WARM students with Wisconsin-based residency programs if we are to optimize the potential for recruiting them to practice in our state," according to Shabino. "Equally important is that as the number of WARM students graduating each year increases and the Medical College of Wisconsin expands its class size, we must increase the number of graduate medical education (GME) positions in our state by a corresponding number."

The WHA GME Task Force continues its work on developing strategies to expand the number of residency training positions in our state and connect medical students, including those in the WARM program, with Wisconsin-based residency training programs.

For more information about WARM, visit www.med.wisc.edu/warm. The biographies of the newly-admitted WARM students and is at: www.wha.org/Data/Sites/1/workforce/2012WARMprofiles.pdf.

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Member News: CEO Garith Steiner Announces Retirement

Vernon Memorial Healthcare (VMH) Chief Executive Officer Garith Steiner will retire July 20, 2012. Steiner has been at the helm of the rural independent southwest Wisconsin corporation which owns Vernon Memorial Hospital, five medical clinics, three retail pharmacies and a home health/hospice agency for the past 24 years.

Steiner has worked in VMH administration in Viroqua since 1985 when he served as assistant administrator under then CEO, Jim Hudson. He was named associate administrator in 1987 and was named CEO/administrator in April 1988. Prior to that, Steiner worked as a registered nurse for VMH and the Vernon County Health Department.

Steiner has served on the Wisconsin Hospital Association Board of Directors and he has also served as a board member of Shared Health Services Corporation, Tri-State Ambulance Service, Bad Axe Development Corporation, and the Western Wisconsin Technology Zone Board. In addition, he is a past member of the Governor’s Task Force on Telemedicine, Viroqua Area School Board, Bethel Home and Services Board, and State Bank of Viroqua Board of Directors.

Steiner was named the Young Healthcare Executive of the Year in 1992. He and his family were honored as the 2002 Viroqua Rotary Club Family of the Year. He was honored with the 2005 Best of the Best Award from the Partners of Wisconsin Hospital Association. He received the 2007 Leadership in Rural Health Award from the Coulee Region Community Action Program and was named a 2010 Rural Health Ambassador by the Rural Wisconsin Health Cooperative.

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Wisconsin Hospitals Community Benefits: Acute, Chronic and Communicable Disease Prevention and Control

Hospitals are well aware of the critical role they have in protecting public health. Whether it is working with public health agencies to develop protocols and responses to pandemic flu outbreaks, teaching children proper hand-washing techniques or educating people about how to live with chronic conditions, Wisconsin hospitals partner with key stakeholders to improve the health status of their communities.

Chronic disease initiative

St. Mary’s Chronic Disease Initiative to reduce readmissions has dual goals of keeping the community healthier and containing health care costs. As part of that initiative, St. Mary’s Hospital sponsored a free community education program called "Heart to Heart: Living Well With Heart Failure."

Because the seminar was sponsored jointly with WISC-TV and Channel3000.com, the event received widespread promotion on air and online, and meaningful education occurred before and after the event itself.

Even in its infancy, the Chronic Disease Initiative has tracked success. Readmissions have dropped from 21.52 percent in 2010 to 18.98 percent year to date in 2012, attributed to the careful follow-up by phone with patients who are released from the hospital.

Each patient is called for different durations and with varying frequency, depending on their needs. The first week after discharge, every patient gets two calls to get them into the routine of checking their weight and monitoring other signs. The calls continue for the first month after discharge from the hospital, but some patients remain on the call list for longer periods, depending on their acuity, support system, progress and goals.

St. Mary’s sister hospital in Baraboo, St. Clare, has also adopted the initiative, improving lives on a regional level.

St. Mary’s Hospital, Madison

A hands-on approach

More than 275 second-grade students from Medford, Stetsonville, Gilman, Prentice, Ogema, and Rib Lake public and private schools toured Memorial Health Center as part of the health center’s annual Mini-Medics program.

The children learned about good hand washing techniques and surgical procedures, held a doll that shows the effects of shaking a baby, climbed into an ambulance, and more.

The intention of this annual program is to dispel fears by giving children a positive firsthand hospital experience, to educate them about common health services, and to introduce various medical professions in a simple and fun way.

What started in 1972 with a small group of about 15 children has grown to reach 200 to 300 students from eight schools within the hospital’s service area each year.

Memorial Health Center – An Aspirus Partner, Medford

Oncology patient navigator program

At St. Nicholas Hospital, we take cancer personally.

Hearing the news that you have cancer can, at times, be overwhelming. St. Nicholas Hospital provides a "patient navigator" at no charge to help guide patients medically, emotionally, and spiritually. We take a "whole health" approach as we work with patients and their families in each step of the cancer process. Patient Navigator Joyce Tyeptanar is available to answer questions, lend assistance, and provide a basis for hope and healing for patients.

People often do not think about how important hair is until they face losing it. And if you have cancer and undergo chemotherapy, one of the possible side effects is the loss of hair. This is one of the most emotional experiences a cancer patient can go through. St. Nicholas has a hat and wig room available to oncology patients in Sheboygan County—whether they are a patient of the hospital or not. Joyce has provided more than 345 hats or wigs this year.

"Not only do these women use the headwear they receive for everyday purposes but also special events. I have given a wig to a woman getting a military ID with her husband because she wanted hair in her picture and several women who wanted a wig to wear for a wedding," said Joyce.

In addition to working with cancer patients directly, Joyce works with the general public to connect them with cancer resources and support.

In 2011, the American Cancer Society (ACS) estimates that 230,480 women in the United States will be diagnosed with an invasive breast cancer, while another 54,010 women will be diagnosed with in-situ breast cancer. Aside from skin cancers, breast cancer is the most frequently diagnosed cancer in women and also the second leading cause of cancer death in women.

Mammography rates have more than doubled for women age 50 or older and breast cancer deaths have declined in the last 20 years with the help of breast cancer awareness education. Though this is great news, there is still a need to provide breast cancer education, as early detection is key in saving lives.

One of the key ways for early detection is by getting a mammogram. The ACS recommends women age 40 and older to get a mammogram each year.

Joyce has worked with several women to provide them with a mammogram because they had little or no health insurance. Joyce worked with a middle-aged woman who was recommended by her primary physician to receive a mammogram, but she had no insurance and was not eligible for the Wisconsin Well Woman Program. In 2009, the Koene family from Sheboygan Falls bestowed a gift of $4,000 to the Friends of St. Nicholas Hospital to provide financial support for women who cannot afford to pay for the cost of a mammogram. Through the Friends of St. Nicholas, this woman was able to receive a mammogram.

St. Nicholas Hospital, Sheboygan

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

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

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