July 27,2012
Volume 56, Issue 29


Health Care Executives See Wisconsin as "Leader State" in Reforming Health Care
Regardless of what happens with ACA, Wisconsin is "overhauling" health care system

With or without the Affordable Care Act in place, Wisconsin community health system and hospital executives are already well on the way to transforming the payment for and delivery of care in their communities.

On July 25, four of the state’s leading hospital and health system CEOs discussed health care reform in Wisconsin and the impact of the Supreme Court’s decision to uphold the Affordable Care Act (ACA) during a Wisconsin Health News lunch panel sponsored by the Wisconsin Hospital Association at the Madison Club. WHA Executive Vice President Eric Borgerding served as moderator.

Panelists included:

The panel discussion is available for viewing on Wisconsin Eye at: http://www.wiseye.org/Programming/VideoArchive/EventDetail.aspx?evhdid=6333

An edited transcript of their discussion follows:

Borgerding - AHRQ ranked Wisconsin as having the second best health care in the country (losing out to MN by .10%). In five years of AHRQ ranking, we’ve never ranked lower than #7. Wisconsin is often cited as one of the leading states in health care quality and delivery system innovation. Despite these high rankings from the AHRQ and numerous other studies, please identify one area where Wisconsin is underperforming and if the ACA will help, hinder or have no effect in this area.

Linton –We still are not delivering care exactly like we want to deliver it. We need to start caring for populations and get into the area of prevention. The shift will be in how we describe ourselves. We define ourselves in terms of hospitals and clinics, but those work structures are not ideal to take care of people. We need to think about how to care for people in a model that does not include a visit to a clinic. It pushes us to do what we need to do faster.

Ewert – The incentives should be focused on keeping people healthier. As they move into the exchanges and with the possible expansion of Medicaid, it gives us an opportunity to put them into risk pools where we can keep them healthier and that becomes part of our business plan.

Samitt – There are vast opportunities in service quality. Service is an indicator of quality while the majority of the Accountable Care Act is about coverage. The ACA encourages quality by rewarding organizations for providing better care. It is about payment reform, we need to overhaul the way we pay for care, abandon fee-for-service and volume based payments and pay for quality and outcomes. This notion was present in Wisconsin before the ACA and it will be present regardless of what happens with the ACA.

Samitt - My concern is how do we measure quality and define what better value is? Is it the government, the payer or the patient? It is a complex science. Will we have the data available to accurately measure our definition of quality, service, population health or even our definition of cost? We know that most of our measures are process, not outcome, based. While we might do an exceptional job in quality in this country, it might not include as many measures as it should. We need to be rewarded for better, not more, care. We need to make sure the information we use is reliable and that we bring all the stakeholders together to get a common definition of quality.

Gruner – Everyone is impacted by how we pay for care; it is not just a problem with how insurance pays a physician. When an employer buys based on the best discount they get, you are continuing to reinforce a broken system. When insurance companies negotiate with providers on a win-lose basis and you can’t come to a solution where both have a small win, it reinforces the fee-for-service payment system. Most of our systems pay doctors based on the number of patients that they see. That has to change.

Borgerding – We talked about the role that health systems play. We talked about payers and providers. What is the role of patients? Paying for outcomes puts providers squarely on the hook to be more transparent and produce better outcomes. We have to coordinate that carefully with our patients. We understand the problems with managed care in the 1990s and the response of patients then. Can you comment on why we should expect any different response now?

Linton – It is true there is a risk in defining how is this different. One of the core issues is it will be a challenge to build that trust with our patients. We want to give them all the care they need and not more. To do that we have to understand individual patient needs. What does it mean to the individual patient? All providers and payers have to work in partnership with the patient to build the trust we need to make this work. Overcome the fear that they will not get all the care that they want or that they need. It is not a simple or easy conversation to have. That is why it has not been a conversation. Compare that to getting all the care I am used to getting and I think I want. It is going to take some education.

Samitt- I think the reality is from the beginning the world has changed a lot. When I was in the HMO world reaching outcomes was about control and in the future it will be a partnership. We have much more information on how to manage risk. In the old HMO model, providers got risk dumped on them. In a shared savings program, the patients are not beholden to their health system. If the fear is my doctor is of poor quality, as a Medicare patient, I will switch. We as providers need to focus on better care and better loyalty and give patients exactly what they want. I think we will see some of the highest performers embrace this model first. They are going to demonstrate that they can maintain that trust. It’s a model of control v. partnership. In the HMO, we wanted to build a fence around the patients. That is how we thought we could influence them. But now we know the best possible fence is a greener pasture and that is how we build trust.

Gruner – The world was different from an economic standpoint in the 1990s. Health plans were full coverage. Now world events have influenced where we are. Employers now have high deductible plans. In surveys of our customers, we found that they want help managing their out-of-pocket expenses. I see the economy and the way we pay for health care has been made palatable, but 20 years ago it would not have been acceptable. Customers are asking for help to shop for health care more wisely. That is a significant change from 20 years ago. It will make it easier to have those conversations.

Ewert – From the patient experience perspective, it not about building a fence, but rather that we want them to stay on our pasture. We need to focus on the 5 percent that use 50 percent of the health care. When we focus on these folks we can predict when they will need hospitalization. We can deploy a nurse practitioner to head that hospitalization off at the pass. We know that 20 percent of what makes people sick can be influenced by our health care system, but 80 percent of it is outside of our control and is in the environment and in our communities. By taking care of the 5 percent we focus our efforts where the greatest amount of our health care dollars are being spent.

Borgerding – The ACA includes new models for care delivery, payment and risk assumption called Accountable Care Organizations. Some have been awarded Medicare ACOs, others did not pursue. ACOs have been almost universally recognized as a payment and care delivery model for the future, but some of our leading, most innovative health systems have chosen not to pursue them via MC in the ACA. In the context of payment reform and delivery system transformation, why did your organization take the approach it did on ACOs?

Samitt – At Dean, we historically lived in a schizophrenic place where nearly 50 percent of our revenues came from some form of value-based purchasing. We are rewarded for better care. The schizophrenia is that the other 50 percent is fee for service. We made the decision before the ACA that we would treat all patients one way, better care at lower cost. We did it because it is our strong suit. The ACO program rewards us for that. It is the right thing to do, better care at a lower cost. Our prediction is that we feel like we are skating toward the puck, which is exactly where everyone else wants to go. Ultimately, we will all need to head in that direction and we like to be first, so why not BE first?

Gruner – We became part of a Pioneer ACO. We asked ourselves if we want to be part of the problem or the solution. So we became part of the solution and we are going to try some new things. This is not playing to our strength as we are entirely fee for service, but it was a tolerable risk. Marshfield participated in a group practice demo project, which led to the development of the ACO program. We are now teeing up to apply to be an ACO as of January 1, 2013.

Ewert –The majority of our payments are coming through fee for service, too, but we have had some success negotiating on the value model. The other challenge for the employers is they want to know how soon we can show them a benefit for the care they pay for, say for example, treating high blood pressure can be a two-year deal. If you have a lot of turnover in your business, you don’t care about a savings over two years; they want to see the benefit soon after having paid for the care.

Samitt – This is a house of cards and it’s coming down. The first question I got was if the Supreme Court had decided differently, what would that have meant to the ACO movement? That horse is already out of the barn. Organizations are moving in this direction because of the value in it. Doctors that don’t go this way will be disadvantaged, to stay in the world of volume when the world is about value, waste is revealed in a risk world, not in a volume world. If the cost curve is going to bend, then providers have to engage. I think this is coming faster than any of us think it is. There are pilots all over the country. There will be many other health plans that are going to adopt these models.

Borgerding - Wisconsin has many integrated health systems, most of which are also closely affiliated with health plans. Can we expect a blurring of the lines, if you will, between health plan and health provider in the commercial sector, and does that necessitate a new look regulations in this area?

Samitt – I don’t think it is a blurring of the line, but the relationship is changing. Providers will bear more risk. The relationship will remain strong, integrated and aligned. When the players align--patient, provider and insurer-- the patient benefits.

"We’ve taken a deeper dive into the ACA today and we know there are policy choices and questions that will be confronting our policy makers, but those are different from the choices that are confronting our providers," Borgerding said in his closing remarks. "You have given us a glimpse of how Wisconsin will continue to lead no matter how ACA turns out."

Top of page (7/2

WHA Continues Push to Build Awareness of Wisconsin Health Care Quality, Value
Ads will run in major dailies Sunday, July 29

Wisconsin health care is among the very best in the country based on the quality of care that our providers deliver every day. And WHA is not shy about spreading the news.

This Sunday, July 25, WHA is running ads in 14 major daily newspapers. This is just the beginning. The Sunday print ad launches what will be a long term (12-18 month) effort by WHA to educate our communities and business leaders about the high quality and high value care that is a hallmark of the Wisconsin health care system.

"High quality, high value care is an economic asset and a competitive advantage for Wisconsin," according to WHA President Steve Brenton. "Our plan is to ensure that business leaders and consumers are aware that our state is already transforming care, well before the ACA became a law."

Over the course of the campaign, employers will be encouraged to contact their local hospital leaders to learn how they are improving care locally and how business and health care can work together to improve both community and employee health.

Top of page (7/27/12)

Guest Column: Court Rules Hospitals May File Liens on Injury Settlements Due Medicaid Recipients

by Attorneys Timothy W. Feeley and Sara J. McCarthy of Hall, Render, Killian, Heath & Lyman, P.C. Milwaukee

In Gister v. American Family Mutual Insurance Company, 2012 WI 86 (July 11, 2012), the Wisconsin Supreme Court held that charitable hospitals in Wisconsin may pursue payment for the medical care provided to Medicaid recipients by filing a lien against the settlement between the patient and the insurance company insuring the liability of the tortfeasor responsible for the patient’s injuries.

In Gister, the Court was required to harmonize the rights of Wisconsin charitable hospitals under Wisconsin Statute § 779.80 to file liens on the personal injury settlements obtained by an injured patient, with the prohibition under Wisconsin Medicaid law that hospitals cannot knowingly impose direct charges on Medicaid recipients in lieu of billing Medicaid. See WIS. STAT. § 49.49(3m)(a). The Gisters claimed that by filing statutory liens on their personal injury settlements, the hospital’s actions were akin to direct billing of the patients in lieu of billing Medicaid. The Gisters filed a lawsuit seeking to invalidate the liens on the grounds they were illegal.

After harmonizing the complex state and federal legal framework of the Medicaid Program with the Wisconsin hospital lien statute, the Wisconsin Supreme Court concluded that the liens filed by the hospital were permissible and did not constitute unlawful direct billing of the Medicaid-eligible patients.

Significantly, in rejecting the Gisters’ argument that the liens violated Wisconsin Medicaid laws, the Court also substantially limited the holding of the 1999 decision of the Wisconsin Court of Appeals in Dorr v. Sacred Heart Hospital, 228 Wis. 2d 425, 597 N.W.2d 462 (Ct. App. 1999). The question in Dorr was whether a hospital could file a lien against a settlement between a patient and a tortfeasor when the patient was protected by statutory and contractual immunity because of the contract that existed between the hospital and the patient’s Health Maintenance Organization. The Gisters argued that the court’s decision in Dorr operated to invalidate the hospital’s liens in their case because Dorr held that liens presuppose an underlying debt, and because Wisconsin Medicaid law precludes billing them directly, they owed no debt to the hospital for their medical care to support a lien.

The Wisconsin Supreme Court disagreed with the Gisters, holding that the facts in Dorr were legally and factually distinguishable because the Gisters were not insured by an HMO. The Court also expressly held that it disapproved of any interpretation of Dorr beyond its unique facts.

Attorneys Timothy W. Feeley and Sara J. MacCarthy of Hall, Render, Killian, Heath & Lyman, P.C. in Milwaukee litigated the case and were pleased with the Wisconsin Supreme Court’s decision. They noted that, in addition to placing the burden for hospital expenses on tortfeasors as opposed to on Medicaid, the case should also prevent future misplaced reliance on Dorr as a basis for invalidating hospital liens.

Top of page (7/27/12)

WHA Participates in Wisconsin Eye News Maker Broadcast Focused on Reform WHA: "Wisconsin is focused on improving quality, outcomes and value"

In an effort to help policy makers and the public understand how health reform will play out in Wisconsin, on July 25 Wisconsin Eye hosted a panel discussion to help shed some light on how policy and practice will shape the health care landscape.

Moderated by Wisconsin Eye Senior Producer Steve Walters, the invited panelists included WHA Executive Vice President Eric Borgerding; Tim Bartholow, MD, chief medical officer at the Wisconsin Medical Society; Sara Eskrich, health care policy analyst for the Wisconsin Council on Children & Families; and, Phil Dougherty, senior executive officer, Wisconsin Association of Health Plans.

In response to Walter’s question on what the organizations represented were doing to prepare for health reform, Borgerding explained that WHA’s advocacy efforts are focused on the best interests of Wisconsin’s community hospitals and the patients they serve.

"If you are in the business of delivering health care you have no choice but to do your planning based on the assumption that this law will be implemented and that the changes are going to take place," Borgerding said. "As an organization, we have to understand what the policy choices are going to be for Wisconsin and as an advocate for hospitals, we want to make sure that we are advocating to our decision makers what we believe and what our members believe are the best choices for Wisconsin."

How can organizations plan when there is so much political uncertainty with the upcoming November elections, Walters asked the group?

"One of the things that is minimizing some of the uncertainty here is the fact that Wisconsin is a leader in reforming health care delivery and payment. Because of the integrated nature of our health care, it delivers better quality, better outcomes and better value for our health care dollars," according to Borgerding. "With or without the ACA, Wisconsin is well down that road. It is a place we are not coming back from. The ACA may push some of that forward, or hinder it, but in Wisconsin we are moving in that direction already and we will continue to regardless of what happens in the elections."

The panel discussion in available on Wisconsin Eye at: http://www.wiseye.org/videoplayer/vp.html?sid=8501

Wisconsin Eye is privately financed and editorially independent to serve as an unbiased, non partisan resource for information and education

Top of page (7/27/12)

Physician Engagement Strategies Focus of WHA Leadership Summit
September 21 at Marriott Hotel in Madison

Specific, field-tested communication and collaboration strategies for physicians and health care executives that result in more coordinated, cost-effective quality care, is the focus of the three-hour 3.0 ACHE Face-to-Face Education credit session offered by Dr. Kenneth Cohn at the WHA Leadership Summit September 21.

During his session "Practical Strategies for Engaging Physicians," Dr. Cohn will identify 10 steps to engage physicians and enhance hospital-physician collaboration; as well as new strategies, tactics, financial incentives and tools to balance performance risk with utilization risk. Participate in Dr. Cohn’s session by registering for the Leadership Summit today at:


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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WHA Updates WCMEW on GME Task Force, Snyder Presents New PA Program

The Wisconsin Council on Medical Education and Workforce met July 24 at WHA headquarters in Madison, chaired by Chuck Shabino, MD, WHA senior medical advisor. Shabino introduced a new WCMEW member to the group, Tina Bettin, RN, DNP, FNP-BC, APNP, who is representing the Advanced Practice Nurse Forum of the Wisconsin Nurses Association.

A new physician assistant community–based track has been created in Marathon County, the specifics of which were presented by Virginia Snyder, PhD, PA-C, from the University of Wisconsin School of Medicine and Public Health physician’s assistant program. The objective of the program is to increase the number of physician assistants entering primary care in partnership with the primary care clinicians in north central and northern Wisconsin. The goal is to enroll four students in 2014, eight in 2015, and 12 by 2016, with a 75 percent graduate placement in primary care.

Snyder said the sponsors want to do targeted, regional recruitment and training and eventually place the students in rural areas in northern Wisconsin. The collaborative that supports this effort includes UW-Marathon County, UWSMPH, Aspirus, Marshfield Clinic, Wausau Family Medicine Clinic (Aspirus/UW Health), Ministry, the Office of Rural Health and the Northern Area Health Education Centers.

Larry Pfeiffer, executive director of the Wisconsin Academy of Family Physicians, updated WCMEW on the plans for a Primary Care Summit this fall. The purpose of the Summit will be to convene leaders representing multiple stakeholders. They will discuss issues related to the future of primary care in Wisconsin.

Shabino updated the Council on the activities of the WHA GME Task Force, including the most recent developments related to proposed strategies to increase the proportion of Wisconsin medical school graduates seeking residency training in Wisconsin, recognizing that Wisconsin retains 80 percent of the medical school students that complete an in-state residency.

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CMS Provides ICD-10 Update to All Fee-for-Service Providers

On July 19 CMS sent some words of advice to all fee-for-service providers regarding ICD-10 via their fee-for-service listservs.

Although the final rule on the proposed ICD-10 deadline change has yet to be published, CMS notes it is important to continue planning for the transition to ICD-10. The switch to the new code set will affect every aspect of how your organization provides care, from registration and referrals, to software/hardware upgrades and clinical documentation.

A critical step in planning for the transition is to conduct an impact assessment of how the new code sets will affect your organization. Your impact assessment should include:

Documentation Changes: You will need to consider the increased specificity of ICD-10 codes compared to ICD-9 codes, and ensure that patient encounters are documented with appropriately comprehensive clinical descriptions. You should:

o Train staff to accommodate the substantial increase and specificity in code sets

o Consider physician workflow and patient volume changes

o Revise forms, documents, and encounter forms to reflect ICD-10 codes

o Evaluate processes for ordering and reporting lab/diagnostic services to health plans

Reimbursement Structures: You should coordinate with payers on contract negotiations and new policies that reflect the expanded code sets, since they can affect reimbursement schedules.

Systems and Vendor Contracts: Ensure your vendors can accommodate your ICD-10 needs. Find out how and when your vendor plans to update your existing systems. You will need to review existing and new vendor contracts and to evaluate vendor offerings and capabilities against your organization’s expectations. Work with your vendors to draft a schedule for needed tasks.

Business Practices: Once you have implemented ICD-10, you will need to determine how the new codes affect your processes for referrals, authorizations/pre-certifications, patient intake, physician orders, and patient encounters.

Testing: Work with your vendors to determine the amount of time needed for testing and schedule accordingly.

ICD-10 will affect nearly all areas of your hospital and health system, but with a thorough impact assessment, you can keep your day-to-day activities running smoothly while you transition to ICD-10. The CMS ICD-10 Web site is available at http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10 with the latest news and resources to help you prepare. In addition to the national resources, a Wisconsin-specific resource on ICD-10 implementation issues can be accessed at: WICD10.org

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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. 


Community Care Program

“I have not worked since March, 2010. I have no money, no assets.  My last paycheck was spent on my medicine and was used up in less than a week.  I applied for any and all help that might be available.  I hadn’t heard from anyone, but then Mile Bluff helped me.”

      These words were found in a letter to Mile Bluff Medical Center, thanking the organization for its financial aid.  As a nonprofit organization, Mile Bluff offers programs and services for everyone in the area - regardless of their ability to pay.  This passion for helping people is amplified by the Community Care Program that Mile Bluff has set up to help those who need assistance in covering health care expenses.

      Difficult economic times can take a toll on many people, but when mounting medical bills are added, the stress can be overwhelming.  Mile Bluff understands this and created the Community Care Program to ease the strain of these trying times.  Advocates from Mile Bluff assist patients to determine their individual financial assistance eligibility, based upon each patient’s need. 

      During the 2010 fiscal year, Mile Bluff was able to help 854 individuals who were unable to pay some or all of their medical bills.  Over $1,000,000 of debt was forgiven through its Community Care Program.

      Mile Bluff Medical Center has been serving the community since 1883. Throughout this time, Mile Bluff has stayed committed to providing compassionate and progressive care, improving the health and wellness of the community, and going beyond expectations in health care. 

      Operating the only hospital in Juneau County, Mile Bluff is dedicated to serving the region with health care evolving for life, and this includes helping its patients through the Community Care Program.

Mile Bluff Medical Center, Mauston

Hospital helps stroke patient return to health

Hipolito Valdivia-Ramirez had always been a healthy, working man. But that all changed on July 20, 2010, when he suffered a stroke.

      Hipolito was driving home from Milwaukee when he began to feel ill and lost strength in his right hand and leg. Upon arriving home, he climbed into bed, thinking rest might help. Instead, Hipolito began to feel worse. His wife helped him up and he drove himself to the Emergency Department at Wheaton Franciscan Healthcare – All Saints in Racine where he was admitted for a stroke. He spent four days in the hospital.

      Exactly two months later, Hipolito suffered a second stroke, one far worse than the first.  This time, he was hospitalized for 23 days and received specialized care, including physical and speech therapy.

      “The care I received was amazing, but there was always the worry of how I was going to pay for all of this,” Hipolito said. “It was very scary and troublesome.”

      A financial counselor visited Hipolito during his stay at All Saints and helped him apply for Community Care, which provides free or discounted care to those in need.

      Hipolito’s application was approved, and he was finally able to focus on what was most important – getting healthy again.

      Wheaton Franciscan Healthcare’s Community Care program provides free or discounted care to those in need. In 2010, Wheaton Franciscan Healthcare in Southeast Wisconsin provided approximately $16.8 million in free or discounted health services to those who cannot afford to pay and who meet all criteria for financial assistance.  Charity care is based on actual costs, not charges, and does not include bad debt.

Wheaton Franciscan Healthcare - All Saints, Racine

When people need a helping hand

There are times in life when any good person just needs a helping hand. For Maryann, that time came when, at 55 years of age, she began to experience unexplained rectal bleeding. She knew she needed medical attention. She decided to go to the Emergency Department at Aurora Memorial Hospital of Burlington, where the doctors suggested an immediate colonoscopy to further explore the causes of the bleeding. 

      But Maryann refused to consent to the procedure before consulting with a financial counselor to discuss her financial situation. She had every reason to worry about a hospital bill, as she was homeless, living with a friend temporarily and had no health insurance or income.

      Maryann met with Financial Counselor Diane Mantey to discuss her payment options. Looking back, Diane reports, “She was upfront about her situation and did not want to incur any medical bills.”

      Diane introduced Maryann to various community resources, including the Well Woman program through the Racine County Health Department. In addition, Diane provided Maryann with the Aurora Helping Hand Patient Financial Assistance Program application.

      Within a couple of days, Diane received news that Maryann was approved for a 100 percent discount through the Aurora Helping Hand Patient Financial Assistance Program and was pleased to share the news with her. Relieved, Maryann consented to the procedure and was able to have the colonoscopy.

      Diane noted, “Maryann was so impressed with her whole experience that later, when she was back on her feet, she returned to the hospital as a volunteer to give back and provide community services.”

Aurora Memorial Hospital of Burlington


Community Care patient letter

“Dear Sir/Madam:

      I received your letters . . . and I just want to thank you for reviewing my situation and forgiving my balances due to the hospital and clinic. I received excellent care from all the nurses while I was in the hospital. Dr. . . . has been very kind and has treated me like I am somebody, and I am very appreciative of her. It is so hard to go through something like this, and the stress the bills play are something else! I feel like the biggest junk of steel has been lifted off of my shoulders and now I can focus on healing and getting my body healthy.

      Again – words in this letter cannot explain how you have made me feel! Thank you, thank you, thank you!”

UW Hospitals and Clinics, Madison

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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