WHA Board Discusses State Budget, Hears from Attorney General Josh Kaul

WHA Recognizes Ascension’s Deb Standridge

July 02, 2019

The WHA Board met June 27, and in addition to welcoming special guest Wisconsin Attorney General (AG) Josh Kaul, learned more about WHA’s progress on its annual goals and success with the state budget.

Eric Borgerding, WHA President and CEO, noted that WHA continues to make excellent progress on its annual goals centered around advocacy, the legal and regulatory environment, health care workforce, health IT, and much more.

“We bring value to our members by being impactful and relevant,” said Borgerding. “We remain focused on a robust agenda on both the state and federal level, our priorities reflecting the dynamic health care environment. In the first half of 2019, a majority of our advocacy work has been focused on the state budget, but we have also kept an eye on the rest of our initiatives and continue to make good progress toward achieving our annual goals and the many issues that emerge in the process.”

WHA’s Chief Medical Officer, Mark Kaufman, MD, provided an update on the emerging partnership between WHA and electronic health record (EHR) giant Epic Systems.

“We have been collaborating with Epic the last several months, particularly with its physician well-being committee, on how our organizations can work together to reduce the EHR burden for front-line clinicians,” said Kaufman. “A logical partnership centers around our advocacy efforts, particularly concerning federal government regulations.”

Kaufman shared Epic’s survey results comparing U.S. and international EHR users and noted WHA is already partnering with the company on interoperability rules. (Read Epic Systems Hosts WHA’s June Physician Leaders Council Meeting in WHA’s June 18 newsletter for more details.)

State Budget Success
Borgerding provided a state budget update, recounting WHA’s multi-pronged strategy to work with the Governor and Legislature despite a challenging political environment. “We have been working hard over the past several months to both advance the strong health care budget put forward by Governor Evers and work with the Legislature to find common ground, and with the exception of Medicaid expansion, in the end there is a lot of agreement between the Governor and Legislature,” Borgerding said.

The budget passed by the Legislature, and now back before Governor Evers, contains a number of WHA priorities that will expand access to health care across Wisconsin including:

  • Fully funding the $920 million Medicaid cost-to-continue, as included in Governor Evers’ budget.
  • Providing a nearly $150 million boost to the disproportionate share hospital (DSH) program, which will help sustain and expand access to care at hospitals and health systems serving a high number of Medicaid patients. This is a funding level similar to Evers’ budget.
  • Providing nearly $10 million in additional funding for the Rural Critical Care Hospital Supplement, a significant boost from the Governor’s budget that increases resources for rural hospitals serving high numbers of Medicaid patients.
  • Increasing behavioral health provider rates by $24.6 million. This was a reduction in the funding levels included in the Governor’s budget, yet still the first reimbursement increase for these providers in years and targeted to an area of significant need across the state.
  • Funding and approving Governor Evers’ proposals to increase access to telehealth by allowing Medicaid coverage of consultations and remote patient monitoring.
  • Providing $2.5 million in new funding for dental services for Medicaid members with disabilities, similar to what was proposed in Governor Evers’ version of the budget.
  • Approving Governor Evers’ proposed changes to the Graduate Medical Education matching grant program that will result in training more primary care physicians and psychiatrists who will practice in Wisconsin.
  • Funding the $1.1 million in grants for health insurance navigators, similar to the proposal in Governor Evers’ budget bill. These resources will help expand coverage and connect the nearly 50,000 people currently eligible for Medicaid and the estimated 240,000 people currently eligible for subsidized insurance on the Affordable Care Act (ACA) marketplace who have not enrolled in either program.
  • As proposed by Governor Evers, fully funding Wisconsin’s share of the Healthcare Stability Plan, which helps stabilize and actually reduce premiums for those who purchase coverage on the ACA marketplace.
  • Enabling greater access to care through telemedicine by authorizing $44 million in federal funding for broadband expansion in rural Wisconsin. This was quite a bit less than proposed by Governor Evers, yet substantially more than has been previously allocated for the program.

The Governor could use his line item veto power on the budget bill, veto the entire budget, or approve just the first year of the biennium.

“We are doing everything we can to get this budget across the finish line and remain cautiously optimistic,” said Borgerding. “It has been hard work to get us to this point, not just by our team, but by all of our members pulling in the same direction. Governor Evers introduced a strong health care budget, which contains very positive investments after the Legislature’s actions. It is great health care policy, and it should have bipartisan support.”

WHA Board Immediate Past Chair and Reedsburg Area Medical Center President Bob Van Meeteren thanked Borgerding and the entire WHA team for its efforts. “You have done an excellent job of putting together a very positive budget for all of us, all hospitals across the state. Thank you to you and your team for all the work you have done.”

Note: you can read more about the budget in WHA’s June 25 newsletter. See WHA’s bipartisan advocacy efforts lead to strongest health care budget in 30+ years.

Attorney General Looks to Partner with WHA, Health Care Industry
Wisconsin Attorney General Josh Kaul joined WHA’s Board meeting for a discussion of mental health, addiction, and other issues where health care and law enforcement intersect. He welcomed the invitation and opportunities to work together on shared concerns regarding opioid and drug addiction, as well as emergency detention, mental health, and violence against health care workers.

Opioids and Substance Abuse
Kaul said the Department of Justice (DOJ) is taking a three-pronged strategy focused on prevention, treatment, and accountability to address Wisconsin’s opioid and growing meth problems.

Kaul said the DOJ is focused on educating the public about the risk of addiction and expanding access to diversion programs, such as the drug takeback initiative and providing outlets to dispose of unused medication. Overall, DOJ would like to see a decrease in the volume of opioids prescribed with Kaul noting, “If we look at the number of opioid prescriptions written today compared to the 1990s, it is much higher now, but patient pain levels have not significantly increased.” The Attorney General acknowledged there are certainly times when it is appropriate for a physician to prescribe opioid medication for a patient.

Jeff Bahr, Chief Clinical Officer and President of Aurora Health Care Medical Group, highlighted the success of the Prescription Drug Monitoring Program (PDMP) in Wisconsin in disrupting the illicit flow of controlled substances. However, he asked if it would be possible to get access to PDMP information from bordering states, like Minnesota, so that Wisconsin clinicians would have access to more controlled substance prescriptions for their patients. Kaul responded that he would like to see a national PDMP for enhanced communication among the states.

Beyond prevention, Kaul said that treatment for substance abuse disorders is a key prong in addressing Wisconsin’s opioid problems.

“There are many with a substance use disorder that can’t access timely addiction services,” said Kaul. “We need to significantly expand access to those services.”

The Attorney General noted ongoing work to formalize a statewide “hub and spoke” model for opioid treatment, but highlighted reimbursement and workforce challenges.

“We will need to have a lot more funding [for addiction services],” said the Attorney General. “It is important to make addiction services an attractive career path.”

Kaul also said the DOJ is targeting large-scale drug traffickers who are creating drug pathways to the state and our communities, particularly meth, which Kaul said “seem to be coming in large part through the Twin Cities.”

The Attorney General also talked about recent suits DOJ joined against drug companies that manufacture and distribute opioids.

“We are also going after drug companies who engaged in false and deceptive marketing practices,” said Kaul. “There was a concerted effort to fundamentally change the benefits and potential risks of prescribing opioids; they sought to change the norms through all sorts of vehicles.”

The Attorney General said DOJ would reinvest funds obtained from the drug companies back into Wisconsin communities to battle drug addiction, saying, “Nothing will be a cure-all or solve problems overnight, but this will be an important part of the solution.”

Emergency detention and mental health services
Mental health and emergency detention services are another area of intersection between law enforcement and health care said Kaul. He, in particular, raised questions about the adequacy of Wisconsin having a single state institute for emergency detention and revisiting law enforcement’s role in placing and transporting a person under an emergency detention.

“Having the state offer one facility for emergency detention is inadequate,” said Kaul. He said that a broad group of stakeholders need to come together to “figure out a way to change the incentive structures” to encourage more emergency detention options. The availability of crisis and emergency detention services “is a statewide problem, but counties are bearing the cost,” said Kaul. “This needs to be a statewide solution.”

Kaul also talked about collaborations and identifying easy fixes and longer-term harder fixes, acknowledging the complexity of Wisconsin’s behavioral health laws and infrastructure. He highlighted looking at allowing emergency detention transports across state lines and enabling more private transport.

He also questioned whether it still made sense for law enforcement to be in the role of placing an individual under an emergency detention.

“Admission processes are done different ways in different states, and we should see what works most effectively. Law enforcement is not in the best position to make medical judgments about who may harm themselves,” said Kaul.

Violence against health care workers
Attorney General Kaul wrapped up his conversation with the Board with a discussion of violence in health care facilities.

“From substance abuse to mental health issues, we have workplace violence in all areas of our hospital—the ER, primary care, behavioral health. The challenge of protecting the people who work in our communities is huge, and clinicians do not want to work in these high-risk areas, and we also want to be welcoming to the patients who walk through the door,” said Marshfield Clinic Health System CEO Sue Turney.

The Attorney General acknowledged this is a statewide issue that needs a statewide solution, and he hopes to bring people together on both sides of the aisle. “In encountering people dealing with a mental health crisis, there is a dangerous situation inherently, and there are not easy answers.” All of the issues are intertwined—from the drug epidemic to mental health to the health care workforce, he said.

He also encouraged health care providers to develop strong relationships with law enforcement and to work with law enforcement to share effective de-escalation strategies across Wisconsin. For example, Kaul and the Board highlighted examples recently shared by health care providers and law enforcement of K-9 units’ effectiveness in de-escalating situations in schools and hospitals.

Kaul concluded by reiterating that he would like to bring together stakeholders to determine what are quick wins and what are long-term solutions. “Thank you for your time and all the work you do in your communities. I look forward to working together.”

Implications for Wisconsin of Contemplated Stroke Legislation
At the end of 2018, WHA became aware that the American Heart Association – American Stroke Association (AHA-ASA) was again pursuing their national model legislation to create stroke care mandates for Wisconsin. This is contrary to the forwardthinking approach Wisconsin lawmakers have taken in the past, an approach that recognizes the value of collaboration, data transparency and evidence-tested quality improvement methods to improve care.

Ann Zenk, WHA Vice President of Workforce and Clinical Practice, and Beth Dibbert, WHA Chief Quality Officer, provided the Board with an update on WHA’s work around stroke care, including the recommendations of a special Board sub-committee convened to consider WHA’s response to potential stroke legislation.

The Board sub-committee recommended continued opposition to any legislative mandate around stroke care and ongoing attempts to write medical practice into state statute. The sub-group of Board members from a cross-section of the state also recommended WHA continue efforts to work with AHA-ASA to improve an already-existing statewide structure. The group agreed that WHA’s quality expertise and ability to bring WHA members together should be deployed to continue Wisconsin health care’s tradition and environment of collaboration to move stroke care forward.

Board members supported the sub-committee’s recommendations to continue its current efforts focused on collaboration to improve stroke care in Wisconsin. The WHA Board also agreed that if AHA-ASA insists on pursuing legislation, WHA and its members should continue to oppose efforts to legislatively dictate stroke care and protocols in Wisconsin. As one Board member said, “While such legislation may be well-intended, it ignores the local and state systems of care already in place and the benefits of collaboration.”

Surprise Billing Legislation
The Senate’s Health, Education, Labor, and Pensions (HELP) Committee marked up legislation last week designed to increase transparency in health care costs and reduce instances of surprise billing. Jon Hoelter, WHA’s Director of Federal and State Relations, provided an overview of the legislation, and WHA’s engagement efforts with Senator Baldwin (who sits on the HELP Committee) and the rest of Wisconsin’s Congressional delegation.

While WHA has been supportive of Congress’ efforts to improve transparency and reduce instances of surprise billing, Hoelter highlighted concerns about the proposal to pay providers median contracted rates to resolve instances of surprise billing. This could not only impact providers financially, but could also have detrimental impacts on provider networks and patient choices if insurers choose not to contract with providers that they currently reimburse above the median rate.

Hoelter also highlighted an analysis by the Health Care Cost Institute that suggests surprise billing is not as big of an issue in Wisconsin as in most other states. According to the 2016 study, Wisconsin has one of the lowest rates of hospital admissions that result in an out-ofnetwork surprise bill—at 4%. In addition, WHA received an analysis from the Wisconsin Office of the Commissioner of Insurance (OCI) which found only 61 surprise billing complaints were received in a 15-month period from 2018 to 2019 with five insurers accounting for the bulk of those complaints.

Hoelter also mentioned other efforts aimed at increasing transparency and reducing instances of surprise medical billing, including President Trump’s Executive Order and legislation recently introduced in the state Legislature. The President’s Executive Order, which was released last week, called for various rulemaking and reports from federal agencies, and WHA will be awaiting more details as they are released. At the state level, WHA has been engaging with lawmakers who have introduced legislation that would utilize mediation to resolve balance billing disputes.

In light of the discussion around surprise billing, WHA Vice President of Public Policy Lisa Ellinger said WHA’s Transparency Task Force is reconvening to discuss member efforts around price transparency. (See the article on page 2 in today’s newsletter for more details.)

Proposed 2020 Inpatient Prospective Payment System Rule
Finally, Hoelter concluded his presentation with a brief overview of WHA’s recent comments to CMS over the proposed 2020 Inpatient Prospective Payment System Rule, which centered around proposed changes to the Area Wage Index. WHA’s comment letter focused on urging CMS to resolve inequities that still exist due to the “Bay State Boondoggle.” Overall, the proposed wage index changes in this year’s proposed rule should be a net gain for Wisconsin hospitals compared to current law. For more details, see last week’s Valued Voice story on this topic.

A Fond Farewell to Debra Standridge
Ascension Wisconsin North Region President Debra Standridge retired at the end of June, and the Board honored Standridge for all of her advocacy efforts and support on behalf of WHA and hospitals across Wisconsin.

“Deb exemplifies what it means to be a hospital leader and has been the epitome of an advocate, not just of her hospitals and system, but for the industry statewide,” said Borgerding. “She has been a memorable part of WHA—a very deserving Advocacy All-Star award recipient in 2015, a Conduit participant since 2003, and a champion in all our advocacy efforts. Thank you on behalf of WHA and everyone in this room. We have been honored to collaborate with you on behalf of WHA and the entire industry. I cannot say enough how much you will be missed.”

Standridge said the hardest letter she had to write was notifying Borgerding and WHA Board Chair Damond Boatwright about her impending retirement. “I am so passionate about the work we have done together. Thank you very much; you have such a remarkable team. And I thank my colleagues for the tremendous opportunity you have afforded me.”
 

This story originally appeared in the July 02, 2019 edition of WHA Newsletter