March 2, 2017
Volume 5-Issue 4
President's Column: Obamacare Debate Brings High Stakes for Wisconsin
It seems we may soon see action on the ACA, and nowhere will debate be more contentious or high stakes as in Medicaid where two huge issues are in play—funding for states and spending limits. They are intertwined, must be considered together, and in the end cannot penalize states like Wisconsin that did indeed expand Medicaid, though not as prescribed by Washington.
First, creating spending caps in Medicaid does not diminish the need for this safety net program, nor does it lessen the need for care in our hospitals, emergency rooms and clinics. Demand for Medicaid is driven by social and economic factors that are often beyond the control of an individual, a state or a health system. And there are components of Medicaid, including coverage for the elderly and disabled, that will continue to be expensive and that in an inflexibly capped expenditure environment will crowd out other in-need populations. These dynamics could be particularly troubling in states like Wisconsin that did not adopt ACA-defined Medicaid “expansion” and must be factored into whatever comes next.
Giving states more program flexibility, as is being floated under all the Medicaid proposals, holds promise if exercised prudently and done within a Medicaid program that remains a responsive safety net. But giving states greater flexibility is not a substitute for more equitable funding.
Which brings me to the second, and in some ways even more critical and primary issue—establishing the base level of federal Medicaid funding for each state going forward. This must be done in a manner that treats all states fairly. If not, those that either rejected ACA Medicaid expansion or, like Wisconsin, expanded coverage their own way and with their own money will be harshly penalized under new funding formulas. Sounds strange that in this anti-Obamacare environment a state that actually rejected one of its most heavy-handed federal dictates could indeed be punished for doing so, but it’s true.
Here’s why - the Obama Administration defined “expansion” as making people with incomes up to 138 percent of the federal poverty level (FPL) eligible for Medicaid, regardless of how many people a state might actually add to Medicaid. In other words, expand their way and the Feds would cover up to 90 percent of the cost of doing so…expand a different way, no enhanced funding. This “policy lever” has worked for 31 states, but for 19 it has not, including Wisconsin. Congress and the President should now redefine Medicaid “expansion,” including recognizing how it has been and, as importantly, how it can be achieved.
Here’s why they must - after rigorous debate, Wisconsin rejected Obamacare-defined “expansion” but instead added 130,000 people below 100 percent FPL, those “in poverty,” to Medicaid. But according to Washington, this was not “expansion,” and thus not eligible for enhanced federal funding. It is a consummate example of Washington’s “our way or the highway” mentality that has created a state patchwork of Medicaid haves and have nots that is proving one of the biggest snags in the repeal and replace debate.
Our rough estimate puts the added cost to Wisconsin for not “expanding” Medicaid the Washington way, (despite adding 130,000 impoverished people to our Medicaid program) at about $280 million per year. In other words, 31 states receive nearly 100 percent federal funding for the exact same population that Wisconsin now spends over a quarter-billion dollars per year to cover. Since 2014 we have been essentially penalized upwards of one billion dollars while expanding coverage to 130,000 of our most vulnerable, impoverished citizens. This could also mean Wisconsin will receive fewer federal Medicaid dollars under new funding formulas and spending caps now being considered in the Obamacare replacement.
This is more than a math exercise. These are dollars that could be used to expand our diminishing health care workforce, train more primary care doctors, improve access in underserved rural and urban areas, boost reimbursement and reduce Medicaid cost shifting to employers and families … right here in Wisconsin.
Compounding all this, under the ACA Wisconsin hospitals are taking an estimated $2.6 billion in Medicare payment cuts over 10 years. A portion of those Wisconsin cuts are used to pay for Medicaid “expansion” as defined by the ACA, which means none of those dollars are coming back to Wisconsin.
WHA believes any Medicaid restructuring should continue the federal-state partnership that ensures access to high-quality health care coverage, provide sufficient funding, and treat expansion and non-expansion states in an equitable manner. All states should be fairly and equally funded for what they have done to cover those in need.
For Wisconsin, this is an issue that should transcend the partisanship of the ACA/Obamacare debate. It is about fundamental fairness that our state and federal elected official should coalesce around and demand. We were pleased to see a recent letter from Joint Finance Committee Co-Chairs Sen. Darling and Rep. Nygren urging our Congressional delegation to fight for the Badger State. Governor Walker has been very visible and vocal among the nation’s Governors in calling for fair treatment of states like Wisconsin. But more voices need to be heard.
When it comes to Medicaid, the ACA picks winners and losers based on an arbitrary multiple of the federal poverty level, not on how many people are actually covered. That is unfair to Wisconsin, especially when one remembers that the goal here is to expand and sustain, not penalize, coverage. It is a fixable flaw that both sides of the Wisconsin political aisle can and should work together to remedy.
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Prescription Drug Monitoring Program Status and Guidance Discussed at MEB
Approximately 12,000 prescribers have registered to use the new Prescription Drug Monitoring Program (PDMP) since the new version of the program was launched in mid-January according to a PDMP staff presentation to the Medical Examining Board (MEB) February 15. PDMP staff estimated that around 36,000 prescribers will be registered on the PDMP by April 1. On April 1, most prescribers will be required by state law to check the PDMP prior to prescribing reported controlled substances.
The Board and PDMP staff also discussed the permissibility of delegates to fulfill a required check of the PDMP on behalf of a prescriber, identified barriers to physician registration with the PDMP, the status of additional functionality of the PDMP and how to comply with the new mandate.
PDMP staff said the new PDMP system has a “delegate” function that allows a prescriber to link his or her account to a registered delegate that has also registered with the system. When that linked registered delegate checks the PDMP system for the prescriber’s patient, such check is recorded by the PDMP system as a check of the PDMP by the prescriber. However, PDMP staff said that some prescribers have been having difficulties with the delegate functionality. Staff recommended that prescribers and delegates work together to make sure the delegate has only one account and the prescriber links the exact same name and information identified in the delegate’s registered account to ensure a successful and non-duplicative link to the prescriber’s delegate account.
Various concerns regarding difficulties with the registration process were also discussed by the Board and staff. A key issue was ensuring that a prescriber enter exactly the same information that appears in the prescriber’s licensure information with the Department of Safety and Professional Services. Physicians have also had difficulties registering if the physician is missing information such as phone number or specialty from the licensure information held by the Department. In such cases, physicians will need to contact the Department to complete registration.
Medical Director Access to PDMP
PDMP staff also provided an update on upcoming additional functionalities of the new PDMP system. Staff indicated that by April 1, prescribers will be able to see their own prior prescribing history as they had been able to do so under the prior system. Staff also said that by April 1 medical directors will have access to the PDMP to review prescribing reports of the physicians that he or she oversees.
PDMP Integration with EHRs
Board members asked about the status of PDMP functionality to enable prescribers to check the PDMP through their electronic health record. Staff said they are working with the Department’s technology vendor WIN to have two EHR integration pilots running by April 1, but at this time those pilots and their timelines have not yet been finalized. Staff also indicated that several health care systems have indicated interest in working with the Department’s technology vendor to complete an EHR integration and that integration work would be completed by the vendor on a first-come first-serve basis.
The Board also discussed its compliance role after April 1 in determining whether various physician workflows for checking the PDMP prior to making a prescription are compliant with the upcoming mandate. In particular, the Board discussed how far in advance a physician could check the PDMP prior to prescribing to a patient. The Board indicated a reluctance to set a bright-line time requirement but instead believed that in some cases a check a day ahead of time would be reasonable while in other circumstances a longer timeline would be reasonable. The Board indicated they would discuss this issue in an upcoming Board newsletter.
Additional training materials and contact information are now available on the new PDMP website. To view that information, go to: https://pdmp.wi.gov/training-materials.
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Enroll Your Physicians Today in WHA Physician Quality Academy
Physicians are leading or playing significant roles in a variety of quality improvement efforts in WHA member hospitals and health systems. Knowledge about quality improvement tools and principles can increase the likelihood that those physicians will be more successful in and comfortable with their leadership role.
Enrolling those physicians in WHA’s Physician Quality Academy will ensure they have access to the training and resources necessary to lead successful quality improvement initiatives. Participants will learn to design and conduct quality improvement projects utilizing proven improvement models; interpret data correctly; facilitate physician colleague engagement in quality improvement and measurement; and, discuss quality requirements, medical staff functions and their link to quality improvement.
The Academy will be offered twice in 2017, which will allow a physician to choose the cohort that works best for his/her schedule: Cohort #1 will be held May 10 and July 21; Cohort #2 will be September 29 and November 3. Attendance is limited to the first 100 registrants per cohort, so register your physicians today at www.cvent.com/d/wvq5nm. For more information contact Jennifer Frank at email@example.com or 608-274-1820.
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Hundreds Already Registered for WHA Advocacy Day 2017, April 19
Register by March 17 to be entered into the early bird drawing
The Wisconsin Hospital Association’s Advocacy Day event has grown to over 1,100 individuals over the past decade—close to a 150 percent increase in attendance. WHA knows the success of this powerhouse event is rooted in our hospital and health system leadership, employees, trustees and volunteers commitment to this day. Thank you. Make sure you’re making plans now to attend WHA Advocacy Day 2017 April 19. If you register by March 17, you will be entered into our free drawing where five lucky individuals will win a prize. Make sure you register before March 17 to be entered into the drawing. Register today at: http://www.cvent.com/d/svqylc.
This year’s event will be in Madison at the Monona Terrace April 19. The morning keynote is Amy Walter, who is known as one of the best political journalists covering Washington, D.C. She is national editor of the Cook Political Report and the former political director of ABC News. Over the past 14 years, Walter has built a reputation as an accurate, objective and insightful political analyst. She is a regular panelist on NBC’s Meet The Press, PBS’ Washington Week and Fox News’ Special Report with Bret Bair. She also provides political analysis every Monday evening for the PBS NewsHour. The day’s luncheon keynote will be Gov. Scott Walker (invited), and a legislator panel discussion will round out the morning sessions.
WHA strongly believes the afternoon’s legislative meetings are the most important part of the day and encourages attendees to register for Advocacy Day with a legislative visit. To prepare attendees for their meetings, WHA schedules all meetings and provides an issues briefing at Advocacy Day. Additionally, WHA will host an optional pre-event webinar on these legislative visits April 11 at 9:00 a.m.
Assemble your hospital contingent for WHA Advocacy Day 2017 on April 19. Register at: www.cvent.com/d/svqylc. For Advocacy Day questions, contact Jenny Boese at 608-268-1816 or firstname.lastname@example.org. For registration questions, contact Kayla Chatterton at email@example.com or 608-274-1820.
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Governor’s Opioid Task Force Bills Introduced
DHS announces application for $15 million to fight opioid abuse
On February 17, several bills were introduced as part of the special session of the state Legislature called by Gov. Scott Walker to address opioid abuse. Executive Order #230 establishing the special session to pass various policy proposals recommended in the co-chairs’ report of the Governor’s Task Force on Opioid Abuse was signed by the Governor at HSHS St. Joseph’s Hospital in Chippewa Falls in January.
Eleven bills were introduced, including the following proposals:
To address addiction medicine and addiction psychiatry physician shortages, dedicate an additional $126,000 in GPR funding over the biennium to provide grants to hospitals to expand graduate medical education training in an addiction specialty.
Provide $1 million in GPR funding over the biennium for the creation of an addiction medicine consultation program. Currently, such consults are not typically reimbursable to the consulting physician.
Provide funding for up to three additional opioid treatment programs in underserved and high need areas.
Prohibit the dispensing of schedule V controlled substances that contain codeine (such as over the counter cough medicine with codeine) without a prescription.
Extend voluntary and involuntary treatment services available to alcoholics to persons that are drug dependent.
The bills will now head to committee for hearings in the coming weeks.
Also on February 17, the Department of Health Services (DHS) announced they had applied for over
$15 million in federal funds available in the 21st Century Cures Act to combat opioid abuse. In its application, DHS states it will use the funds to support recommendations made by the Governor’s Task Force on Opioid Abuse. DHS said this effort will include:
Expanding access to treatment for uninsured and underinsured individuals.
Establishing new opioid-specific treatment programs to reduce the distance people have to travel for those services.
Establishing a hotline to provide information on treatment services and recovery supports.
Developing training on proven intervention and treatment strategies for opioid misuse and abuse.
Supporting community coalitions focused on reducing the nonmedical use of opioids in adolescents and young adults.
Establishing a network of recovery coaches.
The Governor’s Task Force on Opioid Abuse will meet again March 24.
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Worker's Comp Research Shows Positive Results for Wisconsin
Low opioid use, low medical price growth...and falling premiums
The State’s Worker’s Comp Advisory Committee received some good news at their February 14 meeting: Wisconsin is one of the lowest of 25 states when it comes to opioid use, and there has been little change in Wisconsin non-hospital medical prices from 2014 to 2015.
Staff from the Worker’s Compensation Research Institute (WCRI) provided the Council with two presentations at their meeting. The first summarized lessons from studies on opioid prescribing reforms. The data showed variation in the use of opioids with Wisconsin ranking third lowest out of 25 states in what is called the “morphine equivalent amount.” The WCRI study covers the time period before 2015, and since then the state has taken tremendous strides in combating opioid abuse with the help of Rep. John Nygren’s HOPE legislation, and with the provider community coming together with the Attorney General in his “Dose of Reality” campaign. WCRI staff said a newer release of their opioid research is expected to be released later this year.
In the second presentation, WCRI staff updated the Council on the latest research findings about worker’s compensation overall. As in past years, the study continues to show Wisconsin has a relatively low percentage of workers who lose more than seven days of work after injury, low litigation, steady utilization, lowest number of injured workers reporting “big problems” getting medical services and lowest percentage of injured workers that are “very dissatisfied” with overall care. With respect to medical prices, in 2014-2015, medical prices for non-hospital services grew just 1.8 percent.
All of this is good news for Wisconsin’s injured workers. As reported in last month’s Valued Voice, the Council also heard from Bernie Rosauer, president of the Wisconsin Compensation Rating Bureau (WCRB)—the independent agency that establishes rates charged by insurance companies for worker’s compensation insurance coverage in Wisconsin—who discussed the positive attributes of Wisconsin’s worker’s compensation system. In a presentation provided to the Council, Rosauer reminded the Council that worker’s compensation insurance rates decreased by -3.19 percent in 2016 for all job classifications in aggregate, but decreased even more for manufacturing at -5.00 percent. Rosauer noted that Wisconsin has “got a good thing going” with its worker’s compensation system, and that other states are aware of Wisconsin’s well-functioning system.
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Influenza Hitting Communities, Schools, Long-Term Care
Wisconsin and the entire country is experiencing a significant increase in influenza activity, with outbreaks in schools, long-term care and communities. According to the Wisconsin immunization report prepared by Jon Temte, MD, in Wisconsin, 85 percent of recent detections are influenza A and 97 percent of A viruses are H3N2. There have been 837 influenza-related hospitalizations since September 1, 2016, with 97 admitted to ICU and 12 requiring mechanical ventilation. This compares to 163 hospitalizations last year at this time, and 3,763 for the 2014-2015 season. Sixty-six percent of hospitalizations have been in individuals age 65 and older. Influenza A[H3N2] is less kind to elders; across the U.S. one out of every 870 people age ≥65 has been hospitalized with laboratory-confirmed influenza.
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