Physician Edition

05-03-2017


May 3, 2017

Volume 5-Issue 9


WHA Post-Acute Care Work Group Dives into Population Health, Other Issues

Jonathan Jaffery, MDHospitals and health systems can improve patient experiences post-discharge in part by paying attention to population health management, according to Jonathan Jaffery, MD, senior vice president and chief population health officer, UW Health. Jaffery met with WHA’s Post-Acute Work Group at its third meeting April 21 to provide some insights into managing post-acute care.

Although alternative payment models and readmission penalties are driving hospitals and health systems to pay attention to post-acute care, focusing on population health can provide necessary information to improve post-discharge patient outcomes and control costs across the care continuum, according to Jaffery. Incorporating a population health perspective into post-acute care starts with examining data on the patient population served by hospital or health system, including where patients live, analyzing the social determinants of health for the overall patient population, and how those factors may affect length of stay, readmission rates, and successful post-acute care outcomes.

Work Group members located in rural areas of Wisconsin noted it is more difficult to examine population health because they lack a critical mass of people in their area on which to gather data. This, coupled with a scarcity of post-acute providers, creates unique issues for some rural providers in managing post-acute care. In many rural areas, improving the social determinants of health is an important factor for successful post-discharge patient outcomes.

Jaffery also emphasized the need to create good post-acute care partnerships, both formal and informal, to improve patient outcomes when discharged to a post-acute setting. Systems of care are still evolving and are not currently optimized to provide patients with the best support. Jaffery noted that both large and small hospitals and health systems are still figuring out the best ways to provide this care and create good handoffs of patients to post-acute settings.

Another issue that affects transition planning for post-acute care is the interoperability of electronic health records (EHR). Not all hospitals, systems and post-acute care providers have the resources to implement an EHR platform that enables universal sharing of information on patients that could enhance transition planning. The Work Group agreed on the importance of developing cost-effective alternatives for sharing essential patient information in real time, which will improve planning for post-acute care.

Some patients may remain in the hospital long after they are ready to be discharged because of the difficulty in locating a post-acute provider that can meet the patient’s needs. The Work Group discussed the need to develop specialized post-acute care options for these patients. Because not all post-acute providers can meet every specialized care need, it may be necessary to create regional, specialized post-acute options to care for complex patients.

The Work Group will meet again in June and continue to identify areas that can improve post-acute care
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1,000 Hospital Supporters Attend WHA Advocacy Day; 600 Meet with Legislators

"You are a powerful voice for your community hospital and patients"

WHA Advocacy Day 2017 crowd
It was an impressive gathering as more than 1,000 hospital supporters converged upon Madison April 19 to attend the WHA Advocacy Day 2017 event at Monona Terrace for a morning of education and networking. And, for the first time in the history of WHA’s Advocacy Day, every available meeting room in the state capitol was booked as more than 600 hospital supporters flocked to the capitol in the afternoon to meet with their local legislators.

In his welcome, WHA President/CEO Eric Borgerding was clearly impressed with the sea of supporters he saw before him.

"This is just a tremendous showing," Borgerding said. "You are a powerful voice for your community hospital and the patients you serve."

Borgerding noted that since 2005, more than 10,000 people have attended Advocacy Day, and of those, 6,500 have gone over to the state capitol and lobbied their legislators.

With the support of citizen lobbyists, WHA and its member hospitals and health systems are effective advocates for sound health care policy, not just in Madison, but also in the nation’s capital. A brief video (see www.wha.org/advocacy-day.aspx) highlighted the multiple in-district meetings and roundtables hosted by WHA members that bring policymakers into their organizations to see health care delivery on the front lines. Borgerding said Advocacy Day is powerful for the fact it brings hospitals together throughout Wisconsin and provides an education and advocacy forum for supporters.

"We gather to learn more about the activities at the state and federal level that affect our hospitals so we can take that knowledge to our state capitol and tell our legislators to help all of us keep our hospitals strong for our patients and our communities," Borgerding said. "Today we have more than 600 people going to the capitol to visit with legislators and their staff. Thank you for your commitment to this event, but more, thanks for your commitment to grassroots advocacy on behalf of your community hospitals. That truly inspires us all."

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In Today’s Political Environment, Walter’s Advice is "Embrace Uncertainty"

Amy Walter with WHA Officers at 2017 Advocacy DayThe health care industry was steeped in uncertainty even before the passage of the ACA, but now with the failed attempt to repeal and replace Obamacare along with all the other changes in reimbursement and regulations, the roadmap to the future is even more unclear.

Health care is not the only environment where change and uncertainty are the norm, political insider Amy Walter told more than 1,000 people gathered for WHA Advocacy Day 2017. She advised the only way to survive the constant drama playing out in the media every day is to embrace uncertainty.

"You have to learn to accept uncertainty to be able to understand the world we are in right now," according to Walter, the national editor of the Cook Political Report and former political director of ABC News.

"2017 has been quite a year, and we are not even halfway through it. It feels like it has been 300 days (since President Donald Trump’s inauguration), not just 90," she said. "It feels a little overwhelming. You wake up every day to lots of drama in our country and in our world. It is exhausting just keeping up with the headlines and the news."

Walter said there are many new faces in Congress, with two thirds of the Republicans serving in the Senate never having served under a Republican President or having a chance to work with their own party.

"The Republicans are used to saying no, but they are finding that getting to yes is very different. Governing is hard," she said.

Walter said we have to accept the fact we are living in uncertain times, and not just here in the U.S.

"The whole world is feeling upheaval. The post-world war era progress is being upended. The surprise was it took this long to happen, 20-30 years to come to a head given the demographics in our country," according to Walter. "Think about the generation over 55 years of age. That generation is overwhelmingly white—80 percent—compared to the kids under five years old now where the majority are not white. Just in the course of one lifetime we have seen a complete change in the demographic makeup of this country."

Walters is a regular panelist on NBC’s Meet the Press, PBS’ Washington Week, and Fox News’ Special Report with Bret Baier, and can also be seen on Face the Nation and Fox News Sunday. She also provides political analysis every Monday evening for the PBS NewsHour.
 

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Walker a "Valued Partner" with Wisconsin Hospitals, Health Systems and WHA

Gov. Scott Walker at WHA's 2017 Advocacy DayGov. Scott Walker was a strong supporter of good health care policy even before he took office in 2010, as WHA President/CEO Eric Borgerding noted in his introduction of Walker before an audience of over 1,000 hospital advocates April 19 in Madison.

In his time serving on the Assembly Health Committee, then Rep. Scott Walker laid the groundwork for what is one of the most stable medical malpractice environments in the country. As Milwaukee County Executive, Walker worked with WHA on the General Assistance Medical Program.

"Today, we can look back on his term as Governor and point to numerous examples of his leadership on health care, but also to his partnership with WHA and our members," Borgerding said.

Wisconsin has been at the forefront in the ongoing debate over repealing and replacing the ACA, working together to preserve and strengthen and be rewarded for the Wisconsin model of coverage expansion that has delivered a 38 percent reduction in the state’s uninsured rate.

"Wisconsin has been a leader in transforming health care, enabled by good public policy," Borgerding said. "There is much more to do in both Madison and Washington. Our partnerships with our elected officials are more important today than ever before."

Walker Touts Health Care as Wisconsin Asset: Accessible, Affordable and High Quality

The Governor felt right at home before the Advocacy Day crowd on what was his sixth appearance before the group. He began by saying he appreciates working with the WHA staff and Board of Directors and with all the hospitals and health systems across the state. He also recognized the dedication of the health care advocates and members of hospital boards who were in attendance.

"Health care, in general, is about three core things: quality, access and affordability," Walker said. "Hopefully in this state, we have shown how to do that in a way that is effective for the rest of the country." He thanked hospitals and health systems for their commitment to quality and mentioned that Wisconsin consistently ranks in the top three states in the nation based on quality.

Walker said since 2011, his Administration has put $3.25 billion worth of new state GPR into the Medicaid program to make sure that it was accounting for not just the people hospitals serve, but make sure that it is not "dished off to everybody else, which becomes a hidden tax on employers."

"When a state does not fully or adequately fund Medicaid, it just becomes a hidden tax on other employers and individuals who have health care plans. They have to pick up the difference, and you have to raise more money to compensate for uncompensated care," according to Walker.

Referencing his days in the Legislature, Walker said ensuring liability protections, not just individually for health care professionals, but also for hospitals and health systems, is important to ensure they are protected from unnecessary liability burdens. Good regulations that ensure public health and safety, which are not obsessively beyond that which place an unnecessary burden on providers, also allow providers to focus on improving quality and increasing access.

"Health care is not only good for quality of life, it has a tremendous economic impact. I say that when you think about it logically it makes sense. We, particularly in government, talk about things in silos. Health care here, taxes there, education over there. It’s interrelated," he said. "When an employer looks to bring a business into a community, or tries to hire talent they need to serve a particular position, they look at a variety of things. It’s good to have reasonable taxes, a good regulatory environment and a limited lawsuit environment, but there are core things they need—access to a great workforce, a good education system and right at the top of the list is a good health care system. No matter how much they pay you, if there is not access to good health care and education system, it is not worth it. It has a direct impact. It’s not just quality—we rank third—but affordability and access are tied together to economic vitality and growth."

On extending Wisconsin Works for Everyone to other programs, including Medicaid, the Governor said people with physical and intellectual disabilities are sometimes hesitant to work for fear they will lose their benefits. He said his plan is to "spread that time out, make the transition longer" so people who are receiving state benefits, such as Medicaid, do not "fall off a cliff." He said his plan, for example, is if an individual’s income reaches 200 percent FPL, for every $3 you make over that, you pay $1 more in copay for child care.

On the Medicaid waiver, he said Wisconsin will ask the federal government if it can charge a premium even at low income levels, at $1 a month.

"Skeptics in the capitol have asked me why you would do that when it costs more to collect that dollar. It is not about saving money," Walker said. "As they churn people off Medicaid, we are getting people ready for the workforce."

Everyone pays some kind of premium for health insurance, according to the Governor; starting to pay even a small premium reduces the shock of paying one. He said the state will also request to put filters in place that allow the state to screen for addiction. Along with that, the Governor put money into the state budget for rehabilitation.

"We didn’t do this to create more uncompensated care. We have more people who are not on Medicaid because they can pay for their individual plan," he said.

On the ACA, Walker said the discussions are all over the board, and there is much work to do. However, he said when he is in Washington he consistently tells people, "If you want to make a change, make a change that goes along with what we did in Wisconsin."

Wisconsin has a better rate of coverage than 43 other states, he said.

"The discussion earlier this year was around reimbursement, but the talk needs to be around not just the cost of health care and reimbursement, but what are we doing to make health care better, and what are we doing to help our constituents live healthier, better lives," Walker said.

Employment and jobs have always been a key priority for Walker. The unemployment rate in Wisconsin has hit an all-time low, 3.7 percent. Good news for job seekers, but not so positive for employers. The Job Center of Wisconsin now has more than 95,000 job openings posted. Walker said workforce shortages are a huge challenge, but if Wisconsin can "connect the dots between skills, education and the qualifications to match the positions," there will be endless opportunities for family-supporting jobs.

Walker’s support for graduate medical education has helped create residencies in rural areas, while Fast Forward grants are encouraging health systems to partner with the state to match those who are looking for employment with the training they need to be successful.

"It is a moral imperative they have access to education or it can be an economic impairment," Walker said. "The biggest barrier to creating more jobs going forward is this one thing: workforce.

The Governor pointed to Project SEARCH as a great example of getting people with disabilities into the workforce. He acknowledged that of the 27 Project SEARCH job sites across the state, all but a couple are sponsored by health systems.

"I was just out in your hospitals on a tour. There is nothing more fulfilling that visiting a Project SEARCH site," he said. "The inspiration they provide makes people want to work harder themselves. When I have 95,000 job openings, I can’t afford to have anyone on the sidelines. We have to have everyone working."

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Legislative Leaders Diverge on Policy Issues, but Agree Health Care is an Asset

WHA 2017 Advocacy Day legislative panelFour of Wisconsin’s legislative leaders participated in a panel discussion at WHA Advocacy Day 2017. This is part one of a two-part series featuring that dialogue. The second article in this series will be in the April 28 issue of The Valued Voice.

It is the most highly anticipated and popular session at WHA’s Advocacy Day, and this year the state legislators participating in the panel discussion moderated by WHA President/CEO Eric Borgerding did not disappoint the audience.

Legislators participating on the panel included: Senate Majority Leader Scott Fitzgerald (R-Juneau); Senate Minority Leader, Jennifer Shilling (D-La Crosse); Assembly Speaker Robin Vos (R-Rochester); and, Assembly Minority Leader Peter Barca (D-Kenosha).

Borgerding kicked the conversation off by asking Barca for his thoughts about the importance of hospitals and health systems to economic development.

"Health care is an important asset in our state. A WHA survey of 300 employers showed they ranked quality health care second in importance only to education," Barca said. "You are making our regions more economically vibrant. We need to do what we can to support your efforts and provide you with the tools to succeed."

Before answering his first question, Vos made a point of dispelling any notion that Wisconsin legislators do not "get along."

"We are fortunate to have four leaders who get along. While we don’t agree on all the public policy points, we know we have good people in our state, and we are lucky that our economy is doing better," according to Vos.

On the point of the importance of good quality health care to the state, Vos noted there is a budget surplus of "almost a half billion dollars."

"That is why in this budget we can make significant investments to improve our business environment. As a business owner, I need access to high-quality health care and a great education system…and it’s important that we fix transportation," Vos said. "This is a time to be proud that we have leaders who work together addressing problems that are really important that keep our economy growing."

Shilling noted she has good access to quality health care in all areas of her district and because of that, she is seeing employers and health systems partner to provide on-site clinics and wellness programs to employees.

"It’s a cost savings. They realize if their employees are healthy, they are more productive," she said. "As we recognize the important role that health care has on our economy, in many communities it is the nursing home, hospital and school district that are the largest employers. But, as we look at Medicaid and uncompensated care, we know we still have work to do."

Shilling said much of the work that has been done in the Legislature on the opioid problem, mental health and telemedicine has been on a bipartisan basis. "Urban and rural, Democrat and Republican, we have worked together on these issues," she said.

Fitzgerald said it is frustrating that so much of health care is driven by the federal system.

"We understand the importance of health care in every community we represent. For us, it is frustrating that so much of health care is driven by the federal government," he said. "We have to look for waivers to implement stuff related to Medicaid. I am hopeful that some of the action we are seeing in Washington results in more flexibility in the state. If there is any place to manage health care, anything that reaches out and touches a hospital, it should be handled at the state level. We have a bipartisan relationship to accomplish things. If a block grant came down, this is where we could do good with that."

Fitzgerald said he appreciates the community programs that hospitals sponsor because it moves them to a prevention model, and that is why "hospitals are so important to mid-sized and small communities."

Moving to the topic of workforce, Borgerding asked the panelists if there is a role for the state of Wisconsin to help meet the demand for health care professionals in hospitals and health systems.

Vos said this is a really critical topic not just for hospitals, but for all employers.

"If you draw a line from Eau Claire to Green Bay, the region north of that line is one of the oldest in the entire United States. That is why we focus so much effort to ensure we have great schools in Wisconsin; the entire community depends on that," Vos said. "We have done some things to encourage people to go into different career fields. We have the patient’s compensation fund to make sure doctors come here and to know we value their services. But it’s a real challenge. Health care is no different than other fields, except you are a 24/7 business, and you cannot stop a line or fill in with a substitute. We need to attract more people to our state and into better careers."

Shilling said career exposure is occurring at younger ages. Students need to know about the career opportunities available in their own town. She said a new rural legislative initiative should help.

"There is a rural health care package that offers incentives and targets some of our rural communities. It has matching grant programs for newly created clinicians and incentives such as loan forgiveness for professionals to practice in remote areas," according to Shilling. "If they practice in those rural areas, they are more likely to stay. I think working together in a bipartisan fashion will help us address these issues."

There are big picture issues to consider, according to Fitzgerald. It is a matter of once they have the right education, to attract and keep them in the community.

"If you open a facility, say with 100 jobs and offer a good wage, but there is not an infrastructure to support having restaurants and adequate housing, those kids won’t want to live in that size of a community," he said. "The hospital is the one place that brings professionals together and there is a real effort to attract physicians, nurses and other clinicians. If there is any place this hits hard, it is hospitals because you need all those professionals in one place."

Borgerding agreed the hospital really is a hub, and we must find ways to keep our kids here. The blueprint is in place, he said, which is graduate medical education (GME).

"We know if a Wisconsin student attends medical school here and completes a residency here, we have an 86 percent chance they will practice here," according to Borgerding. "The Rural Wisconsin Initiative is the exact model we want to follow with allied health professionals to create opportunities for them to stay in our communities and enter post grad training."

Barca is concerned about the shortage of mental health professionals and psychiatrists. He believes the state could do more to attract these professionals to Wisconsin.

"I think getting our education institutions to open more nursing slots is important, but we are asking people to have more post-graduate opportunities, too," Barca said. "We have an aging workforce. We have to do much better at keeping people here and attracting them to Wisconsin. We have to make sure that people want to stay here. We need to do better to support entrepreneurs…refinance their education debt… and in health care it means greater partnerships with WHA and the Medical Society."
 

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Legislative Leaders Differ on ACA Positions; Support Increased Medicaid Funding

This is the second article in a two-part series covering the state legislative leader panel discussion that occurred at WHA Advocacy Day, April 19. The first article focused on the important role hospitals have in fostering economic development and the challenges hospitals and health systems face in attracting and retaining an adequate workforce. Read it here: www.wha.org/pubArchive/valued_voice/WHA-Newsletter-4-21-2017.htm#5.

Legislator panel at WHA's 2017 Advocacy DayIt is one of the most popular sessions at WHA’s Advocacy Day and this year the state legislators participating in the panel discussion moderated by WHA President/CEO Eric Borgerding did not disappoint the more than 1,000 in attendance April 19.

Legislators participating on the panel included: Senate Majority Leader Scott Fitzgerald (R-Juneau): Senate Minority Leader Jennifer Shilling (D-La Crosse); Assembly Speaker Robin Vos (R-Rochester); and, Assembly Minority Leader Peter Barca (D-Kenosha).

Borgerding started the Medicaid discussion by asking the panelists to consider whether a portion of the $330 million Medicaid surplus should be used to improve hospital reimbursement. He said hospitals have helped to create the surplus from reimbursement rates that "subsidize" the program but do not cover the cost of care provided to Wisconsin’s Medicaid enrollees. He asked each panelist for their thoughts about using the additional revenue to increase Medicaid payments to hospitals.

"I look at the Disproportionate Share Hospital (DSH) payment as a way to deal with the fact that we are not taking Medicaid federal dollars here, and it’s a way to compensate hospitals for low payments," Shilling said. "As we look at how we can help with uncompensated care costs, as we think about the $330 million surplus, I would support adding that to the DSH proposal in the budget."

The Medicaid program in Wisconsin is the worst payer in the United States, according to Vos.

"Medicaid…is a one-size-fits-all, Washington-dictated program…then we beg for waivers," Vos said. "A program like DSH makes sense. It is why on a bipartisan basis, Republicans and Democrats said we are going to make sure we direct funds toward the hospitals that deal with the poorest folks in the most challenging communities. I agree we should continue to put more funding into DSH. The difficulty we have with that, when a budget is put together, all the pieces are already allocated—so if we choose to put money into DSH, it means taking it from the university or school districts—neither of which I relish doing. I am more than willing to take a look at it as the finance process goes through, but it is not an easy problem to solve. The fact that we have it in the budget is a major advantage; it is something we could grow over time."

Borgerding said it is important to note that since Wisconsin rejected Medicaid expansion, in every one of the budgets since, the Governor and the state Legislature have increased Medicaid funding. So while we rejected those federal dollars, Wisconsin has replaced those with state dollars and has kept its commitment to the Medicaid program, which is greatly appreciated.

"The heartburn came with the requirement that states expand eligibility to 138 percent FPL," Borgerding said. "There was no alternative. You either expanded the way Washington said to expand, or you were out of luck. The fact is, Wisconsin did expand and put 130,000 more people into Medicaid below 100 percent FPL. The difference between Wisconsin and Illinois is Illinois gets 100 percent, ramping down to 90 percent of federal dollars to pay for that same exact population that Wisconsin is spending $280 million to cover. My hope is in 2017 there is a way to not necessarily refight the Medicaid expansion battle, but instead come together in a bipartisan way that we can petition the Administration, maybe under a waiver, to recognize the expansion Wisconsin did and the fact that we added 130,000 people. Why should we not be recognized for doing that with the enhanced federal match? What is the difference between the traditional federal match at 60 percent and the enhanced federal match at 90 percent? They are both a federal match. Unless we’re proposing to take less money from the federal government and take that match down from 60 to 40, which I don’t think we are doing. My sense is it’s a discussion about what should the match rate be and how should Wisconsin be recognized for the commitment we did make. I think we could find some bipartisan common ground on that."

In his last question to the panel, Borgerding asked for their opinion on what the goals should be as Congress debates the repeal and replacement of the ACA. He asked them to keep in mind that the "Wisconsin model" for Medicaid expansion relied heavily on covering those below 100 percent FPL and moving those above the poverty line into the exchanges.

Fitzgerald led off by emphasizing the importance of allowing states the flexibility to design their own programs to meet the needs of their own state. A one-size-fits-all program does not work, even within a state. When the ACA was rolled out, he said it was that concern that led some states to be reluctant to expand Medicaid and accept the federal dollars.

"I think all legislative leaders, no matter what state they are from, know if they come up with a system that allows those dollars to go into their state coffers, so we can design or redesign what we think is the most effective way to implement that in our state, that is what they are looking for," Fitzgerald said. "We are fortunate to have Speaker Ryan’s ear. I will tell you what I tell him: Don’t penalize states no matter where they landed on whether they created a state or used the federal exchange, and second make sure the dollars come directly to us so we can design our own program."

Barca said he wants to maximize the dollars coming back to Wisconsin. While waivers are vitally important, he cautioned that he believes the worst thing would be block grants for medical assistance.

"If their goal in the block grants is to make sure states have more resources available to accomplish their goal, I would say fantastic. But normally when Congress uses block grants, it is their way to cut the resources coming back. The cost of serving people with disabilities is expensive; frail elderly people who need the quality care you provide is expensive," he said. "I don’t want to see block grants at the expense of the fact that we get waivers we want, but not at the expense of getting only 2/3rds of the funds we need to serve people with disabilities. That worries me."

If we are stuck with the ACA, Barca said, make it the best that it can possibly be. Medicare wasn’t perfect when it was passed, he said, but I don’t hear people saying let’s get rid of Medicare. If they can’t get the votes at the end of the day, then at least let’s tweak it and make it the best program it can possibly be so citizens have coverage and providers have the kind of reimbursement so you can do the job right.

States need more flexibility, according to Vos, without the federal government dictating how to do it.

"When I look at Medicaid, all we (the states) ask is to give us a block grant so we can be the innovators that the framers of our Constitution imagined that every state would be," Vos said. "What happens in Georgia or Florida is not the exact same as what happens in Minnesota or Wisconsin…so the American people can see which one works better. Our current system takes well-meaning unelected bureaucrats, who impose a one-size-fits all system on everybody, and then we have to request a waiver from someone who has never ran for office and has never set foot in your hospital.

"I want Wisconsin government to have control. You can bring us into your hospital and educate us. You do not have the same access to members of Congress that you have to your state legislators as far as making decisions in the interest of your organizations. As we look at where we are going forward with health care, that’s my vision. More power going to us…we can put cost controls in place and innovate," according to Vos.

The federal government could learn a lot from the health care delivery systems in Wisconsin. Shilling believes that story should be told broadly about Wisconsin’s outcome based, patient-centered, evidence-based care.

"Great things are happening here in our health care models. If we look at changes to the ACA, we need to cover preexisting conditions," according to Shilling. "There are people across the country that the idea of taking away insurance and access is frightening to them. Is health care a right or a privilege? What is the right way to access care? I think we should talk about wellness incentives. I know you are doing bold things…You in health care have known this feeling of uncertainty. Are we tweaking the ACA or blowing it up? That uncertainty exists for us as policymakers, but you are on the front lines of this uncertainty."

Borgerding thanked the legislators for the excellent discussion and closed by acknowledging the dedication of our state legislators.

"What we should all take away from this discussion is the substantive grasp and understanding that our legislative leaders have on health care in Wisconsin," Borgerding said.

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