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Physician Edition

07-05-2017


July 5, 2017

Volume 5-Issue 12


Court Decision Risks Patient Access to Health Care

Loss of non-economic damage cap will exacerbate future physician shortages

The Wisconsin Hospital Association (WHA) is concerned it will become more difficult for patients to find care in their communities, particularly in rural and inner city areas, if the July 5 Wisconsin Court of Appeals ruling on the constitutionality of Wisconsin’s cap on non-economic damages in medical malpractice cases is upheld.

“We disagree with the Court of Appeals conclusion that there is no evidence or rationale supporting the Legislature’s policy decision to protect access to health care in Wisconsin by enacting Wisconsin’s cap on non-economic damages in medical malpractice cases,” said WHA President/CEO Eric Borgerding. “Upsetting the Legislature’s informed policy decision by invalidating Wisconsin’s cap on noneconomic damages will negatively impact Wisconsin communities’ efforts to attract physicians to provide accessible, quality health care to their residents.”

“Wisconsin’s unique, balanced medical malpractice system that includes a cap on non-economic damages is a key policy that has helped Wisconsin retain and attract high-quality physicians to Wisconsin communities,” said Borgerding. “Without a sufficient supply of physicians in communities throughout the state, Wisconsin’s high rankings in health care access and quality would not be achievable.”

In 2016, the Wisconsin Council on Medical Education and Workforce (WCMEW) released a report (http://www.wha.org/Data/Sites/1/workforce/2016physicianReport-WCMEW.pdf) indicating Wisconsin may face a shortage of more than 2,000 physicians by 2030. To address that shortage, one of that report’s recommendations was to maintain public policies that preserve Wisconsin’s medical liability environment because of their impact on retention and in-migration of physicians.

Included in the WCMEW report is a 2012 study by economists John Perry and Christopher Clark published in Business Economics that concluded, “We find robust evidence that noneconomic damage caps impact physician populations. This finding is present in the majority of prior literature….The inference from this work is that physicians are less likely to move away from states and more likely to move to states that have implemented certain medical malpractice liability reforms.”

“The WCMEW report highlights the challenges that Wisconsin faces in ensuring Wisconsin’s supply of physicians meets patient demand for accessible health care,” said Chuck Shabino, MD, WHA chief medical officer. “The competition nationally to recruit physicians is fierce. Wisconsin must continue to focus on ensuring the aspects of our state that attract physicians, such as a favorable medical malpractice environment, are maintained.”

Unlike patients in most states or other successful plaintiffs in non-medical liability suits, Wisconsin patients who are injured by medical malpractice have access to unlimited economic damages through the Injured Patient and Family Compensation Fund. Funded exclusively by assessments on health care providers, the Fund places Wisconsin medical liability plaintiffs in a better position than patients in other states and other injured plaintiffs—recipients are guaranteed recovery. Other injured parties are not guaranteed recovery, left instead to hope that a tortfeasor has sufficient insurance coverage for not just non-economic damages but also all past and future medical costs, lost earnings, and other economic damages incurred by the injured party.

The public policy balance of guaranteed recovery for injured plaintiffs to better protect injured patients and a cap on non-economic damages to support accessible health care has served Wisconsin well and is key to Wisconsin’s comprehensive medical liability system. The current cap on non-economic damages was passed with bipartisan support in the Legislature and signed into law by Governor Jim Doyle in 2006.

“We are expecting today’s decision will be reviewed by the Wisconsin Supreme Court, and we believe the Court will uphold the well-supported and bipartisan public policy balance set by the Legislature to help ensure accessible health care in Wisconsin,” said Borgerding.

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President’s Column: The AHCA’s Painful Contradiction

By Eric Borgerding, WHA President/CEO

Politics is full of contorted contradictions and inexplicable ironies. For the latest example, look no further than the Obamacare replacement legislation, the American Health Care Act (AHCA).

For better or worse, Wisconsin rejected Obamacare’s Medicaid expansion. Yet under the House version of the AHCA, Wisconsin will be severely penalized for doing so. Here’s why:

Under the AHCA, the bill repealing Obamacare, states that adopted Obamacare’s Medicaid expansion will receive an average of $1,936/person in federal Medicaid funding through at least 2025. The 19 nonexpansion states, like Wisconsin, will receive $1,158/person.

Under the AHCA, states that adopted Obamacare Medicaid expansion will receive nearly $700 billion more in Medicaid funding through 2025 than those states that rejected Obamacare Medicaid expansion. That means Wisconsin will receive $37 billion less than if it had adopted Obamacare expansion. That’s over three times what Wisconsin currently spends annually on Medicaid.
And it doesn’t stop there. Under the AHCA Wisconsin will actually pay for this massive inequity. Here’s how:

To his credit, Governor Walker did expand Medicaid by adding 130,000 people below the poverty level to the program. But our version of expansion didn’t meet the Obama administration’s definition of “expansion.” That means Wisconsin spends $280 million per year to cover the exact same population that, under Obamacare and now the AHCA, an expansion state would pay roughly $28 million to cover. That’s a difference of nearly a quarter-billion annually we could use to train more primary care doctors and nurses, improve access in underserved rural and urban areas or reduce Medicaid cost shifting to employers and families…right here in Wisconsin.

Under Obamacare, Wisconsin’s hospitals are taking billions in Medicare cuts to pay for Medicaid expansion in other states. Under the AHCA, those cuts continue, and Wisconsin keeps paying.
If anyone thinks the solution is for Wisconsin to bite the political bullet and expand Medicaid, forget it. The current version of the AHCA outlaws any new expansions. That means not only would Wisconsin be prohibited from expanding, we will continue paying for those that did.

I’m not advocating for a redistribution of dollars from the expansion states to the nonexpansion states. Effectuating my preferred definition of “equity” means finding ways to raise states to similar levels of federal Medicaid funding, and there are plenty of ideas on the table.

One of Obamacare’s most glaring flaws is that it creates winners and losers among the states based upon an arbitrary definition of “expansion.” That is redistribution, and no state has felt the impact harder than Wisconsin. The painful irony here is it’s now the AHCA perpetuating this inequity and making fiscal martyrs of states that rejected the very thing the AHCA is trying to repeal.
 

With so much on the line, I believe those who rejected Obamacare Medicaid expansion must assure we are not penalized for doing so. Here is the chance; now is the moment. The AHCA will soon be voted on in the U.S. Senate, where the Republican majority is just 52 out of 100 votes. With a margin that slim, even one GOP Senator can make a game changing, course correcting difference.

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Registration Open for Fall Cohort of WHA Physician Quality Academy

Physician Quality Academy LogoPhysicians are often assigned a role with a hospital or health system’s quality department or committee, or they are asked to lead a quality improvement project. Knowledge about quality improvement tools and principles can increase the likelihood that a physician will be more engaged in, successful in and comfortable with his/her leadership role.

To ensure physicians have access to the training and resources necessary to lead quality improvement initiatives, WHA is offering a fall cohort of the WHA Physician Quality Academy. The Academy offers two non-consecutive days of in-person training and access to supporting resources both between and after the live sessions. 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.

“Attending the Quality Academy was an enlightening experience. [The Academy] helped me develop a broader framework of systems thinking in health care and the importance of critically defining metrics involved,” said Paul Bekx, MD, chief of staff and medical director of quality and regulation for Monroe Clinic, an attendee of the 2017 spring cohort of the Physician Quality Academy. “The quality improvement model tools that were presented helped guide us to define the problem at hand, the critical questions to ask, the proper metrics to measure and how the answers to these items can help in the next cycle of improvement in quality. The conference was very helpful.”

The fall cohort of the Academy will be offered September 29 and November 3, at Glacier Canyon Lodge at The Wilderness Resort in Wisconsin Dells. By enrolling, participating physicians are committing to and expected to attend both days of their enrolled cohort. The full event agenda and online registration are available atwww.cvent.com/d/wvq5nm, and a brochure is included in this week’s packet. Attendance is limited, so register your physicians today.

The Academy is jointly provided by AXIS Medical Education and WHA. AXIS Medical Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for physicians. AXIS Medical Education designates this live activity for a maximum of 10 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity
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WHA-Supported Dental Hygiene Legislation Signed Into Law

Gov. Walker signs AB 146 into law

Since the 2017-18 legislative session began in January, the Wisconsin Hospital Association (WHA) and other health care providers and organizations have been working to advance legislation to expand access to preventive dental care. This bill, Assembly Bill 146, was signed into law as Wisconsin Act 20 by Gov. Scott Walker June 21. The bill was co-authored by Rep. Kathy Bernier (R-Lake Hallie) and Sen. Sheila Harsdorf (R-River Falls) and passed with overwhelming support by both the Assembly and Senate. Act 20 expands the settings in which dental hygienists are allowed to provide, without dentist supervision, preventive oral health care and education.

Dental hygienists are currently allowed to independently practice in schools, dental schools and local public health departments. Under Act 20, dental hygienists will be able to independently provide dental hygiene services in hospitals, outpatient medical clinics, nursing homes, community-based residential facilities, adult family homes, adult day care centers, community rehabilitation programs, hospices, prisons and jails, and through home health agencies, nonprofit dental care programs serving low-income persons, and charitable institutions.

One of the potential outcomes of Act 20 will be the integration of dental hygiene into primary health care visits, especially for young children from birth to age three. Incorporating a dental hygienist into the medical team in a physician’s office may reduce the prevalence of dental disease by allowing the hygienist to begin interacting with children and families as early as six months of age. Ultimately, this may lead to a reduction in emergency department visits for preventable dental conditions and better overall oral health for people in Wisconsin.

Act 20 takes effect June 23, 2017.
 

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DHS Announces New GME Grant Opportunities for WI Hospitals, Health Systems

The Wisconsin Department of Health Services (DHS) has released another round of funding to continue to expand graduate medical education (GME) across Wisconsin with a special focus on developing residency positions in rural and other underserved areas of the state. Eligible grantees include hospitals and groups of hospitals, health systems and academic institutions.

Since its inception in 2013, this GME grant program has obligated $11 million in state and federal funds to Wisconsin hospitals and health systems to help fund the creation of new residency programs, expansion of existing programs and sustainability of new and expanded programs.

In the current state budget, WHA worked with members of the Legislature to commit even more funding to the program and make it ongoing—providing additional certainty that funding will exist today and into the future for expanded GME programs. For more information about the available grant opportunities, note the information below.

A new Request for Applications (RFA) was released June 13 for adding new positions to existing accredited GME programs in five specialties: family medicine, general internal medicine, general surgery, pediatrics and psychiatry. These applications are due August 3 at 2:00 p.m.

Grant awards cover the length of the residency, e.g., three years for family medicine, and are limited to $75,000 per position.
The maximum amount per year per GME program is $225,000.
The grant effective date will be July 1, 2018.
Current policy allows existing successful grantees to apply for a second round of funding.
A Request for Applications to develop new GME programs in one of the five targeted specialties is scheduled to be released in mid-August.
Grant awards are limited to a maximum of $750,000 over three years and may be used for, but are not limited to: consultants, program staff, planning, accreditation fees, faculty and curriculum development and resident recruitment.
Grant funds cannot be used for capital improvements, equipment, software or research.
A 50 percent match, in cash or in kind, is required.
Applications will be due six weeks after release or the RFA with a grant effective date of January 1, 2018.
New for this round of funding (2017) is the use of funds to expand or develop fellowship programs in addiction medicine or addiction psychiatry.

For additional information about the DHS GME Grant Program, contact Linda McCart, Wisconsin Department of Health Services GME initiative director, at linda.mccart@wi.gov or Kyle O’Brien, WHA senior vice president, government relations, at kobrien@wha.org.

To download a copy of the grant application, visit DHS’ GME grant webpage at https://www.dhs.wisconsin.gov/contracts/graduate-medical-education-gme-residency-grant-2017.htm.

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WCMEW Announces Fall Workforce Conference

WCMEW logoOn September 27, the Wisconsin Council on Medical Education and Workforce (WCMEW) will host a conference focused on Wisconsin health care workforce issues. At the full-day event held in Wisconsin Dells, participants will engage in topics ranging from public policy to provider retention and training clinicians for evolving models of care delivery. The conference is designed to bring stakeholders from across Wisconsin’s business, government and non-profit areas together to recognize the urgent demand for creative and cross-sector solutions to health care workforce challenges.

Panels and breakout sessions will feature discussions by Wisconsin leaders including Ann Zenk, WHA vice president, workforce and clinical practice; Bruce Palzkill, deputy administrator, Department of Workforce Development; Jim Wood, Competitive Wisconsin; Rep. Mike Rohrkaste (R-Neenah); Peter Sanderson, medical director, informatics and ambulatory regulation, Ascension Wisconsin; and Nancy Nankivil, director, practice transformation and professional satisfaction, American Medical Association.

Registration for the conference will open in mid-July. Contact George Quinn, executive director, WCMEW, at gquinn@wcmew.org or 608-516-5189 for more information or visit www.wcmew.org/wp-content/uploads/2017/06/9-2017ConfernceFlyer.pdf.

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WCMEW Hears New, Existing Health Care Workforce Initiatives

WCMEW meeting 6/7/17
Members and community partners provided updates regarding workforce-related activities, ranging from legislative initiatives to rural clinical rotations and trends in pharmacy practice at the June 7 meeting of the Wisconsin Council on Medical Education and Workforce (WCMEW). Council meetings serve as a platform to increase awareness of new strategies to address workforce issues, build trust across industry actors and develop policies to improve the Wisconsin health workforce.

WCMEW Executive Director George Quinn introduced new WCMEW Program Analyst Richelle Andrae. With the additional staff member, WCMEW can leverage the work of the Council by expanding data analysis capabilities, developing a more comprehensive annual workforce report and strengthening relationships among statewide partners.

Legislative Update
Kyle O’Brien, WHA senior vice president, government relations, provided an update of health-related legislative items currently under review by the budget-writing Joint Finance Committee (JFC).

To support long-term care, Gov. Scott Walker recommended a two percent increase in funding for both nursing home and personal care rates. The JFC added in additional funding to support dementia care specialists and also an innovative pilot program to provide reimbursement for providers involved in care coordination activities for Medicaid enrollees who are high utilizers of hospital emergency departments.

Of the many issues related to the health of Wisconsin residents, O’Brien focused on those potentially tied to workforce. New dollars for training advanced practice clinicians such as physician assistants, along with allied health professionals, is also included in the budget package put forward by the JFC. Additional state funding for existing graduate medical education (GME) and expansion of related consortia is recommended. See the March 2017 WCMEW newsletter for further discussion of legislative initiatives.

Rural Workforce Training
Kara Traxler, director, Wisconsin Collaborative for Rural GME (WCRGME), presented the ongoing work of rural health care training and education partners. WCRGME provides technical assistance to rural hospitals with the goal of expanding rural GME and supporting urban programs in starting rural care tracks. Activities include connecting academics to rural sites, events for preceptor and administrative training and development of GME regional consortia.

WiNC, a Northern Wisconsin collaborative that includes the Medical College of Wisconsin, 12 health care systems and GME programs—with WCMEW and the Rural Wisconsin Health cooperatives as partners—is seeking to form a consortium to coordinate GME and health care workforce initiatives.

Competitive Wisconsin Initiative
James Wood, strategic counsel to Competitive Wisconsin, described the current initiative Be Bold III, which focuses on maximizing the impact of the Wisconsin business sector in the areas of food manufacturing and health care. The full report, due in late June, will highlight Wisconsin’s greatest resource—its talent. Wood stressed the importance of acting now to develop comprehensive, creative system wide changes through business competitive factors (such as the tax and regulatory environments), cost and quality of living and increased synergy between the public and private sectors.

Changing Role for Pharmacists
Sarah Sorum, PharmD, vice president, professional and educational affairs of the Pharmacy Society of Wisconsin, shed light on the transforming role of pharmacists in today’s complex health care environment. Sorum said practicing at the top of one’s license is essential to advancing the role of pharmacy to support patients. Traditionally seen as outside clinical settings, pharmacists are increasingly included in care teams, particularly through collaborative practices with physicians. Reimbursement challenges, training and lack of awareness regarding pharmacist capabilities in provision of care continue to serve as barriers to more integrated practice.

Wisconsin Academy for Rural Medicine
Byron Crouse, MD, associate dean for rural and community health, UW School of Medicine and Public Health, provided an overview of the WARM program’s accomplishments in training and retaining physicians in Wisconsin. The Wisconsin Academy for Rural Medicine, or WARM, places medical students in rural rotations, aiming to increase long-term interest in rural Wisconsin practice. Of the total 126 graduates to date, almost half (46 percent) accepted Wisconsin residencies, with 52 percent in primary care. Of the 35 graduates who have completed their residencies since the program’s 2007 inception, a staggering 91 percent currently practice in Wisconsin, with 58 percent of these physicians practicing in rural areas. At this point, the program seeks to implement new curriculum, improve the effectiveness and value of community projects and continue to support students through decreasing the burden of travel and strengthening advising services.
  

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Wisconsin Hospitals State PAC & Conduit Fundraising Passes Half Way Mark

Next contributor list to run in July 14 Valued Voice newsletter

The Wisconsin Hospitals State PAC & Conduit passed the half way mark of its 2017 goal of raising $312,500. To date, over $162,000 has been contributed by 161 individuals, putting the campaign at 52 percent of goal. This is an average rate of raising over $6,200 per week. Of the 161 contributors to date, 56 are contributing at one of three “club levels,” which begin at $1,500 and go up. The average contribution of all givers is approximately $1,000.

“We are on pace for another record-setting fundraising year, which is excellent. I want to personally thank all 2017 contributors for helping get us to this point,” said WHA Advocacy Committee Chair Mike Wallace. “But the work is not done, so please make your 2017 contribution now. When you do so, you join your peers across the state and me in helping keep health care in Wisconsin moving forward.”

Contributors who give by July 13 will be listed in the July 14 edition of the WHA Valued Voice newsletter and will also receive a Wisconsin Hospitals State PAC/Conduit padfolio.

Contribute today at www.whconduit.com or call WHA’s Jenny Boese at 608-268-1816 or Nora Statsick at 608-239-4535 to make a contribution.

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Joint Finance Committee Rejects Self-Funding Contracts

Committee uses program reserves, plan design changes to offset savings in Governor’s budget

The state Legislature’s budget committee unanimously rejected contracts sent to them from the state’s Group Insurance Board (GIB) that otherwise would have provided state employee health insurance through self-funded third party administrators. During the last legislative session, the Assembly and Senate passed a bill which was eventually signed into law as 2015 Act 119 providing the Joint Finance Committee (JFC) with “up or down” review of a contract to offer a self-insured health plan(s) for state employees.

The contracts provided to the JFC would have implemented the GIB’s previous recommendation to separate the state into four regions for the purposes of offering one or two self-funded health plans in each region, in addition to a broad statewide network offering. Gov. Scott Walker’s proposed budget used $60 million in state general purpose revenue (i.e. sales and income taxes) from savings associated with shifting from a fully-insured to a self-insured program.

The JFC decided to appropriate slightly more, $63.9 million in savings, from the state employee health insurance program but not as a result from moving to a self-insured model for health plans. The savings would be a result of an additional $22.7 million in negotiated savings with fully insured health plans, using $25.8 million in program reserves to reduce costs and an additional $15.4 million as a result of various other policies, including benefit plan changes. The JFC required that the GIB’s benefit plan changes could not increase costs to state employees by more than 10 percent compared to their current out-of-pocket costs.

In addition, the JFC’s action would require a Legislative Audit Bureau report on current GIB program reserve levels and reporting to the JFC on the Board’s plans to use state employee health insurance reserve funds over the next two years. Finally, the JFC’s action also would add members to the GIB appointed by the four legislative leaders, require Senate confirmation of GIB members appointed by the Governor and require that any changes to the state employee health insurance program be reviewed with the JFC.

Each of these provisions added by the JFC still needs review by both the full Senate and full Assembly before being sent to Walker for his consideration. On the other hand, the contracts sent to the JFC will not move forward since the JFC voted to reject them.

For a copy of the Legislative Fiscal Bureau’s review of the proposed contracts submitted by the GIB, go to https://docs.legis.wisconsin.gov/misc/lfb/section_13_10/2017_06_15_group_insurance_board_contracts_to_self_insure_for_state_employee_group_health_plans.pdf.

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Wisconsin Workers Comp Premiums Plummet

Wisconsin businesses see largest drop in workers comp rates since 1995

Wisconsin employers will see the second largest decrease in premium rates for worker’s compensation in 22 years. This week, the Wisconsin Commissioner of Insurance approved an overall 8.46 percent rate decrease for worker’s compensation premiums for business this year following a 3.19 percent decline last year. According to the Department of Workforce Development (DWD) this decrease represents a savings of nearly $170 million for employers.

Work Comp Annual Premium Rate Change graph


“This is the second consecutive year worker’s compensation rates have declined in Wisconsin, reaffirming our commitment that Wisconsin is open for business,” said Gov. Scott Walker. In a press release, DWD Secretary Ray Allen credited workplace safety efforts, as well as efforts to bring injured workers back to work as soon as possible.

WHA President/CEO Eric Borgerding commended the work of Wisconsin’s health care providers in getting injured workers back on the job more quickly than nearly every other state in the nation, helping to lower the cost of worker’s compensation claims in Wisconsin by reducing an injured worker’s time on disability.

“This astounding premium rate decrease is great news for Wisconsin employers,” said Borgerding. “It’s abundantly clear that injured workers in Wisconsin are getting some of the best care in the country.”

Indeed Wisconsin’s health care providers are an important part of the worker’s compensation program. The health care component of Wisconsin’s worker’s compensation program has a strong record of performance, with fast return-to-work rates, low utilization of health care services, high levels of patient satisfaction and overall cost per claim that is among the lowest nationwide, all of which helps lead to positive premium trends for employers and better care for those injured on the job in Wisconsin.

Meanwhile, Wisconsin’s employers are making progress on reducing nonfatal workplace injuries, and the DWD continues to focus on safety with the hire of a new safety and risk manager just last year (see previous Valued Voice article). The most recent data from the State Lab of Hygiene on workplace safety shows Wisconsin’s private sector rate of injury at 3.6 per 100 full time equivalent (FTE) workers is still about 20 percent higher than the national rate of 3.0 per 100 FTE. However, both nationally and at the state level, the rate has fallen steadily since 2003.

Borgerding says while health care providers do not control the number of injured workers coming through their doors, health care workers are helping craft programs to improve health and safety.

“The commitment of Wisconsin hospitals and health systems to our state’s workforce goes beyond providing exceptional care to those injured on the job and helping them return to work and productivity,” Borgerding said. “Our members are working with local employers across the state to design safety and health management programs and partnering to improve overall employee health. Despite the data, despite these partnerships, some in Madison continue pushing controversial worker’s compensation policies that increasingly appear to be solutions looking for a problem.”

Each year, the Wisconsin Compensation Rating Bureau (WCRB) establishes premium rates for the state’s worker’s compensation insurance carriers. These rates are developed into premiums, based on claims experience and adjustments for industry sectors. According to DWD, over the last 10 years, premium rates for Wisconsin have remained stable, with a 10-year average annual net premium change of -.37 percent.
 

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