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Physician Edition

09-20-2017


September 20, 2017

Volume 5-Issue 17


Health Committee Leaders, WHA Host Capitol Briefing on Health Care Quality

WHA members explain how they improve care, reduce costs, improve patient outcomes

Three innovative programs that are improving patient care and reducing health care costs in Wisconsin were shared at a briefing hosted by WHA in the State Capitol September 14. More than 40 legislators and members of their staff attended the session. State Rep. Joe Sanfelippo, chair of the Assembly Health Committee, led a bipartisan group of Health Committee leaders who encouraged lawmakers and staff to attend this briefing by WHA. Sanfelippo, WHA’s 2017 Health Care Advocate of the Year, provided introductory remarks at the briefing. 

“Over the past few years, with all the distractions we have had with Obamacare and everything, it is easy to get caught up in that and forget about what we have here in the state of Wisconsin,” Sanfelippo said. “This presentation is going to remind us what great hospitals and hospital systems we have in our state, and the level of health care that our citizens get is above and beyond what many of the country get to experience. I am excited to be part of this presentation.” 

WHA President/CEO Eric Borgerding said quality health care is an economic advantage for Wisconsin.

“We need to understand what high-quality care means for Wisconsin. Of course, it means better outcomes for patients, better care for patients and their families, but it also has an impact on our economy, economic development and employers locating to our state,” Borgerding said. “That is why it is important to have good public policy in place that supports quality improvement and population health.”

WHA Chief Quality Officer Kelly Court described how hospitals and health systems are using data and analytics created by the WHA Information Center to identify patient populations who are at higher risk for certain diseases or conditions. WHA’s staff works closely with individual hospitals and health systems to advance their quality improvement activities by using data and creating networks that allow hospitals to share best practices.

Court cited two key pieces of WHA-supported legislation that have advanced quality improvement in recent years. The Quality Improvement Act added legal protections to information shared between hospitals that is used for quality improvement purposes, and the Data Modernization Act provides the WHA Information Center with the ability to assess patient condition information at a more precise and accurate geographic level, which is critical for health care data users, such as hospitals, who are preparing population health strategies in the communities they serve.

Hospitals are working beyond their walls, according to Laura Rose, WHA vice president, policy development. She described WHA’s work in the area of developing policy initiatives aimed at improving the ability of hospitals and health systems to provide or locate post-acute care for their patients.

“We know there are patients who are ready to be discharged from the hospital, but have waited in the hospital for as long as 45 days for placement in an appropriate skilled nursing facility,” Rose said.

Three health systems presented at the briefing. Lois Van Abel from Bellin Health Care in Green Bay, described Bellin Health’s “Next Generation” accountable care organization’s work that has improved quality and the patient experience while reducing costs. Bellin and ThedaCare participated in the Pioneer ACO program, and over three years saved the Centers for Medicare and Medicaid Services $14 million in Medicare costs.

“It requires a lot of coordination to achieve those savings—work we do not get paid for,” according to Abel. “We basically never ‘discharge’ a patient, instead we ‘transition’ them to a new setting and work closely with partners in that community to coordinate care.”

Engaging patients in their own care and connecting them to a medical home is critically important in controlling costs and improving care for those who are high utilizers of emergency department services. Robert Marrs, Aurora Health Care, said high utilizers account for 25 percent of health care services. The problem is how to deliver health care to those who need it most and have multiple other issues that are usually outside of the scope of the hospital to solve.

Marrs said Aurora Sinai developed a program called “Coverage to Care” where social workers receive coaching in behavioral health and do what he described as “forensic care planning.” They determine the usage patterns of these complex, high users of health care, then they connect them to a medical home and the social services to stabilize the patient not only medically, but also ensure they can lead a healthier, more productive life. Marrs credited the bipartisan HIPAA Harmonization Act, championed by WHA in 2013, as a public policy that has strengthened the ability for providers to communicate with each other and make Coverage to Care more successful.

Ascension-St. Joseph’s Hospital, also in Milwaukee, has also implemented a program called “Transitions in Care” that connects patients to a medical home and reduces ER visits.

Linda Puccini said St. Joseph’s has one of the busiest ERs in the state, with more than 85,000 visits every year. Their goal was to reduce non-urgent ER visits by providing patients with education and resources, and connect patients to a primary care physician.

“We built a relationship with the patient, even going with them to their first doctor’s visit if they were nervous about it,” Puccini said.

More than half of the patients enrolled in their care program were enrolled in Medicaid and 14 percent were uninsured. The program was successful in not only reducing ER visits, but also reduced readmissions and revealed social needs of the patients, which the hospital accounted for in their care plans.

Borgerding said hospitals’ and health systems’ efforts to improve the quality of care are also lowering the cost of care, and ensuring patients are able to resume their daily activities, return to work sooner and have better outcomes from the care they receive.

“It’s care that is proven to work,” Borgerding said. “That is why Wisconsin’s health care is an economic advantage to our employers, a benefit to their employees and a factor in moving our state to a higher level of wellness.”  


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WHA Sponsors Statewide Ad Campaign: WI is #1 In Health Care!

Buys include print ads, statewide radio, digital

This week, WHA initiated a statewide advertising campaign to celebrate Wisconsin’s status as the #1 health care state in the country based on quality, according to the federal Agency for Healthcare Research and Quality (AHRQ).

“We want to make sure that everyone in the state—our employers, patients, lawmakers and people living in our communities—is aware that Wisconsin’s health care ranked top in the nation, but as or more importantly, knows that the hospitals, doctors, nurses, care providers and health care leaders in this state are strongly committed to continuing to improve, to staying among the best in the country,” said WHA President/CEO Eric Borgerding.

In 10 of the last 11 years, Wisconsin has never ranked lower than fourth best in the AHRQ report. 

Wisconsin scored exceptionally well across more than 130 measures AHRQ uses to measure health system performance. The Badger state’s strongest performance was in the areas of acute and chronic care, and patient safety. 

“The AHRQ rankings are a national validation of what we know here; Wisconsin’s local and regional health systems are delivering some of the best care in the country,” according to Borgerding. “Across all care settings, in rural and urban communities, we are maintaining consistently high performance, while striving to set even higher standards of care. It is that combination of performance and commitment to be better that makes Wisconsin a perennial leader.

The ads will run statewide on the Wisconsin Radio Network through September 19, print ads will appear in the Wisconsin State Journal on September 15, 17 and 20 and in the Journal Sentinel September 20, 22 and 24 and a banner ad will be in the WisPolitics Health Care Report and in their AM News product into mid-October. Listen to the radio spot here: http://www.wha.org/Data/Sites/1/pdf/WHA-2017-Number%201-WHAX1709-LF01-lt%20REV2.mp3.

The AHRQ top ranking is based on the overall quality of care in the state. It arrives on the heels of Wisconsin’s critical access hospitals (CAHs) being singled out in July 2017 as the best in the nation by the federal Health Resources and Services Administration (HRSA) for outstanding quality performance. That ranking was based on participation in and achievement on the Medicare Beneficiary Quality Improvement Project (MBQIP). Wisconsin CAHs achieved the highest reporting rates and levels of improvement in the country over the past year. CAHs are hospitals with fewer than 25 beds that provide essential services in rural areas. There are 58 CAHs in Wisconsin.

“WHA is proud to represent some of the finest hospitals and health care systems in the country that are staffed by some of the best, most highly qualified health care professionals in the country. We know as we improve quality, we reduce health care costs, and patient outcomes are better,” Borgerding said. “That helps ensure Wisconsin will continue to be known for high-quality, high-value care, which is an economic development asset in every part of the state.”

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JFC Wraps Up Budget Work, Sends Amended Bill to Full Legislature

After a nearly three-month break, the State’s Joint Finance Committee (JFC) quickly resumed work on the state budget in late August and finalized their full amendment to the budget bill September 6. The budget bill, as amended by the Committee, will now move to the Assembly and Senate—with action by the Assembly already scheduled September 13 and action in the Senate as soon as late next week.

Gov. Scott Walker will receive the amended budget bill immediately following action by the Senate. If the Senate and Assembly act next week on the bill, the Governor could have the final budget bill and veto message signed before the end of the month.

The budget’s substitute amendment supported by the Committee includes several key WHA priorities:

  • A $25 million increase in state support of the Medicaid Disproportionate Share Hospital (DSH) program, resulting in over $60 million All Funds (state and federal dollars) increase in the program;
  • A $1.2 million All Funds payment to support rural hospitals who meet the Medicaid payer mix threshold for DSH but do not provide obstetric services;
  • Rural health care workforce investments of $1 million annually for training advanced practice clinicians and allied health professionals;
  • A $1.5 million increase for the state’s Graduate Medical Education matching grant program; and,
  • A $2.25 million pilot program for intensive provider care coordination services for Medicaid patients who are high-utilizers of hospital emergency departments.

In addition to finishing the JFC’s nearly eight-month deliberation of the state budget, the JFC also recommended passage of legislation creating a new electronics and information technology manufacturing zone intended to incent an investment upwards of $10 billion into southeast Wisconsin for electronics manufacturer Foxconn. The Assembly and Senate both need to take action on this legislation before the September 30 deadline established in a memorandum of understanding between Walker and Foxconn CEO Terry Gou. The Senate is planning to take up the final, amended bill September 12 and the Assembly is planning to take up the bill September 14.

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UW Study: Over Half of Physician Workday Spent in EHR

Equates to 5.9 hours of 11.4-hour workday for primary care physicians

Primary care physicians spend more than half of their workday interacting with their electronic health record (EHR) according to a study published this week in the Annals of Family Medicine. The study, conducted by the UW Department of Family Medicine and Community Health, presents findings and conclusions on primary care physician workload related to the EHR. 

The researchers found clinicians spent 5.9 hours of an 11.4-hour workday in the EHR per 1.0 clinical full-time equivalent. The study tracked and measured non-resident UW family practice physician work and interactions with the electronic health record over a three-year period beginning in 2013. 

Documentation, order entry, billing and coding, security and other clerical and administrative tasks accounted for 2.6 hours of the workday, and inbox management accounted for an additional 1.4 hours.  The study also found that 1.4 hours of EHR time occurred outside of 8 a.m. to 6 p.m. clinic hours.

“This study helps to move the conversation within organizations and with policymakers on EHR burden related physician burnout from discussion to actionable quantitative metrics,” said Chuck Shabino, MD, WHA chief medical officer. 

“For policymakers, the study also highlights the cumulative effect that regulatory burden has on physicians’ time,” said Matthew Stanford, WHA general counsel. “A physician’s workday is a finite resource, and WHA will continue to work with policymakers to reduce regulatory burdens to help ensure more of that time is spent providing care to patients.”

WHA’s Physician Leaders Council will be discussing the study at its October meeting, including potential solutions highlighted in the study that align with recommendations in the 2016 WHA Physician Engagement and Retention Toolkit.

The article, “Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time Motion Observations,” appears in the September/October 2017 Annals of Family Medicine, and the full article can be viewed at www.annfammed.org/content/15/5/419.full.pdf.

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WHA Quality Forum: Patient Safety Tools & Concepts, Oct. 17

On October 17, WHA is offering a one-day session focused on patient safety tools and concepts, including an emphasis on the deviation management process, and discussion on a variety of practical tools including FMEA, RCA2, ACA and risk-based decision making and data management. Faculty includes Kelly Court, WHA chief quality officer, and Alex Hunt, quality assurance manager, Community Blood Center, Appleton. Hunt is well-known in Wisconsin quality leadership circles and has served as director of patient safety for Hospital Sisters Health System (HSHS) and was the quality director for the ThedaCare system.

“Patient Safety Tools and Concepts” will launch WHA’s new Quality Forum, a series of day-long education events that will address high priority topics for hospital quality leaders and others involved in quality improvement in Wisconsin hospitals and health systems. The series includes topics such as medical staff quality, survey readiness, meeting external reporting requirements and more, and presenters for each will share topic expertise and best practice applications.

Online registration and information on all six sessions of the WHA Quality Forum can be found at www.cvent.com/d/f5qhb9. Registration at each session will be limited, so those interested should register as soon as possible. For registration questions, contact Kayla Chatterton at kchatterton@wha.org. Contact Beth Dibbert at bdibbert@wha.org, for questions about the content of these sessions.

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WHA Submits Comments on Improving Medicare

On August 24, the Wisconsin Hospital Association submitted comments to the U.S. House of Representatives’ Ways & Means Committee in response to their request for provider feedback on ways to reduce Medicare’s regulatory and statutory burden. WHA’s submission highlighted varying Medicare issues impacting Wisconsin’s hospitals and health systems (rural to urban) as well as issues spanning the health care delivery continuum. Those suggestions for improvements include:

  • Addressing Hospital Outpatient Departments/Section 603 of the Bipartisan Budget Act of 2015
  • Aligning and Improving Quality Reporting and Penalty Programs
  • Removing Geographic Restrictions on Access to Telehealth Services for Medicare Beneficiaries
  • Extending a Moratorium on the “Direct Supervision” regulation
  • Conforming Conflicting “96 Hour” Statutes for Critical Access Hospitals
  • Easing the EHR Incentive Program
  • Creating Consistency in Federal Hospital Regulations Regarding Use of Advance Practice Nurse Prescribers and Other Advance Practice Clinicians in Hospital Setting
  • Addressing the “3-Day Stay” Requirement for Admission to a Nursing Home After a Hospital Stay
  • Revising Requirements for Skilled Nursing Facilities (SNFs) to Become Training Sites for Certified Nursing Assistants (CNAs)

“The Wisconsin Hospital Association’s submission highlights statutes and regulations across the health care delivery continuum that we believe are actionable and would be an excellent start to reducing Medicare’s burden on our hospitals and health systems,” said WHA President/CEO Eric Borgerding. “As Congress and the Administration move into the fall floor period, we ask them to move forward on these important improvements.”

Read WHA’s comments at: www.wha.org/data/sites/1/pdf/8-24-2017WHAsubmissionWMMedicareRedTapeReview.pdf.

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New Census Bureau Report Shows Wisconsin Uninsured Rate at Just 5.3%

Nearly 95 percent of Wisconsin’s population had health care coverage in 2016. That’s according to the latest report from the U.S. Census Bureau released September 12, which estimates about 300,000 people in Wisconsin lacked health insurance coverage in 2016. 

In 2013, the year before the coverage changes under the Affordable Care Act (ACA) were implemented, Wisconsin’s uninsured rate was 9.1 percent. Since then, the rate has steadily fallen reaching just 5.3 percent in 2016—a 42 percent drop in four years. 

Wisconsin continues to have an uninsured rate that is better than 21 of the 31 states that took the full Medicaid expansion under the ACA. While Wisconsin’s version of expansion didn’t meet the definition under the ACA, the state did expand coverage to over 130,000 adults without dependent children with income below 100 percent of the federal poverty level (FPL). At the same time, Wisconsin disenrolled from Medicaid some adult recipients with higher incomes when the federal insurance exchange was implemented and subsidies became available to help people buy coverage in the exchange market. Indeed, Wisconsin now has about 63,000 people with income below 150 percent FPL receiving exchange coverage. 

The Census Bureau estimates the national uninsured rate at 8.8 percent for 2016, a reduction of 0.3 percentage points. Wisconsin just outpaced the national reduction in the uninsured with a reduction of 0.4 percentage points from 2015 to 2016.

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DHS Discontinues Outpatient Behavioral Health Prior Authorization Requirements

WHA work group recommended reforms to behavioral health prior authorization process

The Department of Health Services (DHS) has discontinued the prior authorization requirement in the fee-for-service Medicaid program for outpatient mental health and outpatient substance abuse treatment in excess of 15 hours or $825 per year and for outpatient mental health and outpatient substance abuse assessments in excess of eight hours per year. This change was published in the September 2017 ForwardHealth Update (2017-27) “New Prior Authorization Policy for Outpatient Behavioral Health Services” and is effective October 1, 2017.

“WHA has long supported reducing regulatory burdens on health care providers in a number of areas, including Medicaid,” said Joanne Alig, WHA senior vice president, policy and research. “WHA’s Medicaid Policy Work Group has focused on the area of mental health and substance abuse in particular, and reforming the prior authorization requirements was one of the recommendations coming out of that work group over the past year. WHA is pleased DHS is taking this step.”

In addition to the change in prior authorization requirements, the ForwardHealth Update provides several “reminders” regarding covered services, claims submission, medical necessity and documentation for outpatient mental health and substance abuse services. It also notes the Update contains fee-for-service policy and “applies to services members receive on a fee-for service basis only,” but that “[Managed Care Organizations] are required to provide at least the same benefits as those provided under fee-for-service arrangements.” 

DHS also published changes to covered services and prior authorization requirements for adaptive behavior assessment and treatment for Medicaid members with autism or other diagnoses or conditions associated with deficient adaptive or maladaptive behaviors. Those changes were contained in a second September 2017 ForwardHealth Update (2017-28), “Changes to Coverage Policy and Prior Authorization Requirements for Behavioral Treatment”. Among the changes in this Update, “behavioral treatment technicians” are now permitted to deliver “focused behavioral treatment” under certain conditions. These changes are also effective for dates of services on or after October 1, 2017.

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WHA Submits Comment Letters to CMS

Urges agency to withdraw 340B, HOPD changes

The Wisconsin Hospital Association submitted two comment letters September 11 to the Centers for Medicare & Medicaid Services (CMS) on the proposed CY 2018 Outpatient Prospective Payment System (OPPS) rule and proposed CY 2018 Physician Fee Schedule (PFS) rule.

In the OPPS rule, CMS proposes to drastically cut the 340B drug discount program by reimbursing separately payable non-pass-through drugs acquired through the 340B program at the Average Sales Price (ASP) minus 22.5 percent. Currently these drugs are paid at ASP plus 6 percent. CMS goes further and proposes that those dollars, instead of going to 340B providers, would then be redistributed to other services/providers within Medicare Part B or potentially elsewhere.

“WHA strongly opposes all aspects of the change in 340B policy and payments for our safety-net hospitals…and urges CMS to pull this proposed policy back completely,” WHA’s comment letter read.

WHA’s opposition is based on a variety of reasons, the least of which is it does not believe CMS has the statutory authority to impose this payment change for the 340B program. WHA also believes the change is inconsistent with Congress’s stated purpose for creating the 340B program originally. Further, WHA believes the reimbursement cuts would greatly undermine the program and 340B covered entities’ ability to continue providing more access to care and pharmaceuticals.

In its OPPS letter, WHA also commented on electronic health record (EHR) provisions and recommended CMS delay or cancel altogether Stage 3 of the EHR Incentive Program and establish a 90-day reporting period for every year of the EHR Incentive Program. In addition, WHA expressed support for CMS’s proposal to reinstate a moratorium on enforcement of its burdensome direct supervision requirement for outpatient therapeutic services provided in critical access hospitals and small and rural hospitals. WHA urged the agency, however, to make the enforcement moratorium permanent and continuous (i.e., without CMS’s proposed gap year in 2017). 

With respect to the proposed CY 2018 Physician Fee Schedule (PFS), WHA strongly expressed its opposition to the payment cuts for nonexcepted services in certain off-campus provider-based hospital outpatient departments (HOPDs). Under Section 603 of the Bipartisan Budget Act of 2015, with some exceptions, services furnished in off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 were no longer to be paid for under the OPPS, but, instead, would be reimbursed under the PFS at a much lower rate. That rate was set at approximately 50 percent of the prior OPPS rate. In the CY 2018 PFS proposed rule, CMS proposes an even further reduction to these payments, setting the rate at 25 percent, rather than the previous 50 percent, of the OPPS rate.

WHA strongly objects for multiple reasons, including CMS’s own admission it was basing the payment reduction solely on a comparison of one payment code (hospital outpatient clinic visit) to the payment for a similar outpatient visit under the PFS. “WHA objects to this approach. We do not believe basing an entire group of nonexcepted service payments on one code is sound policy. In fact, CMS admits the proposed methodology fails to take into consideration the many other services provided in off-campus PBDs which are not akin to the one payment code it reviewed,” WHA’s letter read.

WHA further reminded the agency that it “expressed strong concerns in our 2017 OPPS comment letter on the approach CMS was taking at that time to operationalize the Section 603 change….[and] we strongly object to further payment reductions as are proposed in the FY 2018 PFS. Hospitals must be paid adequately in order to continue serving as essential access points to care.”

Finally, WHA’s PFS letter also provided comments in support of proposed changes reducing the number of reported measures under the Physician Quality Reporting System as well as reducing the penalties on providers under the valued based modifier payment adjustment.

Read WHA’s CY 2018 OPPS comment letter.

Read WHA’s CY 2018 PFS comment letter.