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Physician Edition

12-06-2017


December 6, 2017

Volume 5-Issue 22


WHA to DHS: Don’t Overlook Psychiatrists in Outpatient Behavioral Health Payment Increase

WHA submitted written comments November 17 to the Department of Health Services (DHS) on the implementation of Gov. Scott Walker’s October 24 direction to DHS to improve access to treatment for mental health and substantive abuse disorders by increasing the Medicaid reimbursement for behavioral health services. WHA’s written comments can be found at: www.wha.org/data/sites/1/pdf/11-17-17WHAcommentsForwardHealthBHoutpatientClaims.pdf.

In its written comments, WHA thanked the Governor and DHS for this important investment of $7 million in state funds to increase Medicaid reimbursement rates for professionals providing outpatient mental health and substance use disorder services. 

However, as DHS implements that increase, WHA urged DHS to include evaluation and management billing codes for psychiatrists, APNP-psych and psychiatric physician assistants in the list of procedure codes that will receive a reimbursement increase. WHA raised the evaluation and management billing code issue with DHS shortly after the October reimbursement announcement, and DHS invited WHA to formalize its feedback in written comments.

WHA specifically highlighted the need to include evaluation and management billing codes because there is often a misperception that all behavioral health billing codes are psychotherapy codes.

“Following national coding standard changes in 2013 that deleted dedicated psychiatric evaluation codes, the vast majority of outpatient services provided by psychiatrists are now billed on evaluation and management codes applicable to all health conditions and providers,” says Matthew Stanford, WHA general counsel. “WHA wants to ensure the services psychiatrists provide to Medicaid enrollees are not overlooked when DHS implements this much-needed reimbursement increase for behavioral health services.”

According to feedback provided to WHA by its members, evaluation and management billing codes make up at least 80 percent of psychiatrists’ outpatient visits for Medicaid patients.

WHA also noted data in its comment letter that documents the critical shortage of physicians specializing in psychiatry, including that Wisconsin’s psychiatrist supply can only meet 25 percent of the need for services, which ranks Wisconsin 8th worst in the nation. WHA received feedback from members that the psychiatry shortage is far more critical than any other behavioral health professional shortages in Wisconsin.

Because of the more acute shortage of psychiatrists compared to other behavioral health professionals, WHA also expressed concern about a draft implementation proposal that would pay physicians specializing in psychiatry, APNP-psych, and psychiatric physician assistants at the same rates as other behavioral health providers without prescriptive authority and lesser education and training requirements. Currently, psychiatrists, APNP-psych, and psychiatric physician assistants receive a higher reimbursement than non-prescribing psychotherapists.

“Lacking identifiable benefits or policy rationale for moving from a four-tiered payment system to a two-tiered payment system that does not recognize differences in professional training levels, practice permissions such as prescriptive authority, salary expenses, and provider shortages, WHA does have concerns about adopting such a change,” said Stanford in written comments to DHS. “It is unclear how such a change will help improve access to care, and such a change may have unintended negative consequences in Wisconsin’s efforts to address its acute shortage of physicians specializing in psychiatry.”

DHS has indicated it intends to implement the outpatient behavioral health reimbursement increase for Medicaid services January 1.

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WI Supreme Court Agrees to Hear Appeal of Medmal Cap Case

The Wisconsin Supreme Court agreed this week to hear an appeal of the July Court of Appeals opinion in Ascaris Mayo v. IPFCF holding that Wisconsin’s $750,000 cap on non-economic damages in medical malpractice cases is unconstitutional.

In its July decision, the Court of Appeals concluded that the medical malpractice cap was unconstitutional because the Legislature lacked a rational basis for enacting the non-economic damage cap. By accepting review of the case, the Supreme Court will have the final say on the constitutionality of Wisconsin’s non-economic damage cap.

“WHA fought hard several years ago to enact bipartisan legislation establishing the current cap,” said WHA President/CEO Eric Borgerding. “The Legislature held multiple hearings and received ample, credible supporting information as it debated this important public policy that impacts the accessibility of health care throughout Wisconsin. We believe that the Court of Appeals’ July conclusion that this public policy choice by the Legislature lacks any rational basis was a significant error.”

Just as WHA submitted an amicus brief in support of the non-economic damage cap with the Court of Appeals, WHA will be requesting permission from the Supreme Court to file an amicus brief in its review. It is expected that multiple health care and non-health care organizations concerned about the Court of Appeals decision will also be seeking to file amicus briefs in support of the non-economic damage cap in this case.

The case does not impact economic damages, and unlike successful plaintiffs in non-medical liability suits who must rely on the solvency of the defendant to recover economic damages, Wisconsin patients who are injured by medical malpractice are guaranteed recovery of an unlimited amount of economic damages through the Injured Patient and Family Compensation Fund (IPFCF) funded by provider assessments.

The July Court of Appeals decision overturned the non-economic damage cap passed with significant bipartisan support in the Legislature and signed into law by Governor Jim Doyle in 2006. WHA, together with the Wisconsin Medical Society and American Medical Association filed a joint amicus brief with the Court of Appeals in 2015 supporting the constitutionality of the non-economic damage cap.

In the July Court of Appeals majority opinion, Judge Joan Kessler wrote, “We are left with literally no rational factual basis in the record before us which supports the Legislature’s determination that the $750,000 limitation on noneconomic damages is necessary or appropriate to promote any of the stated legislative objectives.”

The Court of Appeals decision overturns the lower court decision in this case by Milwaukee County Circuit Court Judge Jeffrey Cohen that found the non-economic damage cap generally constitutional but unconstitutional for the particular plaintiff in this case. Judge Cohen reached a different conclusion than the Court of Appeals regarding whether the Legislature had a rational, factual basis for establishing the non-economic damage cap.

“[T]he Court has conducted a thoughtful examination of the statutory scheme and determined that the Cap is rationally related to the Legislature’s goals,” stated Judge Cohen in the 2014 lower court decision in this case on the facial constitutionality of the caps. “Studies, reports, and testimony were considered by the Legislature, which then saw fit to advance four specific goals supported by this evidence. That some studies were inconclusive is not enough to show there is no rational basis here. Plaintiffs must disprove the basis for every ‘plausible policy reason’ for the challenged classification. Having reviewed the documentation on which the Legislature relied, the Court cannot say that the goals articulated are ‘wholly irrelevant.’ The documents on which the Legislature relied contain evidence to reasonably support each goal.”

Currently, Wisconsin’s noneconomic damage cap is technically now unconstitutional statewide as a result of the Court of Appeals decision. A decision from the Supreme Court is expected sometime in 2018.

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Encourage Physician Leaders to Attend WHA Physician Leadership Conference

Physicians new to leadership roles within your hospital or health system often need an opportunity to learn important and practical leadership skills that will help them move beyond their clinical training and take a new approach to managerial decision making and problem solving, allowing them to be most effective in their new roles. WHA’s annual Physician Leadership Development Conference can be just that needed opportunity.

Registration is now open for WHA’s 13th annual Physician Leadership Development Conference, scheduled for March 9-10, 2018 at The American Club in Kohler. Full information and online registration are available at www.wha.org or directly at www.cvent.com/d/ktql9j. Discounted registration is available to those registering by January 15. 2018.

This year’s conference will include a full-day session with presenter Allison Linney called “A Leader’s Guide to Resolving Conflict,” in which attendees will focus on the skills needed to make conflict productive and practice conflict management and effective communication skills. In addition, a half-day session called “Putting High Reliability Organizing (HRO) to Work,” led by Craig Clapper, will focus on the physician leader’s role in shaping performance culture, discussing the principles of high reliability organizing, and demonstrating various skills physician leaders can use to shape culture.

For questions about the annual Physician Leadership Development Conference, contact Jennifer Frank at jfrank@wha.org or 608-274-1820.

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Governor Walker Signs WHA Team-Based Care Bill

Act 119 clarifies Medicaid law regarding APNP orders

Gov. Scott Walker signed Assembly Bill 529 November 30 that provides clarification to Wisconsin health care providers that Wisconsin’s Medicaid program covers services ordered by physicians and non-physicians alike when the order is made within the provider’s scope of practice. The bill affirms that advanced practice nurse prescribers’ (APNP) and physician assistant (PA) orders may be covered by Medicaid without a physician co-signature and was one of WHA’s fall legislative session priorities (see www.wha.org/wha-newsletter-11-10-2017.aspx#s5.)

“WHA began discussions with DHS and legislators months ago to identify solutions to address concerns about perceived limitations on APNP practice that this legislation resolves,” said WHA President/CEO Eric Borgerding. “WHA greatly appreciated DHS’s work on this bill to clarify that Medicaid policy is in alignment with modern team-based care delivery and supports advance practice providers practicing at the top of their licensed scope of practice.”

The Act does not change any provider’s scope of practice and maintains the already recognized Medicaid policy acknowledging valid orders made within a provider’s scope of practice under statutes, rules and regulations governing the provider’s practice.

In addition to its work with DHS and the legislative authors Sen. Leah Vukmir (R-Brookfield) and Rep. John Nygren (R-Marinette), WHA led a coalition memo and testified in support of the bill at both the Senate and Assembly hearings. The bill passed the Senate on a voice vote and was concurred by the Assembly on a voice vote.

The text of the Act can be found at https://docs.legis.wisconsin.gov/2017/related/acts/119.pdf.

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Register Your Team Today for Advocacy Day 2018 – March 21 in Madison

Make plans now to make an impact in Madison on March 21. Join WHA for Advocacy Day 2018, one of the best ways hospital employees, trustees and volunteers can make an important, visible impact in the state capitol. You can register yourself and your team today at www.whareg4.org/2018AdvocacyDay.

As always, Advocacy Day 2018 will have a great lineup of speakers, including morning keynote Mara Liasson, national political correspondent for National Public Radio (NPR). In addition, Gov. Scott Walker has been invited to offer the luncheon address. The day will also include a legislative panel and an issues briefing for those planning to visit the state capitol to talk with their state legislators.

The afternoon of Advocacy Day is always a highlight, as hundreds of attendees take what they’ve learned and meet with their legislators in the state capitol. Speaking up on behalf of your hospital by meeting with your legislators during Advocacy Day is essential to help educate legislators on your hospital and health care issues.

Make plans now to join over 1,000 of your peers from across the state at Advocacy Day 2018 on
March 21. More information and online registration are available at www.whareg4.org/2018AdvocacyDay. For Advocacy Day questions, contact Jenny Boese at 608-268-1816 or jboese@wha.org. For registration questions, contact Kayla Chatterton at kchatterton@wha.org or 608-274-1820.

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Wisconsin Hospitals State PAC & Conduit: $50K in 50 Days?

Next contributor list December 8

In early October, the Wisconsin Hospitals State PAC & Conduit challenged individuals to contribute $50K in 50 days to help the fundraising campaign get close to goal. You will be pleased to know the effort raised $49,000 in 50 days, one thousand dollars shy of the $50,000 target! Thank you to the 81 individuals who contributed $49,000 during these 50 days.

As of November 30, the 2017 fundraising campaign topped the $290,000 mark and now sits at $294,500 from 306 contributors. The 2017 fundraising campaign is at 94 percent of goal with over $6,000 contributed, on average, every week.

“The Wisconsin Hospitals State PAC & Conduit had several great fundraising weeks, putting the effort within striking distance of reaching the 2017 goal of raising $312,500,” said WHA Advocacy Committee Chair Mike Wallace. “I know we can reach this goal by year’s end, and I ask you to join me in making your contribution today and in recruiting one other to join you in this worthwhile effort.”

There is still a month to go to raise the remaining dollars to reach goal. Please make your contribution today so your name will be on “the list” that will be published in the December 8 edition of The Valued Voice.

Contribute now at www.whconduit.com or call WHA’s Jenny Boese at 608-268-1816 or Nora Statsick at 608-239-4535.

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Guest Column: Don’t Settle for a Job When You Can Build a Career

By Ann Zenk, WHA Vice President, Workforce and Clinical Practice

The following op-ed was sent to the statewide press November 27, 2017.

It’s hard to top a career pathway where you can increase your salary by more than four-fold in as little as six years, and with perks like tuition support, flexible scheduling and employment while you pursue advancement. That’s the career path open to those who enter the health care workforce, and a career path highlighted in the Wisconsin Hospital Association’s 2017 Wisconsin Health Care Workforce report. I personally pursued that career path, from food service while in high school, to certified nursing assistant while in college, to registered nurse and nurse executive while in grad school, now rounding out my career as WHA’s resident expert on workforce. Health careers are endlessly interesting and rewarding. With health care employment expected to grow by 30 percent in the next decade, it’s a pathway with boundless prospects for the future.

The opportunity for advancement creates constant turnover and high vacancy rates (we call it churn) in entry-level positions as individuals leave their role as a dietary aide or nursing assistant to follow their career path. While this creates concerns for health care employers, who can’t close the doors in this 24/7/365 business, they know advancement fills the need for nurses, advanced practice clinicians and other health care professionals. That means churn in entry-level positions may be health care’s new reality.   

At WHA’s urging, our state policymakers are acknowledging and supporting the continuous investment required to build and sustain a health care workforce. The Rural Wisconsin Initiative, part of the Wisconsin 2017-2019 state budget, provides a chance for health care employers and educational entities to team up and apply for matching grants to create training programs for allied health professionals and advanced practice nurses. These funds will let us grow the workforce we need locally to ensure Wisconsin citizens have access to the best health care in the nation.

Nursing has successfully used this career path to grow the profession. We had 10,000 more nurses in Wisconsin in 2016 than in 2012, and with 26,000 Wisconsin nurses expected to retire by 2030, we will need even more. 

WHA challenges health care organizations, educational entities and professional associations to make their career pathways more visible and attractive to new workers for allied health professions, like respiratory therapy and physical therapy, where the vacancy rates in hospitals for these occupations have nearly doubled since 2014.

The Rural Wisconsin Initiative enhances our ability to maintain and sustain the workforce we need to meet the growing demand for medical services in communities across Wisconsin.

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Wisconsin Hospitals’ Statewide Community Impact Totals $1.8 Billion

Hospitals report over $1 billion in Medicaid losses; Spent $229 million on physician and health professional education, training

Memphis Zettler came into the world as a breech birth, the first of many medical issues he’s faced in his young life. And while all kids are expensive, Memphis required multiple procedures and surgeries that initially were covered by BadgerCare. But when he became ineligible for that program, the family could not cover his medical expenses. That’s when the hospital stepped in to help. Memphis’s family applied and qualified for financial assistance. It was a relief to his very worried family.

Memphis’s story repeats itself multiple times across the state, every day.

In 2016, Wisconsin hospitals reported spending nearly $190 million in free care, a more than $10 million increase over 2015, according to a new report from the Wisconsin Hospital Association.

“While the ACA expanded coverage for thousands of people in our state, it did not eliminate the need for charity care,” according to WHA President/CEO Eric Borgerding. “People still fall through the cracks. The unexpected happens. They lose their job, become very ill or require emergency care that they cannot afford. That’s when hospitals and health systems step in and provide assistance to ensure their patients receive the care they need to resume as normal of a life as possible.”

Hospitals lost more than $1 billion caring for patients in the Medicaid program and lost $1.7 billion on Medicare in 2016, according to the WHA 2017 Community Impact Report. Medicaid only pays hospitals about 65 percent of what it costs to care for this vulnerable, and often medically-complex, patient population. Medicare reimburses hospitals at a rate that is about 78 percent of cost. 

Wisconsin hospitals use their resources to provide programs and services that support the people in their communities. These activities range from providing financial assistance to sponsoring free clinics, sponsoring health education opportunities, partnering with local employers to increase access to care, and working with other community organizations on complex socioeconomic issues.

“Wisconsin hospitals commit financial and human resources to improve the overall health status of the citizens of our state by providing essential services in their communities, which, if they were not available, would place a much greater burden on our state and local governments,” according to Borgerding. “By doing this, Wisconsin hospitals and health systems support a health care ‘safety net’ across the state and ensure our most vulnerable populations receive the care they need.”  

WHA surveys all of its member hospitals and health systems annually and asks them to describe and quantify the programs, services and activities they provide at or below cost, solely because those programs meet an identified health need in the community. 

Hospitals Support Clinical and Graduate Medical Education

Workforce shortages are one of the most pressing issues facing Wisconsin hospitals. It is essential that hospitals have staff to provide critical services 24 hours a day, every day of the year. Hospitals are investing their own resources to ensure Wisconsin has the workforce in place to meet the growing demand for health care.

In 2016, hospitals spent $187 million on graduate medical education for physicians and $12.5 million on education and clinical experiences for nurses.

Hospitals Absorb More Than $14 Million Loss Operating Nursing Homes 

Keeping those who are elderly or in need of rehabilitation services in the community is one of the most valued and necessary services requested by patients and their families. In some communities, hospitals are the sole providers of those services. In 2016, the 15 hospitals that operated nursing homes reported losses totaling more than $14 million, a $2 million increase over 2015. 

Hospitals Identify Community Health Needs, Develop and Implement Plans

Good health requires more than just health care. Hospitals are leading efforts to identify and prioritize community needs, and conducting formal community health needs assessments (CHNA) to assess, address and prioritize community health needs. While the formal process is new to some, the work is not. Improving the health of the entire community is at the heart of every hospital and health system’s mission.

While each hospital conducted a local CHNA, the types of problems identified across the state shared some similarities. Most of the hospitals identified several of the following as issues in their community:  access to care, mental health, alcohol and drug abuse, nutrition, obesity, physical activity and tobacco. Hospitals reported spending $68 million on activities and programs aimed at improving community health. 

“Hospitals have never allowed the boundaries of their campus to restrict their engagement with the community,” according to Borgerding. “Hospitals use their human and financial resources to focus on factors that improve people’s health while creating a healthier environment that attracts new economic development and makes our state a great place to live and work.” 

The WHA 2017 Community Impact Report has nearly 100 patient stories, including Memphis, and descriptions of free and reduced-cost services that hospitals provide in their communities.