May 17, 2013
Volume 57, Issue 20
WI Hospital ERs Treat More Than One Million Uninsured, Low-Income People
The Wisconsin Hospital Association Information Center (WHAIC) reported that in 2011, Wisconsin hospitals provided health care services to over one million patients who were uninsured and low income, an increase of more than 30 percent since 2006. Wisconsin hospitals also helped bring more than 60,000 babies into the world in 2011; about 2,500 babies required care in a neonatal intensive care unit (NICU).
More than 47,000 people are cared for in a Wisconsin hospital every day according to data collected by WHAIC and published in the Guide to Wisconsin Hospitals. The WHAIC is responsible for collecting and disseminating Wisconsin hospital and freestanding ambulatory surgery center data.
Hospitals continue to report an uptick in the number of patients they see on an outpatient basis. In 2011, there were 15.8 million outpatient visits, or about 40,000 people per day, which is up about four percent from 2010. That compares to 2.4 million inpatient days in 2011, or about 7,000 people every day. More than 70 percent or 539,740 of the surgeries and procedures performed in hospitals were delivered in the outpatient department.
"We’ve seen a steady increase in our hospitals’ outpatient visits over the years as technology and medical advances have made procedures and treatments possible that in the past could only be delivered in the inpatient setting," according to WHAIC Vice President Debbie Rickelman.
Wisconsin emergency rooms (ERs) were busy, with more than 1.6 million visits in 2011, which is the most recent year that data is available. The most common reason for an ER visit was abdominal pain, followed by complications from pregnancy or childbirth. The third most common diagnosis seen in Wisconsin ERs was chest pain.
The 24/7, 365-days-a-year nature of health care requires that hospitals have a flexible, well-trained workforce. Hospitals employ more than 100,000 people statewide in a broad range of skills, from high school graduates to highly-specialized health care professionals.
"Our employees are at the front lines of care. Hospitals are the health care safety net in every community that they serve," said Wisconsin Hospital Association President Steve Brenton. "As we observe Hospital Week, it is a good time to celebrate our hospitals and acknowledge their efforts in ensuring that access to the high-value care that we are known for is available to even the most disadvantaged people in our communities."
Begun in 1921, National Hospital Week celebrates the history, technology and dedicated professionals that make hospitals beacons of confidence and care.
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Late last month the United States Supreme Court issued its much anticipated decision in Missouri v. McNeely, 133 S. Ct. 1552 (2013), addressing the legality of warrantless, nonconsensual blood draws for drunk-driving ("OWI") investigations. The Court rejected the State’s argument that the natural dissipation of alcohol in the bloodstream presents a per se exigency, justifying an exception to the Fourth Amendment’s warrant requirement for nonconsensual blood testing in all OWI cases. The Court reaffirmed Schmerber v. California, 384 U.S. 757 (1966), which held that exigency depends on the totality of the circumstances present to determine whether warrantless seizure of blood evidence is reasonable.
Police stopped McNeely for speeding and crossing the centerline. Having observed signs of intoxication, police conducted a field sobriety test, which McNeely failed. When he declined to take a breath test, McNeely was arrested and transported to a hospital for a blood draw, which he also refused. Police then directed the lab technician to complete the test, which showed a blood-alcohol concentration above the legal limit. McNeely moved to suppress the results on Fourth Amendment grounds. The Missouri trial and appellate courts agreed with McNeely, and held that the rationale that had been applied for years in drunk-driving cases—that the dissipation of alcohol creates an exigent circumstance, namely the destruction of evidence—was not reasonable in the instant case. The Supreme Court affirmed, and clarified that the "importance of the government’s interest in [prosecuting drunk drivers] does not justify departing from the warrant requirement without showing exigent circumstances that make securing a warrant impractical[.]"
Although McNeely may change Wisconsin courts’ review of evidentiary blood draws, it has little bearing on Wisconsin hospitals’ current obligations and protocols. As always, a provider’s medical judgment and evaluation of the suspect should be considered whenever law enforcement has directed a blood draw. Under Wisconsin law, it is implied that a person who operates a motor vehicle will consent to testing for the purpose of determining the presence or quantity of alcohol, controlled substances or other drugs in his/her system. WIS. STAT. § 343.305. Pursuant to Wisconsin’s Implied Consent Law, a law enforcement officer may thus direct hospital personnel to perform a consensual blood draw of a person arrested for OWI. Failure to comply with the officer’s directives may subject hospital personnel to prosecution for refusing to aid a law enforcement officer. WIS. STAT. § 946.40. Wisconsin law otherwise provides civil and criminal immunity to the health care provider performing the test, the provider’s employer and any hospital where such test is performed when personnel are acting pursuant to such request. WIS. STAT. §§ 343.305(5)(c) & 895.53. This statutory immunity does not, however, preclude civil liability if the procedure is performed negligently.
The Implied Consent Law does not permit blood draws from persons who refuse to consent, however, so absent exigent circumstances or a valid search warrant, law enforcement may not direct hospital personnel to administer the test. If law enforcement is acting under either authority, however, it may order hospital personnel to complete a blood draw. Wisconsin’s Attorney General has opined that "[a]s long as the officer is authorized to command such assistance, it is immaterial to the health professional’s obligations under § 946.40 whether the authority for the officer’s request to draw a person’s blood arises from the implied consent law or … from a different legal basis." At the same time, the Attorney General has recognized that "a health care professional’s refusal to comply [with law enforcement’s directive to conduct the test] on medical grounds may well indicate that the officer’s request is not legally authorized because both the Fourth and the Fourteenth Amendments forbid involuntary blood tests under medically unsound conditions." 74 Op. Att’y Gen. 123, 129 (1985). Hence, in the event hospital personnel believe the person’s resistance or other medical condition prevents safe performance of the blood draw, they may lawfully refuse to conduct the test. Under these circumstances, hospital personnel should clearly document the reasons for nonperformance in the person’s medical record or on any incident report.
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On May 15, the Joint Committee on Finance passed a five-page budget motion (amendment) that would establish a regulatory, registration and licensing framework at the Office of the Commissioner of Insurance for federal exchange navigators and non-navigator assisters in Wisconsin. Non-navigator assisters are more commonly referred to as certified application counselors, especially in states that have deferred to the federal government for the operation of their health insurance exchange.
WHA, in collaboration with the Milwaukee Health Care Partnership and the Wisconsin Primary Health Care Association, identified several issues that needed to be addressed with the initial proposal. WHA and these other partners were successful in changing the initially-proposed language to ensure that hospital employees would not be roped into overly restrictive licensing, training, fingerprinting and bonding requirements established in the "navigator" definition. Also, the initial language required monthly reporting of an entity who employs a non-navigator assister, which WHA was able to modify so reporting was only required when a change was made. Finally, the budget motion initially proposed broad entity liability language for those who were affiliated with an entity that employs a navigator or non-navigator assister. WHA worked hard to ensure that this liability definition was tightened up and specific to a formal affiliation between two entities.
In April the federal government announced that Wisconsin would receive navigator grant funding of less than $830,000. A national funding pool of $54 million was distributed to each state with a federal insurance exchange based off of the uninsured rate in that state. Unfortunately, this amount of money equates to roughly a dozen or so actual navigators in the state. This means that the state will depend heavily on non-navigator assisters, such as hospital employees, who have not received federal navigator funding to conduct education and outreach for the public on enrollment in exchanges.
"Our involvement in this legislation hinges on one main concern—ensuring to the greatest extent possible that there are minimal barriers to people receiving information about coverage options in the exchange," said WHA Executive Vice President Eric Borgerding. "While the regulations are improved, their impact on exchange enrollment, particularly the transition of Medicaid populations onto the exchange, and how it ultimately affects the insured rate, is an open question. That outcome rests largely on the shoulders of state regulators to get this new regulatory structure in place, and in time. Exchange enrollment begins in just over four months.
The budget motion, which passed with an 11-5 vote, would do the following: require actual navigators to be licensed, bonded, undergo a background check including fingerprinting, and receive additional training beyond what is already required under federal law. The budget motion also defines a non-navigator assister as someone designated by the exchange or working at the behest of the exchange who is an in-person assister, enrollment assister, application assister, or certified application counselor.
To see the actual motion, go to www.wha.org/pdf/BudgetMotionNavigators5-15-13.pdf.
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On May 13 the Wisconsin Hospital Association submitted comments to the Centers for Medicare & Medicaid Services (CMS) on a proposed rule altering current CMS policy on rebilling when certain claims are denied by an auditor. The proposed rule addresses circumstances in which hospitals may be eligible for Part B payment following the denial of a Part A claim for services that would have been reasonable and necessary had the beneficiary been treated as a hospital outpatient, not as an inpatient. CMS’s rebilling policy over the years has not allowed the vast majority of these claims to be rebilled, which has been a significant point of contention for hospitals, especially with the advent of the Recovery Audit Contractors (RACs).
"Medicare law requires reimbursement for all reasonable and medically necessary items and services and provides that these services must be paid under Part B if they cannot be paid under Part A," read WHA’s comment letter. "However, we believe that CMS’s proposal so significantly restricts a hospital’s ability to rebill claims that its practical effect would be to continue denying fair payment for the reasonable and medically necessary items and services provided to Medicare-eligible patients."
While CMS’s proposed rule would allow some claims to be rebilled, the rule would limit the timeframe by which those claims must be filed to 12 months. Such restriction is particularly troubling as the RACs audit claims for services provided during the previous three years, and claims typically reviewed by the RAC are more than a year old. In addition, there is no time limit by which a RAC must complete its review of claims requested for review.
Therefore, WHA and hospitals are particularly concerned that the one-year period for submitting a timely rebill could easily expire before the RAC review is completed or before it has even begun. Hospitals would then face the untenable choice: Accept the RAC’s decision and forgo any payment for the legitimate services furnished to patients, or pursue appeal through a lengthy, costly and newly-restricted scope of review process to possibly restore a full Part A payment.
"In closing, Wisconsin hospitals take seriously the obligation to properly bill for the services provided to all patients, including Medicare beneficiaries. But Medicare’s payment rules are highly complex and the complexity is increasing…We urge CMS to issue a final rule that provides full Part B reimbursement for Medicare-contractor denied claims without the unreasonable restrictions," the letter said.
In order to address the various RAC-related program problems, WHA is supporting bipartisan legislation pending in Congress, H.R. 1250, also known as the bipartisan Medicare Audit Improvement Act of 2013. The legislation makes much-needed improvements to RAC and other Medicare audit programs, including:
WHA thanks U.S Rep. Reid Ribble (R-WI 8th Congressional District) for quickly co-sponsoring H.R. 1250, and asks Wisconsin’s other House Members to do likewise.
Read WHAs’ Rebilling Comment Letter at:www.wha.org/pdf/WHACommentLtrProposedRebillingRule5-2-13.pdf. Read WHA’s issue paper on HR 1250 at: www.wha.org/pdf/HR1250RAC4-2013.pdf.
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Guest Column: The Health Care Law: My Wish List for 2014
We need consistency; now, we have confusion
By Nick W. Turkal, president/CEO of Aurora Health Care and 2011 WHA Board Chair
If retailers can promote Christmas in July, why can’t we talk about year-end holiday wishes in May? Well, when it comes to health care, I believe it’s better to do this earlier rather than later. There’s too much at stake to stand by idly.
Right now, there’s so much confusion about overall health care reform, insurance exchanges and Medicaid. In the past several weeks, I’ve fielded dozens of questions from employees and business leaders alike on these complex and interconnected issues. So here is my wish list for 20l4 and why:
My first wish for health care reform is that we could have a realistic debate about how to restructure an industry that clearly needs reform. Costs have been skyrocketing, and clinical quality has not been uniform. I’d like to see a debate and associated reform legislation that actually helps the patients whom we serve.
The current law, which will be enacted over several years, focuses on the reform of insurance regulations along with Medicaid expansion. The U.S. Supreme Court ruling last year did not provide full clarity on Medicaid. What we need in health care in this country is health care that is consistently high in clinical quality, affordable to the people who pay the bills and delivered with excellent service.
There are only islands of this care available throughout the country, including in Wisconsin; it’s patchwork. And for those of us in health care making progress on quality and cost, there is very little financial incentive to fight the good fight.
My wish for exchanges is that the federal government and all 50 states agree on what’s going to happen in 2014. At this point, we are unable to educate our patients because we have so little information. Unless the timeline for implementation of the exchanges is changed, by later this year we will have many thousands of patients who will need to complete applications to have health care coverage in January 2014.
Our patients deserve some advance notice and a modest amount of time to digest the changes. While I know there will not be a uniform approach across the country, I would settle for clarity in Wisconsin and Illinois. At this time, we are uncertain as to which insurers will participate, we don’t know how employers will react and, therefore, we’re unable to advise patients on how to prepare.
My wish for Medicaid, particularly in Wisconsin, is that we accept the increase in federal funds, at least in the short run. For context, the U.S. Supreme Court last year upheld most of the health care reform law, but not a mandatory Medicaid expansion. As the Wisconsin Legislature considers the next biennial budget, it has an opportunity to accept the larger amount of Medicaid funding from the federal government.
While Gov. Scott Walker opposes this option and has stated his position clearly, the Legislature should consider the short-term harm to Wisconsin in rejecting the federal dollars—ongoing shortfalls in Medicaid funding, increases in charity care absorbed by health care systems and, most important, the potential of tens of thousands of individuals losing health care coverage.
As both a CEO and practicing family physician, I understand that no reform measure is perfect. But in the end, we need to acknowledge that decisions on health care reform have real consequences on human beings, and putting patients at the center of any reform we enact is a wish with which we can all be comfortable.
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Recently Cong. Mark Pocan (D-Madison) participated in a Wisconsin Hospital Association Listening Session hosted at St. Mary’s Hospital in Madison. In front of 50 leaders and staff from at least nine of the hospitals throughout his Congressional District, Pocan provided a look into activities happening in DC that impact Wisconsin hospitals and health care programs.
"We are a leader in delivering high quality health care," said Rep. Pocan. "This was a great opportunity to hear from small and large hospitals all across my district about how they’ve worked to create that environment here in Wisconsin. I look forward to taking everything I learned back to Washington, DC."
The WHA Hospital Listening Session was an opportunity for hospital advocates to hear personally from Rep. Pocan and ask questions. The hour-long discussion included whether Congress would address the Medicare physician reimbursement formula, known as the Sustainable Growth Rate, to how continued federal payment cuts to hospitals and systems negatively impact Wisconsin’s high-quality, cost-efficient health care system.
"It’s always an honor to host a friend in Congress, and Congressman Pocan clearly understands the nationally-recognized, high-quality health care and broader patient access we have here in the second congressional district and across our entire state," said Frank Byrne, MD, president, St. Mary’s Hospital, Madison. "We appreciate his leadership in protecting those high standards and spreading them nationwide."
U.S. Rep. Mark Pocan is a freshman member of the U.S. House of Representatives. He was elected this past November to fill the 2nd Congressional seat previously held by now-U.S. Senator Tammy Baldwin. Prior to being elected to Congress, Pocan spent 14 years in the Wisconsin State Legislature. WHA has held five "Hospital Listening Sessions" with Wisconsin Members of Congress over the past year.
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An annual highlight of the Wisconsin Rural Health Conference is the popular governance education track. This year, trustees and their administrative leaders in attendance have the chance to focus on health care reform considerations specifically for hospital trustees, what trustees should know about health care payment programs, and the trustee’s role in health care public policy. In addition, sessions on creating a culture of continuous improvement, using advanced practice clinicians as hospitalists, and transforming the delivery of care by using patient navigators in inpatient settings will be addressed.
The annual Wisconsin Rural Health Conference is a great way for hospital executives, leadership staff and trustees to examine the issues that impact small and rural hospitals, while networking and collaborating with colleagues and each other. We encourage you to make attendance for yourself, your senior leaders and your trustees a priority in 2013. A full conference brochure is included in today’s packet, and online registration is available at: http://events.SignUp4.com/13Rural.
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Honor one of your hospital’s community health projects by submitting a nomination for a 2013 Global Vision Community Partnership Award, presented by the WHA Foundation.
This competitive grant award is presented to a community health initiative that successfully addresses a documented community health need. The Award, launched by the WHA Foundation in 1993, seeks to recognize and support ongoing projects that support community health.
Any WHA hospital member can nominate a community health project. The project must have been in existence for a minimum of two years and must be a collaborative or partnership project that includes a WHA member hospital and an organization(s) within the community. The official call for nominations for the 2013 Award is included in this week’s packet.
Nominations are due July 19, 2013. Nomination forms can also be found on the WHA website at www.wha.org/global-vision-comm-partnership.aspx. For more information about the Award, contact Jennifer Frank at firstname.lastname@example.org or 608-274-1820.
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ICD-10 will affect all aspects of health care in 2014, so the Wisconsin Hospital Association, the Wisconsin Medical Group Managers Association and the Wisconsin Medical Society have come together to ensure hospitals and clinics are ready. Mark your calendar for "ICD-10 Summit: Ready. Set. Go Live!" scheduled March 17-19, 2014 at the Kalahari Resort in Wisconsin Dells.
The ICD-10 Summit, specifically designed for health information professionals, coding and billing specialists and practice managers will set hospitals and clinics on the path to successful implementation. Attendees will have the tools and gain the confidence that is necessary for a smooth transition on the go-live date of October 1, 2014.
Share this information with your hospital’s HIM professionals, business office staff, quality managers, coding staff, revenue cycle managers and others who may be interested.
A full Summit agenda and registration will be available in fall of 2013. Check www.wha.org for more details.
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The National Rural Health Association (NRHA) named Bill Sexton, CEO, Prairie du Chien Memorial Hospital, as their 2013 Volunteer of the Year. NRHA staff annually honors one member who has gone consistently above and beyond duty, often behind the scenes, on behalf of NRHA. Sexton was honored during NRHA’s national conference May 9 in Louisville, KY.
Sexton has been an integral part of NRHA for more than a decade, including service as President in 2006. He is currently the board chair of NRHA Services Corporation, which he helped launch.
Tim Size, executive director of the Rural Wisconsin Health Cooperative, said, "Bill is an exemplar of the volunteers that make NRHA NRHA."
Steve Brenton, WHA president, congratulated Sexton and acknowledged Bill’s commitment to rural health.
"As a NRHA leader and as a member of the WHA Board, Bill is a strong advocate for rural health and for ensuring that residents across the state have access to high quality care close to home," Brenton said. "Our goal in Wisconsin is to provide consistently high value care that will help to attract economic growth and investments in our communities, no matter where a business decides to locate."
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Nutrition counseling is an important aspect of the service that hospitals provide within their communities. Whether it is offering classes that focus on weight loss or promoting better health, or nutrition education for people who are diabetic, Wisconsin hospitals offer hundreds of free classes that stress the importance of a nutritional, well-balanced diet on overall health. Hospital employees also help deliver Meals on Wheels and they organize and participate in food drives to benefit local food pantries.
What’s on my plate?
Aurora Medical Center Grafton (AMCG) received an invitation to participate in the Partners in Education program at Grafton Elementary School. The Partnership in Education program is a collaboration between local hospital and business leaders to teach students about potential career opportunities. Local hospital and business leaders are asked to visit the class for 30 minutes each month.
AMCG partnered with Mrs. Gaulke’s third grade class. Dietitian Haley Nolan was a guest speaker for the month of January 2012 and presented the topic of nutrition. Haley immediately engaged the class with the "Pass the Peanut" game. Students were asked to share their name and favorite food with the class when they received the paper peanut. Pizza was the most popular food choice.
Next, Haley explained the new nutritional guidelines set by the United States Department of Agriculture established on June 2, 2011, which have replaced the old food pyramid. The new guideline is called "MyPlate." MyPlate is an easy-to-understand visual of the five food groups to help consumers adopt healthy eating habits by learning how to build a healthy plate with fruits, vegetables, grains, protein and dairy.
Haley provided a visual diagram of a plate with pictures of each of the five food groups that represented the building blocks for a healthy diet. She asked each student to place pictures from the five food groups in the correct section of their paper plate and then share it with the class.
"It was great to see their enthusiasm and how proud the students were upon completing their plates correctly," Haley stated. "Students were eager to show their food selections and explain how their plates represented each of the new five food groups guidelines."
Aurora Medical Center in Grafton
Ministry Door County supports inaugural season of FoodShare benefits at the Sturgeon Bay Farm Market
Sturgeon Bay’s Saturday morning farm market bustles with activity, as customers stroll past tables laden with fresh produce, meats and cheeses, and baked goods. This season, Door County families who participate in the FoodShare program were able to purchase fresh, locally-grown foods at the weekly market for the first time. FoodShare is a federally-funded nutritional assistance program formerly known as the Food Stamp Program. Through a grant from Ministry Door County Medical Center, the Sturgeon Bay Parks Department was able to make fresh foods available to FoodShare participants.
"Our goal was simple," says Sturgeon Bay Parks Superintendent Bob Bordeau. "We wanted to provide fresh foods to people who need them."
Jen Lenius, municipal services secretary at the Parks Department, heads up operations of the Farm Market. She says the process for FoodShare participants is easy. "Customers just swipe their FoodShare card to receive tokens that can then be redeemed with vendors at the market." Throughout the summer, she saw more and more residents take advantage of the program. "People are happy to have this chance," she says. "It’s the first time they’ve been able to use the FoodShare benefit at a local farm market. And it also helps support the Buy Local movement, which helps the community."
Ministry donated funds to assist in the start-up and ongoing implementation of the program. "We had to purchase the point of sale terminal, and pay for the license, as well as the manning of the table," explains Lenius. And like many other organizations, the Parks Department budget was tight this year. "Without the hospital’s support, we would not have been able to do it," adds Bordeau.
Hospital staff believes the investment is critical. "This project really aligns with our mission of building a healthier community," says Matt Luders, Ministry’s health and wellness executive. "We’re very glad to be part of this initiative to help families get healthy food on their tables."
Jen Lenius agrees that the program is making an impact. "People can buy healthy local food, and they can also use their tokens to buy plants that produce food like tomato plants and even fruit trees." She recalls seeing one FoodShare participant go home with a box of fresh peaches. "She and her four little girls were taking them home to can them."
The Sturgeon Bay Farm Market has been in existence continually for nearly 60 years. Now the market is pioneering the FoodShare model, too. "We’re one of the few markets in Wisconsin participating in FoodShare," says Lenius. Hopefully more communities will be following Door County’s lead, opening the basket of plenty to all.
Ministry Door County Medical Center, Sturgeon Bay
Submit community benefit stories to Mary Kay Grasmick, editor, at
Read more about hospitals connecting with their communities at www.WiServePoint.org.
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