September 4, 2015
Volume 59, Issue 35
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Guest Column: Physician Compact is “Great Benefit” to the State
By: Rep. Warren Petryk
The Assembly Committee on Health held a public hearing on Assembly Bill (AB) 253, relating to the ratification of the Interstate Medical Licensure Compact and making appropriations. If Wisconsin enacts this legislation, we will be joining 11 other states, including our neighbors Iowa, Minnesota and Illinois, in the compact.
This legislation is simple and would be of great benefit not only to the vastly rural 93rd Assembly District, but to many areas across the state. The Interstate Medical Licensure Compact allows for an expedited licensing option for physicians that voluntarily elect to practice in multiple states. When applying to practice in another state, other than the one currently licensed in, a physician would apply for an expedited license and would forego having to complete a formalized licensure application and providing appropriate documentation to another state’s licensing board. Simply, if the physician meets the requirements to be licensed in their current state, that proves their qualifications to practice in other states as well.
Licensing requirements are different in each state, and those requirements can be burdensome and take a significant portion of time to complete with the submission of duplicative documentation already verified by the state they currently practice in. This can hinder, for example, a rural area of the state being able to hire the necessary physicians to practice and assist rural patients. As many of us know, not only do we currently have a doctor shortage but we also have an issue with access to health care providers especially in rural areas. With the enactment of AB 253, we could help attract qualified candidates to many areas of our state while also retaining the doctors we currently have.
AB 253 would establish a commission to serve as a clearinghouse not only for licensure but also to ensure high standards are maintained. Two representatives from Wisconsin will be members of the commission overseeing implementation of the Interstate Medical Licensure Compact. The bill was also written to ensure that physician fees, paid by those who voluntarily participate in the compact, will support operating costs, including those of the commission, who is charged with administering the compact.
Overall, this is a smart piece of legislation that will greatly benefit Wisconsin with better access to qualified physicians. The legislation has the support of Marshfield Clinic Health System, Mayo Clinic Health System, the Medical College of Wisconsin, the Rural Wisconsin Health Cooperative and the Wisconsin Hospital Association to name a few. I am proud to be a primary co-author of this legislation and look forward to monitoring the progress of the bill as it moves through the Legislature and hopefully to the Governor’s desk.
Warren Petryk (R-Eleva) represents the 93rd District in the State Assembly.
This column first appeared in the Pierce County Herald August 27, 2015. Find at: www.piercecountyherald.com/opinion/columns/3826729-warren-petryk-column-interstate-compact-medical-legislation.
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WHA Submits Comments on CMS Proposed Hip/Knee Bundle Model
22 Wisconsin hospitals mandated to participate
In late July, the federal Department of Health & Human Services (HHS) released a proposed Comprehensive Care for Joint Replacement (CCJR) model—a new Medicare model that would bundle payments to acute care hospitals for hip and knee replacement surgeries. The model mandates hospitals in 75 Metropolitan Statistical Areas (MSAs)—including the Milwaukee and Madison MSAs—across the country would be required to participate. Twenty-two Wisconsin hospitals would be impacted by this model.
WHA’s comment letter, submitted to HHS September 4, highlighted several priority areas HHS should address in order for the model to meet the desired goal of promoting value in Medicare.
“In order to pursue this premise, WHA believes the proposed regulation requires necessary revisions in two large areas—hospitals’ requirement to bear full financial risk without the ability to coordinate care and the quality measurement requirements,” began WHA President/CEO Eric Borgerding in WHA’s comment letter.
Under the proposed model, hospitals would bear full financial risk for the entire episode of care, beginning with the anchor hospitalization and extending 90 days post-acute care. CMS would set a target episode price for each hospital, which is reduced by a set amount. In general, should hospitals fail to meet that reduced amount, it would be required to pay Medicare back.
“WHA has strong concerns with this approach absent appropriate flexibility and protections for managing this financial risk,” said Borgerding. “We believe hospitals and other providers must be able to enter into financial arrangements or agreements without fear of implicating fraud and abuse laws, as the current exceptions and safe harbors are inadequate with respect to the CCJR model’s implications.”
Further, WHA expressed concerns with the proposed quality measures. Should hospitals come in under the target price, Medicare would then share savings with the hospital as long as the hospital meets multiple quality measures. WHA is concerned the proposed model uses measures, such as HCAHPS, already used in other Medicare programs. In this way, a hospital could be financially penalized twice for the same measure. Additionally, the model requires hospitals meet certain thresholds on multiple measures, which would essentially filter out the majority of hospitals across the country from potentially being able to share in any savings.
“We do understand why CMS is using quality measures in the CCJR model and appreciate the underlying desire to ensure hospitals do not furnish fewer services or look to low-cost providers with no regard for quality,” the letter continued. “However, we do not believe it is appropriate for hospitals to be financially penalized twice for the same measure and to be forced to meet three distinct thresholds, which will, in effect, always filter out a set of hospitals from being successful under this CCJR model.”
WHA provided others comments for improving the model and urged HHS to delay the start date from January 1, 2016 in order to allow hospitals sufficient time to prepare.
Read WHA’s comment letter at www.wha.org/pdf/2015CCJRbundledCommentLetter9-4.pdf.
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Telehealth Holds Great Promise for Patients to Receive Care in their Community
Telehealth could be one way to expand health care access and keep patients in their own community. The ability to transmit knowledge from a medical center directly to the patient, no matter where they live, means patients would not have to travel to the care, rather, the care would come to them, according to Robert Nesse, MD, CEO, Mayo Clinic Health System.
Nesse was one of three health care leaders who participated in a Wisconsin Health News “Newsmaker Event” panel discussion September 1 in Madison. Nesse was joined by Art Nizza, president/CEO, Meriter-UnityPoint Health, and Susan Turney MD, CEO, Marshfield Clinic Health System. WHN Editor Tim Stumm moderated the session.
“We have a tremendous interest in telehealth,” Nesse said. “We would like to transfer 50,000 patients to regions here in Wisconsin, rather than have them travel back and forth for care. Telehealth is something we can do right now that can get the care to them in their community.”
Access to care locally is important, and telehealth is certainly a way to address the growing demand for medical services. WHA is supporting the Interstate Medical Licensure Compact, which would make it easier for health systems to increase access utilizing telemedicine, by creating an expedited process for physicians licensed in other states that meet heightened eligibility standards to receive a Wisconsin license to practice medicine.
Another important piece is to understand what people want, and design the system around them, according to Turney.
“The patient cares about getting back to work and to their life. We need to understand what data is helpful in monitoring diseases and preventing untoward circumstances,” Turney said. “It has to be shared in a way that people can understand it. We need to know what is important to measure and what is important to the people receiving the care.”
Nizza said analytics are one of the key pieces to really managing to the level of downside risk that is required in a move from volume to value-based purchasing.
“Where I came from (New York) there were large, multi-specialty medical groups. They became pioneer accountable care organizations (ACOs). They aligned themselves with national payers and they did it just for the analytics,” according to Nizza. “They did it because they needed to get access to and an understanding of the data sets that were at the core of taking care of patients and critical to assessing the downside risk (of working in an ACO model).”
While integrated networks that can deliver coordinated patient care are in place in Wisconsin and Minnesota, Nesse identified the lack of good analytics and an aligned financial model as the two barriers that are holding up the move from volume-to-value.
“I think when we are all talking about the shift to value from volume, we are not all that far along, but we are on the path and Wisconsin is leading the effort,” according to Nesse. He said Wisconsin and Minnesota are in some of the best positions in the country to move to value-based purchasing, but the “transition will be brutal.”
That said, Turney expressed confidence that the “providers are ready, the system is not.”
“When we talk about aligning financial incentives it is a challenge when you talk about care management—it isn’t that people don’t want to manage care—it is that the payment system is not there,” according to Turney. “When you look at the payment system, it is based on a unit-cost system. As long we try to live in both worlds it will take a long time. It we take a leap, we may get there more quickly, but I don’t think there is a willingness. If we (providers) could be in the driver’s seat, it would be different than it is now.”
Turney noted that it is positive for providers and patients that Wisconsin has a pluralistic insurance market, with many provider-owned health plans. These plans, she said, have an intimate relationship with the patient and provider that facilitates “good care for the patients.”
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WHA Brings Hospitals, Patient Advocates Together to Improve Care
Wisconsin hospitals are working hard to improve quality and safety. Hospitals that are effectively engaging patients and families as a strategic partner in improvement are experiencing sustained improvement and break-through results related to overall patient satisfaction, health outcomes and care transitions.
WHA created a Patient and Family Centered Care and Engagement (PFCC&E) Advisory Committee. This group has met monthly since late last year, but on August 27 had its first opportunity to meet in person at WHA’s offices in Madison. The Committee is comprised of hospital leaders from organizations that have extensive experience in incorporating patient and family-centered strategies into their cultures. Even more importantly, the Committee is also staffed with patient advisors and advocates, and co-chaired by nationally-known patient advocate and WHA Patient Advisor Rosie Bartel.
In early 2015, the group developed an aim that speaks to the uniqueness of this project:
“Pool the existing resources within the state of Wisconsin to develop a strategy and structure for facilitating the spread of Patient and Family Centered Care and Engagement through education, consultation, collaboration, training and dedication.”
From the start, the participating organizations have been open and willing to share their experiences, resources and valuable insights on how best to build PFCC&E programs and strategies. In addition, they have invited and encouraged their patient and family advisors to do the same.
“Although the hospital information and resource sharing has been essential, hearing the perspective, opinions and insights directly from their patient and family advisors has been invaluable,” according to WHA Quality Coordinator Tom Kaster.
During the August 27 meeting, the committee members wasted no time and immediately dug into difficult and challenging topics and strategies. The day was full of rich and passionate discussions on topics ranging from improving care transitions, discharge communication and access to essential resources to more basic topics such as improving signage and reducing waiting times, to name just a few. By the end of the day, the committee compiled a long list of topics, resources and patient perspectives that will be used to build resources to help hospitals across the state.
“We know that the projects we are working on to improve quality and safety, such as readmissions and hospital-acquired infections require multiple strategies,” said Kelly Court, WHA chief quality officer. “Partnering with patients and families in new ways is one of these strategies, which is why WHA is placing new emphasis on this topic.”
The WHA Patient and Family Centered Care and Engagement Advisory Committee members are:
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WHA Participates in First UW System Listening Session on Health
WHA participated in what was the first of nine listening sessions hosted by the University of Wisconsin System. UW System President Ray Cross presided over the September 1 meeting in La Crosse, which focused on health care. Cross encouraged participants to provide feedback that will help shape UW’s next strategic plan.
More than 50 health professionals as well as several government leaders were present and shared suggestions on how to improve health and wellness in Wisconsin. Key issues shared by Steven Rush, WHA vice president of workforce and clinical practice, included the aging of the health care workforce, emerging roles in health care and the increasing need for team-based care. Wisconsin’s ongoing challenges of addressing the physician shortage, especially in primary care and mental health, were also emphasized by Rush.
“In the future, Wisconsin health systems will be serving a large population that will have higher incidences of chronic conditions. Rural areas are aging at faster rates than our urban and suburban areas. In addition to these shifting dynamics, the health care workforce is also aging,” according to Rush.
The WHA 2014 annual Health Care Workforce Report found that nearly 20 percent of hospital employees in professional occupations are age 55 or older. Nearly a quarter of the nurses employed are over 55 years of age, and in some specialty areas such as ambulatory care, the percentage of older nurses is even greater.
Rush said the UW System must be prepared to meet the increasingly complex medical needs of Wisconsin residents and be able to meet those needs regardless of where those patients reside. Health care professionals educated in Wisconsin must be prepared to deliver care that is preventive and longitudinal, smoothly transitions across care settings, and is outcome-based.
“This will require that all parts of the delivery system become more adept at population health management, team-based care, quality improvement, and are able to use the technology available to make that happen. Developing effective workforce strategies will require finding new ways to deliver care more efficiently, along with being able to educate, recruit and retain health care professionals,” Rush shared.
Cross concluded by informing the group that the input provided would be summarized and categorized. Identified themes will then be distributed back to attendees for further comment and clarification before formal incorporation into the next UW System strategic plan. WHA will continue to participate in the UW System strategic planning process.
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NLRB Decision Could Impact Hospitals Utilizing Staffing Agencies
On August 27, the National Labor Relations Board (NLRB) in a three-to-two decision overturned several decades of precedent when it issued a decision that significantly expands the number of organizations that would qualify as “joint employers” for labor relations purposes. As a result, such companies now become subject to the duties of direct employers under the National Labor Relations Act, including the duty to bargain collectively with unions over essential terms and conditions of employment. Many have raised concerns that this decision creates significant uncertainty for organizations, such as hospitals, that contract with staffing agencies.
Prior to the decision, the NLRB had held that an entity was a joint employer for labor relations purposes only if the entity both possessed and directly exercised authority over wages, hours and working conditions. Under the new joint employer standard established by the decision, the NLRB determined that an entity could be a joint employer even if it did not actually exercise authority to control employees. The NLRB then looked at multiple factors to determine whether an entity utilizing an employee agency “shared or co-determined those matters governing the essential terms and conditions of employment” and thus would be a joint employer. Those factors included, but were not limited to, who determined the standards for hiring the agency employees, who possessed the right to discipline or remove the employees, who controlled the tasks, number of workers required, work shifts, and hours, and the fact that the entity utilizing the agency employees played a significant role in establishing the employees’ wages.
The two dissenting members of the NLRB strongly disagreed with the majority.
“The new test is fatally ambiguous, providing no guidance as to when and how parties may contract for the performance of work without being viewed as joint employers,” wrote the dissent. “This change will subject countless entities to unprecedented new joint-bargaining obligations that most do not even know they have, [and] to potential joint liability for unfair labor practices and breaches of collective-bargaining agreements…”
It is likely that the NLRB decision will be appealed and further, additional litigation will be required to resolve the number of new issues left unanswered by the new decision.
The NLRB’s decision can be found here: www.wha.org/pdf/2015NLRBjointEmployerRuling8-27.pdf. For additional information, contact Matthew Stanford, WHA general counsel, at firstname.lastname@example.org, or Andrew Brenton, WHA assistant general counsel, at email@example.com or 608-274-1820.
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FEMA Training Helps Prepare Hospitals, Communities for Wide-Scale Attack
A wide-scale attack would test the health care, law enforcement and other key infrastructure capabilities of a community. That is why more than 10 hospitals and health systems recently participated in first-of-its-kind training developed by FEMA’s Institute of Emergency Management. In addition to hospitals, the training attracted about 80 representatives from law enforcement, fire, schools and public health. Attendees participated in class instruction and small workgroup discussion focused on an intense scenario of multijurisdictional attacks designed to test the capabilities and resources of all responding agencies within the Southeast Wisconsin Healthcare Emergency Readiness Coalition (HERC).
During a large-scale attack, every city, county, and region whether urban or rural will share the same challenges of information sharing and appropriate distribution of a surge of patients to already overwhelmed facilities during a large-scale incident. Participants of the course agreed that an influx in the number of patients would overload scarce resources and require coordinated multi-agency response plans to achieve optimal outcomes for the patients as well as meet the expectations of the public.
“Engaging the HERC partners in this training and small workgroup discussions provided insight into each agency’s plans and assumptions of the other agency’s plans,” according to Elizabeth Corneliuson, BSN, MS, HERC coordinator. “Working together as a coalition provides a framework for each agency to integrate plans to provide support, share limited resources effectively, and promote a more efficient coordinated response.”
Wisconsin is divided into seven health care coalition regions (HCCs), comprised of hospitals, clinics,
long-term care, mental health, public health, fire and EMS, law enforcement, emergency government, Red Cross, and other private and public partners who work together on a coordinated approach to integrate resources for a major disaster.
For more information, visit: www.wha.org/HealthcareCoalitions.aspx.
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WI Medicaid Program Will Enforce Specificity of ICD-10 on October 1
The Wisconsin Medicaid program recently confirmed they are poised to move forward in implementing ICD-10 effective October 1, 2015.
On July 6, 2015, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) issued a joint announcement indicating that Medicare would be relaxing its enforcement of specificity on ICD-10 claims for 12 months following the October 1, 2015 implementation date. Recently, CMS issued additional guidance clarifying that Medicare will not deny claims based solely on the specificity of ICD-10 diagnosis codes, but that ICD-10 implementation is not delayed.
In response to this announcement, the Wisconsin Department of Health Services clarified its intent to enforce specificity of Medicaid diagnosis codes on claims beginning with ICD-10 implementation on October 1, 2015. Claims without this detail will be denied, and prior authorization (PA) requests without this detail will be returned. These claims and PA requests will then need to be resubmitted with a specific ICD-10 code in order to be processed. These claims may also be subject to audit and recoupment if correct specificity is not applied.
Because of Medicare’s relaxation of specificity enforcement, it is possible that crossover claims received from Medicare for 12 months after compliance could be denied by Wisconsin Medicaid due to lack of specificity. These denied crossover claims will need to be submitted directly to Wisconsin Medicaid with a specific ICD-10 code in order to be processed.
As a reminder, ForwardHealth is currently offering ICD-10 testing to all entities. The Medicaid program strongly encourages providers to test claim submissions to assess their ICD-10 readiness. Testing information can be found on the ICD-10 Code Set Testing page on the ForwardHealth Portal.
Other ICD-10 information, including readiness resources, ForwardHealth Updates, and CMS links, can be found on the ICD-10 Code Set Transition page of the Portal.
The Department has included some language regarding ICD-10 specificity enforcement noted below:
“Based on recently-issued guidance from CMS, ForwardHealth is moving forward with its approach to enforce specificity of ICD-10 diagnosis codes on claims and prior authorization (PA) requests beginning with ICD-10 implementation on October 1, 2015. ForwardHealth will enforce specificity of diagnosis codes at the highest level on all claim and PA request submissions with dates on and after October 1, 2015. Refer to the August 2015 ForwardHealth Update (2015-39), titled “Effective Dates and Transition Information for ForwardHealth’s Implementation of ICD-10 Code Sets,” for more information about code set specificity and enforcement.
Please send any question to the ICD-10 email address at VBEDSICD10Support@wisconsin.gov.”
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New WCMEW Website
The Wisconsin Council on Medical Education and Workforce (WCMEW) has a new website, www.wcmew.org. It includes background information on WCMEW, recent WCMEW activities, links to recent articles on health care workforce issues, and copies of publications and reports.
“We hope visitors to our website find it interesting and informative on health care workforce issues, and gain an understanding of what WCMEW is doing to enhance our workforce here in Wisconsin,” said George Quinn, WCMEW executive director.
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Member News: Kosanovich Announces Retirement
Watertown Regional Medical Center (WRMC) CEO John Kosanovich will retire this month after 20 years of leadership at WRMC.
Over the years, Kosanovich has led WRMC through a variety of projects and investments designed to advance health care in the greater Watertown community.
“I am thankful to have been a member of this remarkable team for the past 20 years,” said Kosanovich. “I am most proud of the organizational culture we’ve developed that puts the patient and family at the center of all that we do. I thank all of the staff members, physicians, the WRMC Board and everyone involved in advancing health care and positioning WRMC for the future.”
Kosanovich participated in a wide range of WHA councils and task forces for more than a decade as a WHA Board member. He also served on the Council on Public Policy, Council on Finance & Payment, Task Force on Community Benefits and the Task Force on Access & Coverage.
“John has been a tremendous WHA partner, member advocate and volunteer leader. We wish him the best,” said WHA President/CEO Eric Borgerding.
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