April 22, 2011
Volume 55, Issue 16

WHA’s Advocacy Day Tops 700 for First Time

The Wisconsin Hospital Association’s 2011 Advocacy Day event has topped all previous registration records, surging past 750 this year with more registrations coming in daily.

"Advocacy Day is the most important legislative grassroots day for Wisconsin hospitals," said WHA President Steve Brenton. "This year’s attendance shows how committed hospital representatives are to speaking up on behalf of their hospitals, their patients and their communities."

Over 450 Advocacy Day attendees will take the hospital message to the halls of the State Capitol next Wednesday afternoon and will meet with over 100 of the Legislature’s 132 members or their staffs. During their meetings, attendees will discuss important 2011-2013 state budget issues, stabilizing the Medicaid program as well as community benefits and the economic impact of hospitals in Wisconsin.

"We anticipate well over 450 hospital advocates will meet face to face with their legislators and staff," said WHA Executive Vice President Eric Borgerding. "This massive show of hospital support couldn’t come at a more important time as the Joint Finance Committee and Legislature prepare to tackle a projected $1.8 billion deficit in the Medicaid program. Changes are in store for Medicaid, but those changes cannot result in more Medicaid cost-shifting and higher health care costs for employers."

During the day’s programming, attendees will also hear from a full line-up of important speakers including the keynote address from Jim VandeHei, co-founder and executive editor of Politico.

A full brochure and registration are available at: http://events.SignUp4.com/AdvocacyDay. For Advocacy Day questions, contact Jenny Boese at 608-268-1816 or jboese@wha.org.

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Guest Column: Hospital Property Tax Exemption: Its Day in Court
Supreme Court Hears Arguments in Covenant Case
By David Edquist

The Wisconsin Supreme Court heard oral argument on April 15 in Covenant v. City of Wauwatosa, a landmark case involving property tax exemptions for Wisconsin nonprofit hospitals. The stage is now set for the court to resolve the increasingly nettlesome debate between hospitals and assessors on the status of freestanding outpatient hospital departments.

Covenant involves the St. Joseph’s Hospital Outpatient Center (SJOC) in Wauwatosa. When St. Joseph’s moved various outpatient services from another facility to the SJOC in 2003, the city assessor asserted that the new facility did not qualify for exemption since it was used solely for outpatient services. The City reached this conclusion even though the SJOC is operated under the hospital’s license as a provider-based hospital department. The trial court rejected the City’s claim in 2009, but the Court of Appeals reversed the trial court’s decision in 2010.

The case presents myriad issues, but the justices and the parties kept coming back to one central point: was the SJOC essentially a "doctor’s office," and therefore ineligible for exemption under Wisconsin law? Chief Justice Abrahamson repeatedly pressed for a working definition of a "doctor’s office," seeking counsel’s input on whether a bright-line standard could be adopted, or whether instead the court should identify criteria that could be employed on a case-by-case basis. The Chief Justice paid particular attention to factors identified in an amicus curiae brief filed by the Wisconsin Hospital Association. Counsel for Covenant endorsed the WHA criteria, while encouraging the court to recognize the core principle that a doctor’s office "is where doctors have their offices," that is, where they actually maintain their practices. Covenant’s counsel contrasted that concept with the "cubbies" made available to physicians at the SJOC for charting and other purposes. Counsel for Wauwatosa, on the other hand, argued that so long as doctors have a workspace, no matter how small, that’s sufficient to support the characterization of a freestanding outpatient facility as a doctor’s office. In the City’s view, if a facility is off-campus and delivers services on an outpatient basis only, it’s taxable. Other members of the court, notably Justice Roggensack, focused on the need to look at how a hospital delivers its services, not just at whether those services are delivered within the four walls of a traditional inpatient hospital. Justice Bradley questioned the City’s suggestion that the characterization of a facility as a "doctor’s office," and therefore its entitlement to an exemption, could be based on the personal perspective of a patient who is receiving services in the facility.

A second question posed in Covenant involves the significance of intra-system cost allocations to St. Joseph’s Hospital that benefitted its sole member Covenant Healthcare. According to Wauwatosa, this benefit rules out an exemption since the statute states that no part of the net earnings of the hospital may inure to the benefit of a member. Covenant argued that this inurement language is inapplicable to nonprofit members, a position adopted by the trial court in the case. While the Supreme Court justices did not seriously question that conclusion, the contrary position advanced by Wauwatosa would have a wide-reaching impact on hospitals that are affiliated with larger health care systems.

Two other issues, involving whether the SJOC was "reasonably necessary" to the efficient functioning of the hospital and whether it was operated for ineligible "commercial purposes," received relatively little attention during the course of the argument and are not expected to affect the outcome.

The Supreme Court is expected to issue its decision in the next few months.

David J. Edquist, a shareholder with the law firm von Briesen & Roper and a prominent Wisconsin health care attorney, authored the Wisconsin Hospital Association’s amicus curiae brief. A copy of the brief is available on the WHA Web site.

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Dr. Joe Bujak to Keynote 2011 Rural Health Conference

The 2011 Wisconsin Rural Health Conference will feature keynote speaker Dr. Joe Bujak, a nationally-known speaker, facilitator, consultant and author on issues related to health care organizations—physician relationships, clinical quality and patient safety, and leading and managing transformational change. Focusing on the conference theme of "A Call to Action: Maintaining Steady Ground in Unsteady Times," Dr. Bujak, author of the book "Leading Transformational Change: The Physician-Executive Partnership," will focus on the relationship among a hospital board, its administration and its physicians, and the impact of issues such as health reform, generational differences, changing technology, and payer, regulator and patient expectations have on those relationships.

This year’s event will take full advantage of The Osthoff Resort’s beautiful setting on Elkhart Lake. Plan to join your colleagues at the Wednesday evening welcome reception for networking and a chance to visit corporate member exhibitors. Register to bring your families and guests to the Thursday evening dinner on the shores of Elkhart Lake, for a great meal, networking, and the relaxing sounds of a steel drum band.

As a reminder, hotel reservations need to be made by May 23 to ensure a reservation and the special conference group rate. Due to a race at Road America, it is very likely that no hotel rooms will be available to conference attendees after that date. It is recommended that you make your hotel reservations immediately to avoid problems.

This year’s conference is scheduled June 15-17 at The Osthoff Resort in Elkhart Lake. Full conference information and online registration are available at http://events.signUp4.com/Rural.

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EHR Incentive Programs Update
CMS announces May calls on Medicare EHR program attestation

CMS will hold a national call for hospitals on May 3 from 1-2:30 p.m. CDT that will walk through the attestation process for the Medicare electronic health record incentive program. A similar call will take place May 5 from 12:30-2:00 p.m. CDT for physicians. CMS has indicated that additional information, including registration and call-in information will be made available soon.

Hospitals and physicians eligible to participate in the Medicare EHR incentive program can, if they choose, begin attesting that they meet the program’s meaningful use requirements. Hospitals need not attest to meaningful use in federal fiscal year 2011 to benefit fully from Medicare EHR incentive payments, and there may be both risks and benefits to seeking payment in FY 2011 depending on a hospital’s circumstances. Hospitals wishing to attest in FY 2011 must report on the meaningful use measures for a 90-day period during the federal fiscal year, which ends September 30. For more information, visit www.cms.gov/EHRIncentivePrograms and/or www.wha.org/toolKit/EHR.pdf.

Upcoming Wisconsin Medicaid EHR Incentive Program Webinars for Hospitals and Eligible Professionals

Over the next few months, DHS will be hosting several informational webinars on Wisconsin’s Medicaid EHR Incentive Program targeted at physician practices, hospitals, Federally Qualified Health Centers, Rural Health Centers, and dentists, respectively. The first programs are for physician practices on April 26 and May 3. The hospital-focused webinar will be June 21 and 27.

For more information and registration information, go to: www.dhs.wisconsin.gov/ehrincentive/Training/index.htm.

DHS announces that the Wisconsin Immunization Registry is now able to fulfill providers’ public health meaningful use requirement

As of April 1, the Wisconsin Immunization Registry (WIR) is now able to receive submissions of immunization data from eligible hospitals and eligible providers in either HL7 2.3.1 or HL7 2.5.1 format. According to DHS, submission of data to WIR fulfills the meaningful use objective for submission of immunization data. However, per DHS, it appears it may take WIR up to 90 days to establish a "live connection" with a provider, so providers should keep that timeframe in mind as they plan for meeting meaningful use.

For more information on WIR specifications and the process for connecting to WIR, go to: www.dhs.wisconsin.gov/immunization/imu.htm. In addition, DHS has additional information and a status update on syndromic surveillance and electronic laboratory reporting functionalities related to meaningful use at: www.dhs.wisconsin.gov/ehealth/PHMU/index.htm.

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President’s Column: More Ugly Medicare Payment Hocus Pocus From CMS

The nation’s PPS hospitals face a second year of actual Medicare payment reductions. That’s largely due to a formula-driven adjustment to eliminate the alleged effect of coding changes associated with the new DRG system implemented a few years ago.

But that’s not all. The new inpatient payment formula beginning October 1 is arguably incomprehensible to all but the CMS bureaucrats responsible for its construction. And its impact on community hospitals will be profound.

Here it is...

+2.8% (hospital market basket inflation update assuming that quality measures are reported)

-1.2% ("productivity cut" agreed to as part of the ACA)

-0.1% (market basket cut agreed to as part of the ACA)

+1.1% (one time correction of technical error related to rural wage floor)

-3.15% ("behavioral offset" as described earlier)

-0.55 (The net result of the above adjustments).

For hospitals other than CAHs, this is the second across-the-board payment cut in as many years, largely forced by offsets arrived at via "black box" number crunching. The reality is that Wisconsin PPS hospital Medicare margins continue to dip despite alleged claims "up coding." And the "productivity" adjustment has the potential to become the hospital version of the Medicare physician payment boondoggle...annual decreases arrived at through an opaque, almost inexplicable process that can only be stopped by Congressional intervention.

This is a sorry development for hospitals, especially as they begin to develop revenue forecasts for next year, and beyond.

Steve Brenton


P.S. For the fiscal technicians out there, the "productivity adjustment" is an annualized 10-year moving average of changes in economy-wide business productivity. The "productivity adjustment" has never been part of the Medicare payment equation. But in the tradeoff for coverage expansions under the ACA last year, AHA and other national associations agreed to have a significant portion of the "adjustment" subtracted from the annual hospital market basket (inflation) increase....in perpetuity.

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CMS Releases FY 2012 Inpatient PPS Proposed Rule

The Centers for Medicare & Medicaid Services (CMS) on Tuesday, April 19, issued its hospital inpatient hospital prospective payment system (PPS) proposed rule for fiscal year (FY) 2012.

The rule proposes to continue FY 2011’s 2.9 percent cut to inpatient PPS payments, as well as make an additional 3.15 percent cut to eliminate what CMS claims is the effect of documentation and coding changes the agency says do not reflect real changes in case-mix. This represents a total proposed coding cut of 6.05 percent for FY 2012. Together with other policy changes, this cut would cause FY 2012 payments to decrease by 0.55 percent on average.

WHA is deeply disappointed with the proposed level of payment for FY 2012. We disagree with any further reductions to a system in which hospitals already are paid less than the cost of providing vital services, while at the same time struggling to make important investments in areas such as accountable care and information technology to enhance care. We also have concerns about the large number of quality measures CMS proposes to add over the coming years, which would bring the total number of measures to 73 by FY 2015.

Based on our preliminary read, some of the key provisions of the proposed inpatient PPS rule are as follows:

In addition to updating inpatient payments for FFY 2012, the content-rich rule also includes proposals related to the ACA’s Medicare inpatient readmissions payment policy, set for implementation beginning FFY 2013, and proposals related to the FFY 2014 Medicare inpatient value-based purchasing (VBP) program. The VBP proposals for FFY 2014 have been issued as the field awaits the final rule from CMS that will establish the initial FFY 2013 VBP program.

CMS Fact Sheets on the proposals are available on the CMS Web site at: www.cms.hhs.gov/apps/media/fact_sheets.asp.

Comments on the proposed rule, available at www.cms.gov/AcuteInpatientPPS/IPPS2012/list.asp#TopOfPage, will be accepted until June 20. The final rule will be published by August 1, and the policies and payment rates will take effect October 1. Watch for a more detailed analysis of the proposed rule in the coming weeks.

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Physician Leaders Encouraged to Participate in AHA Webinar on Accountable Care Organizations

AHA’s Physician Leadership Forum will host a webinar focused specifically on what physicians need to know about Accountable Care Organizations (ACOs). The webinar will be held Tuesday, May 3 from 1:30 - 3 p.m. Central time.

The webinar, entitled "Medicare Proposed Rule: What Physicians Need to Know" will provide an overview of the Medicare ACO proposed rule, answer questions, and gather physician input and reaction to CMS’ proposals. Dr. Nicholas Wolter, chief executive officer, Billings Clinic, Billings, MT, will provide his perspective on the Physician Group Practice Demonstration Program in which Billings Clinic was a participant.

To register for this webinar, go to https://www.hospitalconnect.com/secure/plf/webinar11.jsp. There is no charge for AHA members. To participate in the live event, you will need a telephone line and a computer with an Internet connection.

There is a high level of interest in ACOs among physicians, and this is an opportunity for hospital physician leaders to learn more about ACOs. Please share this information with physicians throughout your facility.

In addition to the Physician Leadership Forum Webinar, AHA will host a conference call for all hospital members on specifics in the rule regarding barriers to clinical integration on Monday, May 9 at 12 p.m. Central time. To participate on that call, go to www.surveymonkey.com/s/X2XDDPW.

If you have questions, contact Dan Paloski at 312-422-2914 or physicianforum@aha.org.

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WHA’s Medicaid Advisory Group Holds Second Meeting in 2011

The second meeting in 2011 of the WHA Medicaid Advisory Group (MAG) with staff from the Wisconsin Department of Health Services (DHS) was held April 20 at the DHS offices in downtown Madison. DHS presented the DRG weights that will be used in calculating the 2012 base rates, along with data on the top 20 DRG codes by inpatient payments, outpatient charges, and volumes. In addition, DHS reviewed potential policy changes that will be incorporated into the calculation of the base rates.

Brett Davis, the State Medicaid Director, also took time to thank Jim Johnston of DHS for his years of service to the State of Wisconsin and the Medicaid program. Johnston, who has been a key contact for WHA on a variety of Medicaid issues, is leaving DHS to take a job with the federal Center for Medicare and Medicaid Innovations.

With respect to rate-setting, DHS plans to release the draft base rates at the May meeting of the MAG. DHS is seeking input on potential policy changes by April 27. A list of the policy issues and all materials from the April 20 meeting can be found on the WHA Web site at www.wha.org/financeAndData/MAG.aspx.

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WI Office of Free Market Health Care Releases Health Reform Insurance Market Analysis

The Wisconsin Office of Free Market Health Care (OFMHC) recently revised its Web site to include new features and highlight a Health Insurance Exchange prototype. Governor Walker created the Office of Free Market Health Care earlier this year with the goal of ensuring that Wisconsin maintains a competitive and consumer-driven health insurance market based on free market principles. The Office is directed by the Department of Health Services (DHS) and the Office of Commissioner of Insurance (OCI).

The Web site allows users to test drive a prototype of the Exchange and complete an online survey to provide the OFMHC with feedback on the Exchange design. In addition, OFMHC has posted an actuarial analysis of the current Wisconsin health insurance market and how it will be impacted by the Patient Protection and Affordable Care Act (PPACA).

According to DHS, the analysis (conducted by Gorman Actuarial) predicts that 75 percent of Wisconsinites in the individual insurance market would see an increase in the health premiums as a result of various provisions in the PPACA. Additionally, DHS indicates 38 percent of Wisconsin citizens in the individual market will need to purchase richer benefit packages than they have today, equaling higher premiums. According the OFMHC Web site, these results "will be used to help guide policy decisions as the Exchange is designed and implemented."

Earlier this year, Wisconsin DHS Secretary Dennis Smith referenced the Gorman Actuarial study in testimony before a U.S. House Budget Committee hearing on the impact of PPACA. Smith stated that their analysis revealed "46 percent of individuals who will move into public subsidies either through Medicaid or the new tax credit entitlement already have private coverage" and that "at least 457,000 people in Wisconsin will likely be displaced from their current coverage. This includes 160,000 individuals from the individual market, 175,000 individuals from employer-sponsored coverage and 122,000 individuals, including children, who are currently in our public programs."

Access the Office of Free Market Health Care at: www.freemarkethealthcare.wi.gov/Index.asp.

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Wisconsin Hospitals Community Benefits: Physical Activity

The increasing rates of obesity among adults and children are raising concerns because of the dire implications on American’s health. In communities across Wisconsin, hospitals are dedicating resources and doing what they can to encourage people of all ages to lose weight and stay active.

Luther Midelfort collaborates with YMCA to offer camp for kids who struggle with weight issues

Childhood obesity in the United States has more than tripled in the past 30 years. To combat this problem, Luther Midelfort - Mayo Health System and the Eau Claire YMCA are offering Camp Wabi, a summer camp for kids ages 10 to 14 who struggle with weight issues and obesity to make lifestyle changes necessary to achieve a healthy weight.

The setting for Camp Wabi (pronounced Wah-bee) is the YMCA’s Camp Manitou on the shores of beautiful Long Lake, near New Auburn. Camp Wabi will run August 7 to 19.

"Our goal is to provide children with a fun, outdoor experience they will never forget all while learning how to make healthy lifestyle changes," said Randall Linton, M.D., Luther Midelfort president and chief executive officer, who also is a pediatrician.

As part of camp, parents will participate in an orientation to learn how they can contribute to their child’s weight management and healthy attitudes. When camp ends, parents have opportunities to participate in discussions, go over educational material and meet other parents. Camp staff will work with parents, sharing ways to reinforce, support and prepare for when their child returns home.

"One of the best strategies to reduce childhood obesity is to improve the diet and exercise habits of the entire family," said John Plewa, M.D., Luther Midelfort pediatrician and medical director of Camp Wabi. "We know parents want to see their children be happy and healthy. That’s why helping the whole family understand the importance of treating and preventing childhood obesity will help protect the health of children now and in the future."

Camp Manitou is well known for its fun activities, like swimming and boating. Camp Wabi will offer the same, plus wellness education taught by specialists in nutrition, behavior therapy, and exercise physiology.

The cost of this 12-day camp is valued at more than $800 per person. However, the Luther Midelfort Foundation is contributing half the cost for each camper, bringing tuition to $400. Tuition also includes three reunions held quarterly after camp. Financial assistance also is available to low-income families.

Luther Midelfort, Eau Claire

Aurora Memorial Hospital of Burlington, Western Racine County Health Department hold community "Health and Fitness Challenge"

The Western Racine County Health Department, a department of Aurora Memorial Hospital of Burlington, has held a community "Health and Fitness Challenge" for the last eight years to encourage members of the community to join together to stay active and healthy.

In 2010, 524 participants from 32 business and community organizations formed 131 teams. Friendly competition waged as participants earned team points during each of the eight weeks for engaging in healthy behaviors such as weight loss, smoking cessation, increased water intake, fruit/vegetable consumption, putting together an emergency preparedness kit, using organic, vegetarian, or locally grown foods in a meal, and taking an exercise break during the day.

Health information newsletters and weekly scores were sent to participants via e-mail and were also made available on the Western Racine County Health Department website. In conjunction with other community providers (UW Extension, local grocers, fire department, and wellness centers), free evening events including a self defense class, healthy cooking classes, yoga and Zumba classes, and blood pressure screening/ body mass index/ bone density testing were also provided. Incentives and prizes were presented during the course and at end of the Health and Fitness Challenge.

Of the 524 participants, 18.5 percent completed post-Challenge evaluation surveys. These demonstrated that seven people either quit smoking or reduced the number of cigarettes they smoked per day, the average number of days per week participants engaged in physical activity increased from three to five days per week by the end of the Challenge. Participants who drank six or more glasses of water per day rose from 34 percent to 63 percent. Participants who consumed five or more portions of fruit/vegetables daily rose from 26 percent to 64 percent. Of the 15 local organizations that registered four or more teams in the challenge, seven responded to the survey identifying the policies and support systems that promote healthy behaviors within their organization. Eighty-six percent are smoke-free, 14 percent offer low-fat, healthy food choices to their employees, 43 percent have fitness equipment accessible to their employees and 57 percent have made environmentally friendly changes to their facilities. Seventy-one percent offer health screening such as blood pressure checks, cholesterol screening, BMI, and weight management at their sites.

These fitness challenges have been a fun and unique way to educate and motivate the residents of western Racine County as they make efforts to live healthy and active lifestyles.

Aurora Memorial Hospital of Burlington

Every Loser Wins in Weight Loss Challenge

Promoting healthy lifestyles goes beyond the confines of the hospital.

Lakeview Medical Center (LMC) Dietitian Sarah Anderson is one of many staff members who have helped bring healthy lifestyle choices to the public. Anderson and Exercise Physiologist Stephanie Fleming have provided nutrition and exercise sessions for companies and employees involved in the Worksite Weight Loss Challenge, a program organized by Lakeview Medical Center.

The 12-week program, now in its second "season," drew rave reviews and helped its participants lose a combined total weight of over two tons in 2010.

A total of 408 employees from area businesses joined together on teams of four, and the race to see which team could lose the most weight began. The winning team, from Mastercraft Industries of Rice Lake, lost a collective 141.8 pounds. The Worksite Weight Loss Challenge was successful beyond its time frame, with many employers continuing the program, and employees still encouraging each other to work towards healthier lifestyles.

"At LMC, we also offered everyone in the program monthly nutritional presentations by an LMC dietician," said Program Coordinator Char Mlejnek. "Core strength training classes were offered two times per week, taught by an LMC exercise physiologist. We also gave opportunities for participants to try new exercise classes with a class of kickboxing and a new kind of dance fitness called Zumba. Classes were full."

The individual winner, from the 3M Corporation in Cumberland, lost 49.94 pounds to win the top award. He says he participated to help ease himself back in to a healthy lifestyle, and was excited by the prospect of getting healthy with the help of co-workers/teammates.

"I thought as a team we could use each other as support to achieve our goals," he said.

"We plan to offer the program annually," said Mlejnek. "The competition was about more than just losing weight. It also taught employees to practice healthy behaviors long after the competition ends. This was a successful effort to improve the health of our community, and we are all looking forward to future success stories with this program."

Lakeview Medical Center, Rice Lake

Submit community benefit stories to Mary Kay Grasmick, editor, at mgrasmick@wha.org.

Read more about hospitals connecting with their communities at www.WiServePoint.org.

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