On December 16 The WHA Board approved a plan to raise awareness of the "hidden tax" created when government programs, like Medicaid, don’t cover what it costs to care for their recipients. WHA Senior Vice President Eric Borgerding, in describing the Medicaid issue advertising strategy, said the campaign would be mounted to create a new constituency for Medicaid…those who pay the "hidden tax."

The key to success, according to Borgerding, is to develop strong allies, educate the public and legislators on the impact that the hidden tax has on health insurance costs, and to reframe the debate. WHA will partner with Wisconsin Manufacturers and Commerce (WMC), which has perfected the use of "issue advocacy," for assistance in developing, placing and targeting the "hidden tax" message. In addition, a strong grassroots campaign will be developed and deployed to engage lawmakers at the local level.

"We plan to take our message to the public through radio and print media, targeting key areas of the state," said Borgerding. "The message is ‘state government is shifting the cost of its health care programs to you,’ which we expect will outrage taxpayers when they realize that they are supporting the state’s medical assistance program with both their paycheck and their health insurance premium."

Ford Titus, chair of WHA Information Center Board of Directors, described another project that centers on providing information and education to consumers. Titus told the board that the WHAIC staff has developed a Web site that will display retail pricing information on all Wisconsin hospitals, information that has not been readily available to the public. Titus said WHAIC has solicited comments from both its own board members, and the WHA Board of Directors, incorporating the feedback into the Web site. The Web site link will now be sent to all WHA member hospitals for their input before it is introduced to the public in mid-January.

WHA President Steve Brenton said WHA is in a position of "doing the right thing, and pushing information out in the right way." He and Titus agreed that if hospitals do not embrace the concept of pricing transparency and do it themselves, someone else "will do it for us," according to Brenton.

Following a comment period on the Web site that will solicit member input, Brenton said the expectation is that it will be ready to be unveiled to the public in mid to late January. A Q&A on the Web site that hospital will find useful when they are answering questions from their employees and public will be sent available in January.

The Board approved a white paper that lays out a plan for bridging WHA’s CheckPoint with the Wisconsin Collaborative for Healthcare Quality in joint efforts to maximize efficiency and reduce confusion. One of the first goals of the joint collaboration will be to build a single point of access Web site, which will allow consumers to access information from both efforts on one portal.

Dana Richardson, WHA vice president of quality, discussed four new measures that will likely be added to CheckPoint, WHA’s public reporting program. The new measures include:

• Surgical infection prevention (4 surgical procedures; 3 measures each)
• Error prevention—Medication reconciliation
• Patient experience of care-H-CAHPS survey.

Richardson also presented a preliminary summary of comments received during four CheckPoint focus group discussions with legislators, hospital quality experts, and purchasers. She said all groups were knowledgeable about and support CheckPoint, but the value of measure depends on the anticipated use.

In other action, the Board approved:

• The membership rosters of the WHA Councils; and,
• Three resolutions related to health delivery reform recently adopted by the Competitive Wisconsin, Inc. Board.

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The WHA Board of Directors at their December 17, 2004 meeting honored Charles Shabino, MD, chief medical officer at Aspirus, Inc., in Wausau, for his leadership as Chair of the WHA Board in 2004.

In recognizing Shabino, WHA President Steve Brenton expressed his appreciation for "Chuck’s leadership not only as Chairman of the Board this year, but for the past several years as he helped us navigate through the early stages of public reporting and accountability as we strive to provide information to our patients and communities on quality, safety, service and pricing."

The Board acknowledged Shabino’s service to the Association, which will continue as he assumes a leadership role by chairing both the WHA Advocacy Committee and the Nominating and Awards Committee.

If your health insurance agent walked in today and announced, "With no change to your company health plan, I can save you about 20 percent on next year’s premium," you would probably faint dead away. With rare exception, rising health care costs are overwhelming Wisconsin businesses and their employees, who are often picking up a significant share of premium costs. With very limited ability to pass on costs in higher prices, most companies cover growing health care expenses by limiting wage increases or reducing benefits. So, talk about a 20 percent reduction in premiums ought to get our attention!

The cold, hard facts are that the State of Wisconsin imposes a "hidden tax" of about $250 annually on every insured family in the state by, in effect, not paying its bills. Here is how that works.

Over the years, our elected officials have established state health care programs for individuals who don’t have, can’t get, or can’t afford health insurance. Medicaid (MA) is the lead program, with BadgerCare targeted to poor families with children, and HIRSP designed to provide coverage for the state’s medically uninsurable population. The problem with these programs is that the state adopts reimbursement policies that fail to cover the cost of the care provided. With hospitals, for example, the state reimbursed only 59 percent of what it cost to provide hospital services to Medicaid patients in 2003. The total amount of underpayment was at least $349 million — which was then shifted onto the health insurance premiums of businesses and individuals who are insured.

Wisconsin’s Medicaid reimbursement rates are among the lowest in the nation, and because the program is funded approximately 60 percent by the federal government and 40 percent by the state, the state’s failure to raise reimbursement rates leaves federal dollars on the table that should come to Wisconsin. Instead, we add a hidden tax to the insurance premiums of everyone who has health insurance. Those inadequate government payments add up to almost a 20 percent increase in insurance rates for everyone else.

As recently as 1997, Wisconsin was covering a little better than 80 percent of a hospital’s Medicaid costs. That wasn’t optimal, but with relatively stable cost inflation, it was tolerable. Unfortunately, over time, lawmakers and governors have cut back on reimbursement rates so that they could create new programs, and health care cost inflation has skyrocketed. The $349 million shortfall in 2003 is nearly five times what the state spends as its share of the BadgerCare program, and infinitely more than the zero dollars the state commits to the HIRSP program. Since it is a hidden tax collected by insurance companies, the insurance company gets the black eye for cost increases, and politicians can take credit for expanding health care benefits without paying for them. The resulting artificially high commercial insurance rates make it hard for businesses to provide workers with health care benefits.

In the last biennial budget, Wisconsin hospitals took an all funds cut of $79 million in Medicaid reimbursements. They have not received an inpatient payment increase for eight years - even as the costs to treat Medicaid patients have increased just as they have for all patients. But unlike some

health care providers, pulling out of treating Medicaid patients is not an option — hospitals treat anyone who walks in an emergency room door. And so that cost shifts to the insurance premiums of businesses and workers throughout the state.

Many of us think the state’s health benefit programs could be fine-tuned so that they continue to provide a safety net, but on a more cost effective basis. But, there is also a need for the state to stop the erosion of reimbursement rates by increasing state funding and capturing more federal dollars — especially for those hospitals who are training future doctors and who are serving high numbers of Medicaid patients.

Failure to do so will simply continue to add an oppressive "hidden tax" to the already escalating health insurance premiums paid by businesses and individuals.

The day of the incident, we knew almost immediately there were three people wounded and five dead. We enacted our emergency response plan. Of the three victims transported to Lakeview, one was immediately taken by helicopter to Saint Joseph’s Hospital in Marshfield, and two were treated here. Of the two we treated, one man was so severely wounded he could not be transferred so he was taken to surgery immediately. He later died. The other gentleman was not as critical, and we performed surgery on him and he was discharged the next night.

We were prepared to treat more people that day. It was difficult for the staff when they realized that so many of the victims had died in the woods, and they would not have the opportunity to help them.

This must have been rough on your staff, given that Rice Lake is a small community and your employees were treating people they knew, while dealing with the deaths of community members. How did they handle the emergency before them?

We have disaster codes and we practice them. When we looked back, we realized that we have a major event about every five years or so. Our staff—physicians, nurses and paramedics in the hospital—are true professionals in every sense. Even though it was traumatic for them, they go to the top of their game and do everything that is needed and more. The physicians responded immediately, and our emergency department performed splendidly. They could have triaged and treated many more people. I think it is not until the adrenalin rush and need for immediate care is over that you get the emotional let down and it affects them emotionally. This incident hit us in a very personal way in this community and within the hospital. We have employees who had family members killed and wounded in the woods. One of our employee’s daughters, Jessica Willers, was also an employee of Aurora BayCare in Green Bay. It was a very difficult situation for many people.

What services were offered to employees to help them cope?

By Monday evening, most of the actual care was done, so on Wednesday our Employee Assistance Program offered two counseling sessions for physicians, staff and auxilians who were directly involved. We had close to 100 people attend. I personally wrote 100 notes to those who had assisted during the emergency. They ranged from thanking nurses and our physicians, to the housekeeping staff who monitored the doors.

What was your biggest challenge during this emergency?

Our biggest challenge was handling the media. The media built over two days to the point where it took two of us to manage it. Our public relations person, Jennifer Greshowak and I fielded calls throughout the day and night. She did a wonderful job not only with the media, but also with the families of the two victims we were treating in the hospital. She explained the media interest to the families, so they issued a statement that evening and we helped coordinate that for the families. We found it was better to get it out, rather than let rumors get a foothold in the press corps covering the incident.

We had a tremendous amount of press at the hospital. Monday morning I read a statement from the families, and our surgeon reported out the condition of the patients—the story went national and international. We had 10-12 TV satellite trucks parked in our lot.

While the press reported that we had "locked down" the hospital, actually we were just monitoring the doors. When people turned up at the door, we asked them a few questions just to make sure that we could control access to the families and to our patients. And until the shooter was found, we had to be very careful.

The families of those who were killed also came to the hospital to receive news of their loved ones. We accommodated them, and the families of those we were treating, in a medical office close to the main entrance. We had social workers, a couple of auxilians, and staff there to help the families. The sheriff used that conference room to later announce who had died while we waited for news on the shooter.

For most of the media, the story ended Wednesday, but some stayed on through the last funeral on Monday. We found the clinical aspect of this situation was over pretty quickly, but the press stayed on.

You have to realize in this day and age the media have their role and it is going to happen whether you decide to work with them, or against them. We communicated often with them, we gathered their names, and got information to them as quickly as we could. We found it was better to over communicate with them than to hold back information.

It was a lesson about the press. You think because you are in a small, more remote community, you’d get little attention, but this experience illustrated, depending on what happens, the press descends upon you. We became almost immediately accessible to the national press.

Two new nursing programs were given authorization to admit students at the December meeting of the Wisconsin Board of Nursing. Maranatha Baptist Bible College of Watertown is adding a Bachelor’s Degree Nursing Program and will begin admitting students in fall 2005. Watertown Memorial Hospital, Oconomowoc Memorial Hospital and Waukesha Memorial Hospital will serve as clinical sites for the Maranatha program.

Northland College was also granted permission to admit students. Northland will be offering a BSN completion program and will begin admitting in May 2005. Clinical arrangements for the Northland program have not been finalized.

"Wisconsin is fortunate to have several excellent nursing programs in the state," said Judy Warmuth, WHA’s vice president of workforce. "These new programs will offer nurses additional opportunities to advance their education, and some students will be able to get off the waiting list and into a nursing program."

Carroll College and Bryant & Stratton College are new programs that have admitted students, but not yet graduated a class. The addition of these new programs is good news for Wisconsin hospitals as it ensures that Wisconsin will have additional nurses entering the workforce and provide options for nurses seeking bachelor’s degrees.

The Board of Nursing also discussed several procedural changes proposed by the Department of Regulation and Licensing, which is preparing for budget reductions in the next biennial budget. Changes will most likely include loss of the traditional nursing code book, changes to standardize impairment orders and possibly significant changes in the impaired professionals program.

Meeting at WHA’s new headquarters this week, the WHA Board acted on several initiatives designed to frame and advance current and future Association advocacy themes.

On the Medicaid front, the Board approved the funding of a major paid issue advocacy campaign that will advance the Association’s Medicaid message and agenda. That agenda calls for no new cuts in 2005 and a "down payment" on specific hospital payment improvement priorities.

The Medicaid media campaign will focus on the impact of cost shifting created by Medicaid underpayment. The "hidden tax" message strategy will be joined by the Wisconsin Manufacturers and Commerce, who will be our partner in the issue advocacy campaign. We’ll target a variety of paid media strategies including both radio and print messages.

While a paid issue advocacy campaign is a new approach for WHA, we believe it is an approach warranted for what is expected to be an extremely difficult and challenging state budget environment. With a willing and respected partner from the business community standing at our side, the Board is optimistic that our message will be heard and well received.

On the health information (transparency) front, the WHA Board endorsed the continued evolution of CheckPoint^SM and the implementation of a new WHA Information Center (WHAIC) Web site. Both initiatives are responsive to a growing and bi-partisan desire by policymakers, purchasers and consumers for more information about health care quality, safety, service and pricing.

The WHA Board’s action on new CheckPoint measures sets the stage for the public reporting of surgical infection prevention measures and at least one new error prevention measure in 2005. The Board also desires that WHA be a national leader in reporting patient experience of care (patient satisfaction) scores. That effort will largely align with expected CMS activity in coming months.

In endorsing a WHAIC pricing transparency Web site, the Board operationalized recommendations from its July Board Planning Session that embrace the notion that WHA must seize the public policy pricing transparency agenda. WHA members will soon receive a link to the proposed Web site and be invited to provide feedback to staff in anticipation of a January Web site rollout.

WHA Board action this week sets the stage for bold and meaningful Association programming intended to advance our top two advocacy priorities—Medicaid payment improvement and private sector health information initiatives.

Steve Brenton
President

The WHA, with the Wisconsin Medical Society, submitted a brief in Lagerstrom, as amicus curie arguing that the legislation is constitutional as it meets the rational basis standard of review, the standard of review applied in such cases. WHA further argued that Wisconsin’s medical malpractice statute allows plaintiffs to be fully compensated for any economic losses they actually suffer, but does not permit plaintiffs to recover for costs not incurred.

To begin his argument before the Court, attorney Guy DuBeau, representing the defendants, read from the closing instructions that juries receive before they are sent to deliberate: "Let your verdict speak the truth, whatever the truth may be." DuBeau elaborated, "The truth of the matter in this case is that the plaintiffs here paid out $755 out of pocket for medical expenses. The truth of the matter is the jury awarded them $755 for the medical expenses they paid out. I would suggest that that verdict did exactly what the jury was instructed to do by announcing the truth. And the only way that the jury was able to recognize that as the truth is through the existence of 893.55(7)." (Section 893.55(7) is the statute abrogating the collateral source rule.)

Conversely, attorney Charles Harris, representing the plaintiffs, argued that the statute abrogating the collateral source rule is unconstitutional because it impermissibly treads on a "core judicial function" by permitting the jury to hear evidence that the plaintiff’s medical bills have been paid by a health insurer: "It seems to me courts should not be willing to accept a rule in evidence forced upon them by the legislature that requires them to allow a jury to hear evidence that simply is totally unrelated to the factual question a jury is supposed to determine." He further argued that the statute also violates Wisconsin’s constitution by denying the plaintiff equal protection and due process: "When you assign this function of making the law or deciding what rule of law should govern damages to the jury, it obviously won’t apply equal and across the board to the class of individuals. Rather it will be applied arbitrarily and capriciously - decided differently on a case by case basis."

A decision from the Court on this case can be expected in two to six months.

More than one-third of all physician assistants (PAs) reported their primary work setting is a hospital, according to the American Academy of Physician Assistants (AAPA) 2004 Annual Physician Assistant Census Report. Almost two-thirds (64%) of respondents report seeing patients in at least one hospital and one in five (21%) report seeing patients in more than one hospital.

In "Who Will Care for our Patients?" a task force report released by the Wisconsin Hospital Association and the Wisconsin Medical Society, the important role of non-physician providers was acknowledged. Advanced practice providers such as physician assistants and nurse practitioners must be recognized as essential members of the health care team in order to ensure adequate access to care for all of Wisconsin’s residents in a future likely to include a shortage of physicians.