The Democrat-led Senate passed its version of the state budget on June 26. The $66 billion proposal, like the budget approved by the Joint Finance Committee earlier this month, included a 1 percent tax on hospital gross revenues. While a $1.25 increase in the state’s cigarette tax also remained, the Senate raised significant concerns by including among their changes, a massive $15.2 billion universal health care plan to completely overhaul the state’s health care system (see related story and this week’s President’s Column).

According to the Legislative Fiscal Bureau, under the budget approved by the Senate, overall state spending would increase by 23 percent over the next two years – state spending would go up only 9 percent under the Senate version over this same time period if the universal health care plan was not included.

In total, Senate Democrats approved over 150 changes to the budget approved by the Joint Finance Committee, but hundreds of millions of dollars are still taken from the state’s Medicaid program and the Injured Patients and Families Compensation Fund (IPFCF) and used for other state spending.

One notable improvement in the Senate’s version is a provision to ensure recognition of fiscal re-estimates related to Governor Doyle’s proposal to increase nursing home reimbursement rates by 2 percent each year over the biennium. The re-estimates were not included by the Joint Finance Committee.

During debate on the Senate floor, comments from legislators showcased drastically differing views on budget-related issues, especially health care.

While discussing health care reform, Senator Jon Erpenbach (D-Middleton) maintained that people have had enough of "excessive" profits of hospitals. During the hospital tax debate, Senators Alberta Darling (R-River Hills) and Dan Kapanke (R-La Crosse) both countered that there are no guarantees the proposal will receive Federal approval, and the cost of the tax will end up ultimately being passed on to patients. Senator Rob Cowles (R-Green Bay) added that a tax on hospitals was inappropriate and "nothing more than a shell game."

Budget discussions also continued in the Assembly, where Republican leaders have pledged to craft a budget without tax increases. Assembly Republicans have continued to meet in closed caucus this week to discuss proposals from individual budget working groups.

The Assembly is expected to vote on their version of the budget, which will be dramatically different than the Senate’s version, as early as July 10. From there, differences between the two proposals will be hammered out in Conference Committee before identical budget language meets approval by each house of the Legislature and is forwarded on to Governor Doyle for his line-item veto and ultimate signature. The entire process could last well into the fall.

Last week, Majority Democrats in the State Senate approved one of the most sweeping policy changes in state history into their version of the state budget. Called Healthy Wisconsin, the plan is a composition of three existing reform plans, all of which rely more heavily on state government to plan, administer and finance the health care system.

Under the proposal, the role of the insurance industry is significantly reduced, accounting for much of the plan’s projected cost savings. A new Healthy Wisconsin Authority, comprised of 16 members (almost one-third of which represent labor unions and no health care providers) will negotiate with health care providers and have very broad authority to "Establish and administer a health care system in this state…"

All would have coverage under the new plan, which is modeled after the health insurance benefits currently given to state lawmakers.

Though already generous by most standards, the Healthy Wisconsin plan would include even higher amounts of coverage for dental and mental health than the state employee plan.

There is also a fundamental change in how health care is financed. Rather than paying premiums to an insurance company, all employers would instead pay a new 10.5 percent tax on social security wages to the state. And instead of buying insurance directly or contributing towards a share of premium, individuals will be assessed 4 percent of their social security wages. Proponents argue that this is merely a "swap" of funding sources (new taxes instead of insurance premiums). Both taxes are projected to generate $15 billion – about $3 billion less than what the state now spends on health care.

"The plan as its stands spends about $3 billion less on health care than we spend currently," said WHA President Steve Brenton. "While that may seem like good news, and there is undoubtedly some administrative savings to be found by largely eliminating the insurance industry, you can’t simply cut or cap spending on something like health care, do little to harness demand-related cost, and expect the delivery system to keep humming along at the same nationally-recognized levels of access and quality. As Canada and Europe are coming to learn, there are trade-offs for global health care budgets that the public should be aware of and that warrant far more scrutiny and discussion."

The money from the payroll and income taxes would be held in a new Healthy Wisconsin Trust Fund and used to pay "health care networks" (a "provider driven, coordinated group of health care providers…" as defined in the bill) and providers. The amount of money available to fund the state’s share of the cost of the new health care system will be limited to the increase or decrease in revenue collected from these taxes. And just like Injured Patients and Families Compensation Fund and numerous other examples, the new "trust" fund could be raided to pay for other state spending.

The most positive aspect of the plan is its universal coverage. Healthy Wisconsin would cover just about every person in Wisconsin, which currently has one of the smallest uninsured populations in the country (around 10 percent). With few exceptions, all people under age 65 would be required to have coverage under the new plan. One of those big exceptions is the Medicaid population, which would not be mainstreamed into the broader covered population. Presumably, hospitals would still be reimbursed at 50 percent of cost for MA patients while likely seeing significant payment reductions from the insured population.

Both the plan and process have come under fire, starting with Governor Jim Doyle, who clearly is uncomfortable overhauling the entire health care system in order to extend coverage to the 10 percent that remain uninsured. Speaking to reporters last week, Doyle said that while covering the uninsured and making care more affordable are "worthy goals," he also wants to accomplish some "very practical" things.

The Governor has taken a more incremental approach to reform by focusing on providing Medicaid coverage to the relatively small number of Wisconsinites who are uninsured, bringing the covered population to 100 percent.

"I know there’s going to be a broad debate on all kinds of issues on health care, but I’m living in the real world here," Doyle said. "I put forth a plan that I’m hoping we’re going to get done in this budget that will extend affordable health insurance to about 98 percent of the people of the state."

When asked if the Governor would sign the proposal into law, Doyle spokesperson Matt Canter responded, "It was not included in the Governor’s budget bill." Doyle wields one of the most powerful veto pens in the country.

Healthy Wisconsin is backed by a number of advocacy groups and is being strongly pushed by labor unions. Business, on the other hand, is mostly shunning the proposal.

Small businesses will be hit hard by the plan, prompting the National Federation of Independent Business (NFIB) to come out in opposition.

"This proposal will discourage the creation and growth of small business, and place in jeopardy the jobs our small businesses provide every day which are essential to Wisconsin’s economic growth," Smith said. "This proposal and other so-called universal health-care reform initiatives are especially burdensome for small firms currently unable to provide a health insurance benefit and simply the wrong medicine for a complex problem."

In May, NFIB released the results of a national member survey in which small business owners identified cost as the single most important problem facing the health care system. According to the survey, most NFIB members are suspicious of programs that increase government’s role in health care, believe costs could be controlled if consumers are made more sensitive to those costs and that individual behavior that influence health outcomes should be included in the calculation of individual insurance premiums.

WMC, the state’s largest business organization, also strongly opposes the plan.

Others have raised concerns about the matter in which the plan was developed and analyzed. The vote came roughly 24 hours after the first and only public hearing was held on the plan. The actual legislation creating Healthy Wisconsin was released to the public at about the same time. Unlike previous reform legislation, the non-partisan Legislative Fiscal Bureau has not been asked to produce a summary of the plan. The only impact analysis provided thus far is contained in a PowerPoint compiled by the Lewin Group. Details behind the analysis have not been released.

Senate Majority Leader Judy Robson (D-Beloit) defended the plan and its inclusion in the budget bill. "Wisconsin’s working families are tired of paying skyrocketing health premiums and having claims denied while out-of-state drug and insurance companies report record profits. They’ve waited a long time for someone to stand with them and say ‘enough is enough.’ That’s exactly what Senate Democrats did today by passing ‘Healthy Wisconsin: Your Choice, Your Plan,’" Robson said.

Calling Healthy Wisconsin a "disaster for Wisconsin," Senate Minority Leader Scott Fitzgerald (R-Juneau) ripped the process used to adopt the plan in the Senate. "With no opportunity for public review or debate, Senate Democrats are trying to ram through the biggest policy change in state history…and (are) deliberately shutting the public out from this debate," Fitzgerald said on the eve of the Senate vote.

"No one would argue with the plan’s motivations and end goals, but this is our health care system we’re talking about. It has flaws, but in many quantifiable and measurable ways its also one of the best in the country," said WHA Executive Vice President Eric Borgerding. "Turning that system upside down will have enormous ramifications that should be explored and of which the public should be aware," he added.

The short-term fate of Healthy Wisconsin will be determined when the Senate and Assembly sit down to hammer out a compromise budget bill in conference committee. While it seems unlikely the plan will survive that process or be signed into law by Governor Doyle, the health care battle lines have been drawn and the differences in reform philosophy could not be clearer.

In a recent national survey of more than 1.5 million patients treated in more than 1,500 acute care hospitals across the country, Milwaukee hospitals ranked number one in patient satisfaction when patients were asked to evaluate their experience in the emergency departments in that city. Average time spent in the emergency room (ER) is up nationally with significant variations by state, but Wisconsin overall had the ninth shortest wait time in the country.

Overall patient satisfaction with emergency departments continues to rise as well, while communication remains the biggest patient priority, according to the 2007 Emergency Department Pulse Report: Patient Perspectives on American Health Care. Press Ganey Associates, Inc., one of the health care industry’s leading providers of measurement and improvement services, issued the comprehensive report.

"This report is the definitive source on the quality of ER care from the perspective of the American patient," said Dr. Melvin Hall, president and chief executive officer of Press Ganey. "With a strong grasp of the existing state of health care quality, health care providers are equipped to push quality improvement to the next level."

The report also ranked the metropolitan areas with a population of 500,000 or more with the highest levels of patient satisfaction about their ER experience:

1. Milwaukee
2. Indianapolis
3. Columbus
4. Oklahoma City
5. New Orleans
6. Detroit
7. Nashville
8. Cleveland
9. Kansas City
10. Chicago

"These cities represent some of the most competitive health care markets in the country, and their exemplary focus on the patient’s experience is setting a new standard for excellence," said Hall. "Hospitals are continuing to distinguish their emergency rooms by reviewing the entire patient experience and by seeing patients as an integral part of their own health care."

Wisconsin Hospital Association’s Bill Bazan, vice president, Metro Milwaukee, said the top ranking is partially attributable to the fact that, "Milwaukee hospitals have placed the needs of the patient first by developing systems and protocols that have literally transformed the delivery of care in our emergency departments citywide," he said.

In the future, according to Bazan, Milwaukee hospitals have plans in place to develop a 24/7 real time communication link among all ten hospital emergency departments in Milwaukee County.

"The recently announced emergency department linking project will greatly assist clinicians by putting pertinent medical information at their fingertips that can help physicians diagnose and treat patients even faster," Bazan said.

The goals of the Milwaukee County emergency department linking project are to reduce the wait time, provide continuity of care, and assist in the care planning process.

"The Press Ganey findings are consistent with other recent studies that show Wisconsin hospitals delivering some of the highest quality care in the country," said WHA President Steve Brenton. The Agency for Healthcare Research and Quality (AHRQ) recently ranked Wisconsin number one in the country based on the quality of care delivered to patients.

"Wisconsin hospitals are continuously reinvesting in their facilities and staff in order to give our patients the best care possible," according to Brenton. "We will always strive to improve, and these latest studies indicate those investments are paying off in high quality care and better patient experiences," he said.

The WHA Nominating Committee will meet in late August to consider nominating a WHA Chair-Elect, one or two At-Large members for the WHA Board and candidates for the Trustee Award and Distinguished Service Award (information on these two awards can be found on the WHA Web site).

WHA members interested in being considered for an At-Large WHA Board seat or the Chair-Elect position should contact either WHA President Steve Brenton at sbrenton@wha.org or WHA Nominating Committee Chair Mary Starmann-Harrison at msharrison@ssmhc.com.

Nominating Committee members for 2007 are:

Mary Starmann-Harrison, President/CEO, SSM Health Care of Wisconsin, Madison, Chair
David Fish, Executive Vice President, St. Joseph’s Hospital, Chippewa Falls
John Kosanovich, President/CEO, Watertown Memorial Hospital, Watertown
Terri Richards, Executive Vice President, Saint Joseph’s Hospital, Marshfield
Garith Steiner, CEO, Vernon Memorial Healthcare, Viroqua
Ford Titus, CEO, ProHealth Care, Inc., Waukesha
Tim Wick, CEO, Burnett Medical Center, Grantsburg
Gerald Worrick, President/CEO, Door County Memorial Hospital, Sturgeon Bay
Steve Brenton, President, WHA, Madison

"If you wait until the crisis is here, it’s too late to act. Have a plan." That was the advice hospital public relations professionals received from the speakers at the PR Issues Forum co-sponsored by the Wisconsin Hospital Association and the Rural Wisconsin Health Cooperative. The forum was aimed at preparing hospital public relations professionals for four of the biggest issues facing hospitals now, which included: union campaigns, billing and collection issues, public reporting, and the hospital tax.

Kris Baird, Baird Consulting, and Kevin Stranberg, Memorial Medical Center, Ashland, co-presented "How to Write a Strategic Communications Plan," emphasizing that it is both a plan and a philosophy that supports the organizations goals while providing focus and direction for all communication. It is also an organized approach to addressing specific issues as well as strategic goals.

First understanding how an issue is perceived through the eyes of key stakeholders is central to determining how best to communicate with both internal and external audiences. Baird cautioned that not considering multiple, and sometimes conflicting, viewpoints can lead to ineffective resolution.

WHA staff members presented information and current challenges that hospitals are facing, starting with the hospital tax presented by Paul Merline, vice president, government affairs. A discussion of the issues associated with publicly reporting quality measures (www.wicheckpoint.org), infection rates and adverse events was led by Dana Richardson, vice president, quality initiatives. Joe Kachelski, vice president, WHA Information Center, reviewed WHA’s PricePoint program and showed how www.wipricepoint.org can effectively be used to answer many questions associated with hospital charges from reporters and the public.

Rich Donkle, director of financial consulting services at RWHC, and Brian Potter, WHA vice president of finance, explained the new WHA Billing and Collection Guidelines and asked for audience input on how best to communicate these policies in their communities. Judy Warmuth, vice president, workforce, ended the day on a cautionary note about being aware of the signs of a union organizing campaign effort.

Mary Kay Grasmick, vice president, communications, said the day provided an opportunity for public relations professionals to learn how to plan for issues, rather than simply react. "It’s a step we have to discipline ourselves to take because in the long run, having a communication plan in tow will save time when we’re facing hard deadlines and there are multiple demands on our time," she said.

Here are some questions to ponder (and demand answers) that relate to the Senate Democrat’s massive health reform initiative (Healthy Wisconsin) that was included in their version of the biennial budget bill one week ago:

• Is the roll-out of this proposal reasonable given the magnitude of what is at stake? The fact that Senate Dems developed the proposal behind closed doors, released the actual statutory language the morning of a legislative hearing, and then incorporated the proposal within their version of the state budget bill 24 hours later has pretty much been universally panned. The notion of enacting a sweeping, fundamental overhaul of our health care system in a budget bill should give pause to even the most ardent supporters of single payer health care. This is not a change in fishing licenses, the naming of a bridge or some other budget bill minutia — this is a MASSIVE OVERHAUL OF OUR HEALTH CARE SYSTEM. Surely we can employ at least the same level of due diligence that is afforded legislation of much lesser impact.

• Where’s the Legislative Fiscal Bureau (LFB) Analysis? One would think that an initiative of this magnitude ($15+ Billion price tag for starters) would deserve analysis by the non-partisan and widely respected LFB. That hasn’t happened, some critics suggest by design. Instead, initiative supporters point to a paid consultant’s (Lewin Group) analysis that amounts to a PowerPoint replete with sound bites. Is there a real actuarial analysis that backs up the PowerPoint?

• Do the numbers add up? The total revenues raised by the new payroll tax fall short of financing current Wisconsin health care spending—more than $3 Billion short—despite purporting to cover hundreds of thousands of currently uninsured lives (a laudable goal) with a health benefit package that surpasses current benefits enjoyed by most Wisconsin citizens. Initiative supporters cite "administrative savings" and "primary care emphasis" as budget gap "fillers" without substantive documentation. What will the impact be if they are wrong?

• What about those fee schedules? The Authority created to run the new health system (no providers allowed) will set hospital and physician "fee schedules" for one of two plan options (the "open network" option) that will be available for program participants. Given the fact that the plan will be financed by a sum certain, global budget—the adequacy of the payment rates is problematic. Experience with Medicaid and Medicare fee schedules should be considered here. The pending Medicare physician payment "cut" due to "volume increases" is the type of thing that can happen with a global budget.

• What are the powers of the new Healthy Wisconsin Authority? At first glimpse, the Authority’s statutory power is breathtaking. Arguably, there is little that the new Authority’s governing board is not permitted to do…. The statutory language reads…"The Board shall establish and administer a health care system in this state…." The statutory language also empowers the Board to "establish, by rule, a program to contain health care costs in this state during any year in which the board determines that health care costs increase at a rate exceeding the national average of medical inflation…" It doesn’t get more carte blanche than that. Consider the Medicare physician payment issue described above.

• Why is Medicaid not "mainstreamed" in the plan? The Medicaid program is an orphan within the larger context of Healthy Wisconsin. Medicaid enrollment will soar under the plan due to federal waivers that, in theory, will provide coverage to several hundred thousand unemployed uninsured. But Medicaid payment rates are not pegged to either of the health plan options (networks or open network fee-for-service). So hospitals and physicians serving a disproportionate number of Medicaid patients will be at an economic disadvantage in "competing" to be part of regional networks established by the initiative. Given tight budgetary limitations, the networks are unlikely to subsidize Medicaid "cost shifting."

• Will Government Do Better? No one will argue that our health care system is not in need of fixing, starting with the rising cost and its many contributing factors. But as Healthy Wisconsin was being unveiled amid claims of how "irreparable" and "broken" our system has become, a number of independent studies were released lauding Wisconsin’s health care system for its quality and accessibility. In fact, the federal government’s Agency for Healthcare Research and Quality says Wisconsin’s hospitals provide the highest quality of care in the entire nation. Will the new government administered health care system do better? How will the plan truly impact the quality of our health care system? In the rush to pass this plan few seem interested in asking, and answering, this critical question.

The Doyle Administration has distanced itself from Healthy Wisconsin and instead urges support for Medicaid expansions designed to provide coverage for 98 percent of Wisconsin citizens. The Administration, along with some GOP leaders, also supports the rapid implementation of information technologies and health care transparency as promising initiatives that can improve delivery performance and efficiency. Those approaches, along with incentives for chronic disease management and employer based wellness initiatives deserve active WHA support. Healthy Wisconsin deserves more scrutiny.

Steve Brenton,
President

As discussed in the June 1 edition of The Valued Voice, beginning July 1, 2007, hospitals must deliver to their patients who are Medicare beneficiaries a new notification of hospital discharge appeal rights. Medicare beneficiaries who are hospital inpatients have a statutory right to appeal to a QIO for an expedited review when a hospital, with a physician concurrence, determines that inpatient care is no longer necessary. A revised version of the Important Message from Medicare that informs Medicare beneficiaries who are hospital inpatients about their appeal rights and other material concerning this requirement are available on the CMS Web site at www.cms.hhs.gov/BNI/12_HospitalDischargeAppealNotices.asp#TopOfPage.

On July 1, the Wisconsin Department of Health and Family Services (DHFS) placed a new version of Form DPH 43025, "Document of Anatomical Gift Authorization for Organ and Tissue Donation," on the DHFS Web site’s Forms Library. The new form can be downloaded at http://dhfs.wisconsin.gov/forms/DPH/dph43025.pdf.

The new form reflects slight modifications proposed by DHFS’s Advisory Committee on Organ and Tissue Consent to make the original form more user-friendly. The Advisory Committee was created in 2006 to provide recommendations to the Department of Health and Family Services on the need for a uniform form for hospitals, organ procurement organizations, tissue banks, coroners or medical examiners to obtain consent for organ, tissue and eye donation.

On Monday, June 18, Saint Joseph’s Children’s Hospital-Ministry Health Care in Marshfield welcomed State Representative Scott Suder (R-Abbotsford) and State Representative Amy Sue Vruwink (D-Milladore) to its new, NACHRI-designated Children’s Hospital, the third such hospital in Wisconsin.

The State Representatives met with staff and physicians and learned about Wisconsin’s newest children’s hospital.

This is the final call for quality and safety improvement project submissions to be included in the 2007 Wisconsin Quality & Safety Forum Project Showcase. Only those projects submitted by July 18 will be eligible to participate in the Project Showcase, be included on the CD-ROM of all submitted projects, be considered for offering a breakout presentation focused on your project, and be published in a future issue of the Wisconsin Medical Journal.

Showcase projects submissions are only being accepted via completion of the online submission form at www.wha.org/QSFshowcase. The online form is now available and all submissions are due to WHA by Wednesday, July 18, 2007. For questions about project submission, contact Brian Competente at 608-274-1820 or bcompetente@wha.org.

Projects that have not previously been submitted are eligible, as are new phases of a previously submitted project. A full project submission brochure, describing all submission criteria, is available on WHA’s Web site at www.wha.org.

Submissions for the 2007 Global Vision Community Partnership Award, presented by the WHA Foundation, are due one week from today, and must be received no later than 5pm on July 13, 2007. You can find the nomination brochure online at www.wha.org.

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 member hospital 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 Award will be presented at the WHA Annual Convention on September 20, 2007. Nomination forms can also be found on the WHA Web site at www.wha.org. For more information about the Award, contact Jennifer Frank at jfrank@wha.org or 608-274-1820.

The Northern Wisconsin Area Health Education Center is sponsoring a Hispanic/Mexican Culture Workshop August 15 at the Jefferson Street Inn in Wausau, Wisconsin.

Melina Kolbeck, Language Services Manager for Ministry Health Care Central Region and Medical Interpreter for Saint Joseph’s Hospital in Marshfield, is the presenter. Kolbeck has presented several Hispanic Culture workshops for health care providers and community-based organizations.

Space is limited to the first 75 registrants. This workshop fills quickly, and registration closes on August 1, 2007. Workshop information and online registration are available at www.ahecmanager.org/nahec/CurrentEvents.asp. For more information, contact Suzanne Matthew, Executive Director, Northern WI Area Health Education Center (NAHEC), at 715-849-2432.

Red Cedar Medical Center – Mayo Health System helped The Free Clinic of the Greater Menomonie Area open its doors to patients in March of 2005. Housed at the Medical Center, the Free Clinic sees up to 30 patients every Tuesday night. In 2006, the Free Clinic had 1,212 patient visits; 416 of them were new patients. Of the 1,324 volunteer hours given to the clinic, over 880 hours were donated by Red Cedar Medical Center physicians and staff. Furthermore, in 2006, providers referred 23 patients to their regular clinic practice at no charge.

In 2006, the Medical Center provided the Free Clinic with other assistance, including lab, radiology services, and prescriptions. The free clinic is funded by grants, in-kind donations and community fundraisers.

In total, RCMC gave over $485,000* to charity care. In addition to helping the Free Clinic, the Medical Center helped over 150 patients pay their medical bills through the Financial Assistance Program.

About the Free Clinic

The Free Clinic’s mission is to provide access to primary health care and preventive health education for the people of western Wisconsin who have no health care alternative. Clinic staff focuses on disease prevention. They strive to teach people to take care of themselves through education and health screening services.

"I decided to get involved because there is a gap in health care in the US. People aged 18-65 may not have access to health care," said Dr. James Walker, family physician at Red Cedar Medical Center and Free Clinic president.

Free Clinic services include health screenings, primary care, referrals for necessary health-related services, patient health education and referrals for necessary social services.

*All dollar amounts are at-cost charges

Submit hospital community benefit stories to Mary Kay Grasmick, editor, at mgrasmick@wha.org or call 608-274-1820.

Please note the following WHA directory changes:

Effective July 1, 2007, Osseo Medical Center has changed its name to: Luther Midelfort Oakridge.

Effective June 1, 2007, Barron Medical Center has changed its name to: Luther Midelfort Northland.

Effective May 1, 2007, Bloomer Medical Center has changed its name to: Luther Midelfort Chippewa Valley.

The Web site for these hospitals is: www.mayohealthsystem.org.

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