AgendaAn acronym that was unknown a little more than a month ago is now in common usage in health care circles across the country. The American Health Care Act (AHCA) was publicly introduced by House Republicans March 6 to replace the Affordable Care Act (ACA). That effort failed, but since its introduction, the WHA staff has dedicated hundreds of hours analyzing the impact the proposal would have on Wisconsin hospitals and health systems, the state’s Medicaid program and on residents of the state who purchase insurance on the exchange, especially those who are now receiving significant subsidies.
At the WHA Board meeting April 6 in Madison, WHA President/CEO Eric Borgerding said he, along with Wisconsin Medicaid Director Michael Heifetz, who was a guest at the WHA Public Policy Council meeting March 30, were invited to testify March 5 before the Assembly Committee on Federalism and Interstate Relations. Borgerding said his testimony focused on the impact health reform, including the potential repeal and replacement of the Affordable Care Act (ACA), would have on Wisconsin’s Medicaid program, the insurance exchange and on the "Wisconsin Model" of coverage expansion.
Borgerding told the Committee Wisconsin has a "proud tradition of high-quality, high-value and high access to health care."
"We are proud to represent hospitals and health systems that, together, have helped to build this reputation that is envied across the nation," Borgerding said. "Our strong interest is in working with you to support and sustain access to this high-quality care." (Read article on WHA’s testimony below.)
Good Progress Noted on WHA 2017 Goals
Several new initiatives were introduced in the WHA 2017 Goals, and Borgerding said solid progress is being made on those as well as the perennial issues, such as Medicaid, workforce and quality.
One newer initiative in the goals that Borgerding said is rising in importance is engaging physician leaders in WHA’s advocacy and clinical improvement agenda. Borgerding said the WHA Physician Leaders Council (PLC) has been a valuable resource in guiding the development of a stronger tie between the Association and physicians employed by WHA members.
Borgerding also previewed the Board Planning Session. He said for the past several years the Board has had a high level and ongoing discussion about who WHA is now and what, as an organization, it will be in the future. The perception of WHA’s brand continues to evolve, as evidenced by the Association’s ongoing work on an integrated physician agenda and its more recent post-acute care strategy. He said WHA is working with a well-known national branding expert who will be conducting research over the next two months, which will include surveying and interviewing Board members and others that will help inform a deeper discussion at the Board Planning Session in July.
American Health Care Act – what’s next?
Joanne Alig, WHA senior vice president, policy & research, provided an in-depth review of the process and policies contained in the American Health Care Act (AHCA). Alig said there is still uncertainty about the timing of any legislation, and while talks continue in Washington, WHA will continue to be engaged.
Alig said Wisconsin experienced a 38 percent decline in the uninsured rate. That, coupled with reductions in uncompensated care have been positive for Wisconsin. Although Medicaid and Medicare shortfalls increased during the same time, more than 195,000 people gained coverage from 2013 through 2015 in Wisconsin.
WHA has advocated any bill that includes changes to Medicaid financing must ensure equity among expansion and non-expansion states. Wisconsin expanded coverage to childless adults without receiving higher federal funding like many other states. At the same time, Wisconsin reduced Medicaid eligibility for about 60,000 adults in 2014, relying on income-based subsidies being available for low-income Wisconsinites to obtain private coverage.
Under the AHCA, Wisconsin could have received an estimated $70 million in "safety net" funding. But under Wisconsin’s Model for coverage, Wisconsin is spending about $280 million in state dollars for a population group for which other states get full federal funding. In short, the bill continued to create inequities for states like Wisconsin because it still did not recognize Wisconsin’s coverage expansion as a "full expansion."
WHA members have identified several concerns with the AHCA as it was structured, including that the level of the tax credits would be insufficient to ensure affordable coverage for low-income Wisconsinites. Wisconsin relied on the income-based subsidies available under the ACA to ensure access to coverage. Overall, Alig reported, the long-term viability of the insurance exchanges continues to be of concern nationwide, as evidenced this week with reports of Wellmark in Iowa announcing it will no longer participate in the insurance exchange. Wisconsin is fortunate to have more robust competition in its insurance markets, yet must continue to focus on the stability of the overall market. Alig reviewed the insurance market policies currently under consideration at the federal level.
WHA will continue to assess the developments in Washington and Madison to help shape the path to come.
Wisconsin State Budget & 2017-18 Legislative Session
Kyle O’Brien, WHA senior vice president, government relations, briefed the Board on the Governor’s proposed state budget and on the work WHA is doing to advocate for additional investments in the state Medicaid program through the legislative process. O’Brien provided an update on the Association’s advocacy work, including testimony being prepared for the Joint Finance Committee’s statewide public hearings that asks the Committee to use a portion of the $300 million lapse from the Medicaid program to fund several WHA budget priorities.
O’Brien reported WHA is working to increase the Medicaid Disproportionate Share Hospital (DSH) program, fund elements of the Rural Wisconsin Initiative related to health care, provide additional resources for outpatient mental health care and create a payment methodology for provider care coordination for the state’s Medicaid program.
Alig discussed what WHA knows about the Department’s Medicaid waiver request requiring premiums for able-bodied adults on the Medicaid program, along with additional co-pays and drug screening requirements for Medicaid enrollees. Alig said WHA would review the requirements once official documentation is made public and will comment to both the Walker Administration and members of the Legislature regarding the impact of these provisions on Wisconsin’s hospitals.
Along with the budget, O’Brien said WHA is working alongside a coalition of providers to advocate for Assembly Bill 146—legislation that allows dental hygienists to practice in additional settings without supervision by a dentist. The legislation passed the Assembly Health Committee March 29 with unanimous support from the Committee. WHA expects the legislation will be approved by the full Assembly next week.
WHA Post-Acute Care Work Group sets aggressive, achievable goals
Laura Rose, WHA vice president, policy development, described to the Board WHA’s work on issues related to post-acute care. Rose noted post-acute care is one aspect of WHA’s expanded policy agenda that looks beyond the walls of the hospital to include the continuum of care. The post-acute agenda is increasingly important to hospitals and health systems due to expanded application of alternative payment models such as bundled payments under which hospitals are responsible for patient outcomes over an episode of care. Further, integrated health systems are seeking partnerships with post-acute providers and are aware of the need to increase communication and collaboration between these providers and hospitals.
WHA formed a Post-Acute Care Work Group (P-AC) earlier this year. Rose said the Work Group will explore how WHA can help hospitals and health systems address their post-discharge challenges and opportunities. Their goal is to develop a package of achievable policy initiatives aimed at improving the ability of hospitals and health systems to provide or locate post-acute care for their patients.
The Work Group is focusing on post-acute care provided during the first 90 days (with special focus on the first 30 days) following discharge from an acute care hospital. Other areas of focus for the Work Group include improving access to appropriate, timely, high-quality and patient-focused post-acute care, especially for challenging patients; ensuring access, to the extent possible, to post-acute care in the patient’s community, or, for more specialized care, in their region; improving communication and collaboration between hospitals and post-acute care providers; educating hospitals on the importance of engaging with post-acute care providers and how they can affect post-acute care choices; and, removing non value-added regulatory barriers to post-acute care.
Charisse Oland, CEO, Rusk County Memorial Hospital, who is a member of the P-AC Work Group, noted rural hospitals are experiencing a decline in swing bed usage that may be attributable to bundled payment initiatives. She said hospital patients may be discharged to the home before they are ready, without receiving appropriate post-acute services. This can lead to readmissions. Sandy Anderson, regional vice president, Ascension/Ministry Health Care, noted a similar decline in swing bed usage and said it is important to gather data on the types of patients who are using swing beds.
Mark Thompson, MD, chief medical officer, Monroe Clinic, emphasized the importance of establishing training and education programs for skilled nursing facilities (SNFs) so they can become effective post-acute partners. He added that better data on SNFs is needed to assess their quality of care and other factors that are important to hospitals when selecting post-acute care partners. Kelly Court, WHA chief quality officer, said she has been invited to present on post-acute care quality at LeadingAge Wisconsin’s annual conference in May, where she will discuss many of the issues raised by Thompson.
Lange recognized for Board service
During his President’s Report, Borgerding recognized George Lange, MD, for nearly 15 years of service on the WHA Board. Lange, who has served as an ex-officio representative for the Wisconsin Medical Society, was an engaged participant not just at the Board level, according to Borgerding, but also on the WHA Physician Leaders Council and in educational programming.
"I looked through my emails from George over the past years and noticed the many times he complimented the WHA team and our Board for the work we do here," Borgerding said. "That is nice to hear from such a dedicated, committed member of our Board for so many years."
AHA Regional Policy Board 5 Report
AHA Regional Policy Board (RPB5) representative Sandy Anderson reported that at the last meeting, AHA President Rick Pollack discussed the national impact of the AHCA and described AHA’s advocacy roadmap. Anderson said AHA is developing an integrated physician agenda, as are other hospital associations around the country.
Borgerding said hospital associations are looking at the next generation of physician leadership and aligning their resources to meet the needs of physician partners.
"As health care changes, so do the relationships between the hospital/health system and the physician and between the hospital association and physicians," Borgerding said. "Everyone is talking about our changing role. In Wisconsin, we have had integrated systems for a long time so we have more experience and are further along the continuum that some other states."