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November 21, 2014 Volume 58, Issue 47
Sen. Vukmir Tours Milwaukee Safety Net Hospitals
Aurora Sinai, Wheaton St. Joseph’s provide frontline
perspective
Sen. Leah Vukmir (R-Wauwatosa) recently toured Milwaukee’s two
safety net hospitals—Aurora Sinai Medical Center and Wheaton
Franciscan-St. Joseph campus—to see firsthand the role these
hospitals play in their communities. Vukmir is a certified pediatric
nurse practitioner and educator with more than 25 years of nursing
and teaching experience.
“We appreciate Sen. Vukmir taking time to visit Aurora Sinai
Medical Center to learn about the unique challenges faced by
Milwaukee’s last downtown hospital. Aurora Sinai serves a critical
role in Milwaukee’s and the state’s health care infrastructure, as
Medicaid patients make up nearly 50 percent of our annual volumes.
In 2013, Aurora Sinai’s Medicaid shortfall totaled -$28 million and
we provided $4.4 million in charity care,” said Carolynn Glocka,
president, Aurora Sinai Medical Center. (continued on page 6)
U.S. Sen. Baldwin Leads Bipartisan Letter Urging
President Not to Cut Rural Hospital Funding
Green Bay Press Gazette Editorial: Rural hospitals play
important role
U.S. Sen. Tammy Baldwin (D-WI) led a bipartisan
group of 27 senators, with Sen. Mike Crapo
(R-ID), in support of rural hospitals and the
value they provide to communities across
the country. Baldwin and 26 other senators
expressed opposition to provisions the President
has previously included in his budgets. Those
include reducing Medicare reimbursement levels
for critical access hospitals (CAHs) and removing
Tammy Baldwin
the “critical access” designation for any hospital
within 10 miles of another hospital.
“I am deeply concerned by this proposal from the Obama
Administration. If enacted, these policies would compromise access
to health care and weaken rural economies in Wisconsin and across
the country. I fear these proposals could even force many rural
Wisconsin hospitals to shut their doors—causing a ripple effect on
our economy and leaving many without access to care,” Baldwin
Guest Column
Team-Based Care in
Wisconsin: Moving it Forward
By George Quinn, WCMEW executive
director, and Chuck Shabino, MD, WHA
Chief Medical Officer
In the WHA 2011 report, “100 New
Physicians a Year: an Imperative for
Wisconsin,” the projected shortage
of physicians in 2030 was based, in
part, on the assumption that teambased care would leverage physician
resources by involving other caregivers
in health care delivery, therefore
limiting the projected shortage. One
recommendation in the report was
to have stakeholders in Wisconsin’s
health care workforce investigate
team-based care to better understand
how it will impact the future of care
delivery.
Acting on that recommendation,
the Wisconsin Council on Medical
Education and Workforce (WCMEW)
earlier this year established a
workgroup on team-based care.
Their first goal was to create a
forum that would showcase existing
team-based care teams and provide
a foundation for understanding the
culture necessary to make these
teams successful. That idea grew
into the “Building a Culture for
Patient-Centered Team-Based Care”
conference held November 12, 2014,
which drew 200 attendees and
attracted 30 team presentations.
The workgroup outlined five critical
questions that were addressed at the
conference:
Q. What is the state of team-based
care in Wisconsin?
A. It is important to note that
team-based care is not limited
to ambulatory/clinic-based care.
(continued on page 5)
(continued on page 7)
Board Chair: Ed Harding, president/CEO, Bay Area Medical Center, Marinette Editor: Mary Kay Grasmick, VP Communications - [email protected]
5510 Research Park Drive P.O. Box 259038 Madison, WI 53725-9038 P (608.274.1820) F (608.274.8554) www.wha.org
House Ways & Means Release Comprehensive Draft Medicare Hospital Bill
Draft proposal includes “Bay State Boondoggle” fix, RAC fixes, 96 hour fix
This week the U.S. House Committee on Ways & Means released a 150-page draft proposal, known as
the Hospital Improvements for Payment (HIP) Act of 2014, which would make multiple changes to the
Medicare system for hospitals. The Wisconsin Hospital Association continues to analyze the provisions
and will provide comments to Wisconsin’s Congressional Delegation and the Committee.
Several very positive provisions included in the bill have been the focus of WHA’s advocacy, including:
• “Bay State Boondoggle” – to correct a provision included in the health reform law that provides
Massachusetts hospitals hundreds of millions of dollars in bonus payments—at the expense of
nearly every other state in the country. Close to two dozen state hospital associations, including
WHA, have come together seeking to reverse this manipulation of the Medicare payment system.
• “96 Hour Fix” for critical access hospitals (CAHs) – to harmonize Medicare’s Conditions of
Payment with its Condition of Participation. The two have differing 96-hour requirements,
believed to be a drafting error dating back to the enactment of the CAH designation itself.
• Medicare Data – allowing for entities like the Wisconsin Health Information Organization (WHIO)
to have access to Medicare data
In addition, the proposal includes multiple provisions to address problems with the Medicare Recovery
Audit Contractor (RAC) program. Those provisions include:
• Creation of a new Hospital Prospective Payment System to deal with shorter stays. (Short stays
have been a target of the RACs and have resulted in an overwhelming backlog in the federal
Medicare appeals process.)
• Additional six-month extension of RAC audit moratorium (through September 2015)
• RAC provisions, including limits on RAC reviews, allows for rebilling, and more RAC monitoring
• Requires notice to be provided to Medicare beneficiaries if in observation 24 hours or more
A few other provisions included in the bill are:
• Requires hospitals, including CAHs, to report “assessment data” on conditions, functionality,
cognitive function, living situations/access to family, etc.
• Makes some adjustment to the readmissions program related to dual-eligibles, socio-economic
factors.
There are also provisions related to price transparency, among others. To read the full draft log onto:
http://waysandmeans.house.gov/news/documentsingle.aspx?DocumentID=397845
Watch for more information in The Valued Voice in the coming weeks.
Common and Complex ICD-10-PCS Coding Scenarios Focus of WHA Webinars
The October 1, 2015, deadline for ICD-10 implementation allows Wisconsin hospitals and health systems
the opportunity to take full advantage of the additional time to prepare for the ICD-10 transition. In
early December, WHA is offering two webinars featuring well-known coding expert Lynn Kuehn. Kuehn
will focus on helping coders, coding managers, and members of a hospital or health system’s ICD-10
implementation team better understand how to work through common and more complex ICD-10-PCS
coding scenarios, to be better prepared for on-time and efficient implementation.
On December 2, Kuehn will lead a webinar focused on making root operations selections and assigning
all characters for the codes included in 10 common ICD-10-PCS cases encountered at hospitals and
health systems of all sizes. This interactive webinar will be a great way to work through some of the
most common cases you’ll encounter after October 1, 2015.
(continued on page 4)
The Valued Voice -- Page 2 -- 11/21/14
President’s Column
Wisconsin’s Strong, Vibrant High-Performing Rural Health System under Siege
Twenty years ago a small group of rural, upper Midwestern lawmakers led by Iowa Sen. Chuck Grassley
and former Iowa Congressman Jim Nussel championed legislation that transformed rural health care and
saved hundreds of rural hospitals from closure. They convinced colleagues to allow individual states to
define small rural hospitals as “necessary providers”—organizations deserving slightly higher Medicare
payments because of their “necessary” function of providing accessible health care services to their
communities.
Today Wisconsin has 58 critical access hospitals (CAHs), nearly all of which owe their designation to
the “necessary provider” criteria. Every one of these hospitals has strengthened local health delivery.
And as a group, these hospitals have ensured access to hundreds
of thousands of individuals and families all across Wisconsin at
Today Wisconsin has 58 Critical
a marginal additional cost that amounts to “erasure dust” in the
Access Hospitals (CAHs),
context of the larger Medicare program.
nearly all of which owe their
designation to the “necessary
Other supplemental payment programs like Low Volume
provider” criteria.
Adjustment, Sole Community Provider and Medicare Dependent
Hospital each provide a few extra dollars to slightly larger rural
hospitals that serve a disproportionate number of older and often times sicker patient populations.
Unfortunately, the CAH program in particular has been under siege recently via Obama Administration
budget proposals and OIG reports that attack the “necessary provider” criteria and instead suggest
mileage requirements. Similarly, CMS last year announced a new rule that undermines a 20-year
precedent related to length of stay in a CAH bed. If a patient stays longer than 96 hours, payment is
denied. This is an astounding and baffling example of regulatory fiat
This is an astounding and
usurping clinical decisions.
baffling example of regulatory
fiat usurping clinical decisions.
It is particularly fitting as we celebrate Rural Health Day to recognize
Wisconsin’s strong rural delivery system and remind lawmakers
to not tamper with low cost, essential payment programs that are foundational to achieving rural
health care excellence—a situation in which Wisconsin rural residents today receive health care from
organizations whose clinical infrastructure and performance is equal to that in more urban settings.
Special thanks to Sen. Baldwin (see www.baldwin.senate.gov/press-releases/us-senator-tammy-baldwinleads-bipartisan-support-for-rural-hospitals) for standing up for rural health care!
Steve Brenton,
President
Mark Your 2015 Calendar for the Wisconsin Rural Health Conference
Glacier Canyon Lodge at the Wilderness Resort in Wisconsin Dells *** June 17-19, 2015
More information will be available in spring 2015 at www.wha.org.
The Valued Voice -- Page 3 -- 11/21/14
Quality Residency Hits the Mark
The quality residency program
formed by Wisconsin Hospital
Association (WHA) and the Rural
Wisconsin Health Cooperative
(RWHC) is a big success with new
quality managers. The program is
designed to engage new and novice
hospital quality improvement
directors in a two-year track of
education, leadership training
and networking. The program
was enhanced in September to
accommodate additional residents
and allow veteran residents to
attend individual program sessions.
Quality Residency Program participants
Thirty-six residents recently
completed the fourth session of
their ten-session program. The modular format of the program is designed to allow new applicants to join
at any time.
Each session begins with a learning needs assessment and then content is designed to the needs of the
current residents. Faculty for the program includes a combination of staff from WHA, RWHC and external
quality experts.
”The residency is a very rewarding experience for both the residents and instructors. The high level
of resident participation and collaboration, and the value
of customized curriculum has exceeded everyone’s
“Thank you for giving me the tools I
expectations,” said Kelly Court, WHA chief quality officer.
needed. Your classes have helped me
tremendously in my new job role.”
- Jerene Managan,RN,
Riverside Medical Center
Jerene Managan, RN, case management coordinator at
Riverside Medical Center who participated in the program,
said, “Thank you for giving me the tools I needed. Your
classes have helped me tremendously in my new job role.”
The WHA Foundation and Wisconsin Office of Rural Health are helping fund the program to keep it
affordable for participants. Contact Kelly Court at [email protected] or Beth Dibbert at
[email protected] for an application package and additional information.
Continued from page 2 . . . Common and Complex ICD-10-PCS Coding Scenarios Focus of
WHA Webinars
On December 9, Kuehn will focus on teaching participants to improve critical thinking skills by tackling
more complex ICD-10-PCS cases. Kuehn will provide tips on how to differentiate between root
operations groups and similar individual root operations. Intended as the capstone for the webinar series,
this session will assist attendees in making decisions to code 10 common but more complex ICD-10-PCS
cases.
Full information on both sessions and online registration are available at: http://events.SignUp4.net/14WICD-10-PCSSeries. Encourage your team to gather for this webinar series and learn together through one,
low-cost registration.
The Valued Voice -- Page 4 -- 11/21/14
Continued from page 1 . . . Guest Column: Team-Based Care in Wisconsin: Moving it Forward
Teams range from population-targeted teams such as those that target the unmet needs of veterans in
rural Wisconsin, to specific clinical processes such as coordinated coagulation therapy. There is great
diversity in how the team-based approach is applied. In addition, there is a desire to connect with others
interested in team-based care. Future meetings could be structured around this idea. Finally, there is an
increasing body of knowledge suggesting that team-based care is a critical element of success in the
quality and effectiveness in care delivery. This knowledge needs to be widely disseminated.
Q. Why are teams formed?
A. The most often-mentioned reasons for creating teams were to improve quality of care and patient
safety while making better use of resources; in other words, enhancing the value of care being provided
to patients. Team-based care also has benefits to those providing the care. It enhances professional
satisfaction and minimizes burnout. It provides a more even sharing of workload, and it builds cohesion
across work groups.
Q. What are the key ingredients needed for teams to be successful?
A. A shared vision of the mission, roles and responsibilities is critical to the team’s success. In addition,
organizational support and leadership are necessary for teams to have staying power. Leadership is
demonstrated by a clear indication of caring; a willingness to listen in a non-defensive way and seek
input by encouraging team members to speak up about issues that concern them and take action on
those concerns; a facilitation of communication and teamwork; and, by enhancing information sharing.
The right skill sets, attitudes and knowledge base are also keys to success. Skills mean how to do a
certain task, attitudes are represented when individual team members know why a task is important
and they are willing to carry it out, and knowledge is understanding what to do in the appropriate
circumstance.
Finally, team members display characteristics such as adaptability, situational awareness, good
interpersonal relationships, coordination and communication, and good decision-making. These skills and
characteristics can be built through training and experience.
Q. What are the barriers to team-based care?
A. Organizational culture, while a key ingredient for success, can also be a barrier if the culture does not
provide the leadership, empowerment and encouragement of self-learning and autonomy necessary for
teams to thrive.
Limited time and resources were also repeatedly mentioned as barriers, as well as the regulatory and
payment environment.
Q. How do we as a state move team-based care forward?
A. The next step will be to continue sharing best practices in team-based patient care. WCMEW is
helping to create the educational resources and networking opportunities that will be helpful to hospitals
and health systems as they implement new models of care.
The WCMEW workgroup will continue to analyze data on team-based care outcomes, including quality
measures, the cost of care and patient and team-member satisfaction, and make the information available.
Finally, WCMEW will follow this first conference with others that will involve more networking and
sharing of best practices, showcasing innovative models and skill building in areas such as coaching and
mentorship.
The Valued Voice -- Page 5 -- 11/21/14
Continued from page 1 . . . Sen. Vukmir Tours Milwaukee Safety Net Hospitals
“Despite these financial constraints, we remain committed
to helping our patients access high-quality and cost-efficient
care through medical homes and many unfunded case
management and supportive services. We look forward to
working with our legislative leadership next session to find
ways to further improve the health of our patients while
increasing efficiencies within government health programs
that support this population,” said Glocka.
During her time at Aurora Sinai, Vukmir was able to see and
understand the passion and commitment by the hospital,
Dawn Porter, interim NICU manager and Sen. Vukmir
physicians and nurses for treating the often complex needs
discuss the highly-specialized care provided at Aurora
of their economically-disadvantaged patients. She was
Sinai’s neonatal intensive care unit
able to hear from several veteran OB nurses about their
pride in being able to successfully provided care to an opiate-addicted newborn. It was later relayed to
the Senator that the cost of that care was over $400,000, for which Medicaid reimbursed the hospital
$40,000. Vukmir was also able to learn about the mental health care-related problems in the Milwaukee
area. In fact, she was told there were three behavioral health patients with posted security each waiting
for a bed to open or for the arrival of the Milwaukee County crisis team.
While visiting Wheaton Franciscan St. Joseph
campus, Vukmir heard similar examples of the
role the hospital played in their community.
In order to address the medical and even
socio-economic needs of their patients, the
hospital has taken a comprehensive, multifaceted approach. This approach includes case
managers, social workers and a primary care
clinic at the hospital among other strategies.
All of this work has led to what is known as a
52 percent “stick rate,” which is the rate that
individuals without a primary care doctor then
establish one and receive follow-up care there.
Deb Standridge, right, and several emergency room physicians discuss
with Sen. Vukmir, second from right, the complex issues surrounding ER
usage, lack of medical homes and Medicaid reimbursement.
Deb Standridge, Wheaton’s North Market CEO, had this to say about this complex problem:
Dr. Nena Stanley, left, discusses the medical home/primary
care clinic established at Wheaton Franciscan-St. Joseph
campus with Sen. Vukmir. Regarding her passion to
help, Stanley said, “I am at the right place. I am making a
difference here.”
“Wheaton Franciscan - St. Joseph has the busiest
single hospital emergency department in Wisconsin, on
track to experience a record 90,000 patient visits this
year. We attribute the increase in part to newly-insured
childless adults now eligible for Medicaid. Because an
estimated 50 percent of our emergency department
visits could take place in a primary care setting at a
lower cost with better continuity of care, we work hard
to link patients to a medical home in the community or
on our St. Joseph campus.”
The overarching goal at both Aurora Sinai and Wheaton
Franciscan - St. Joseph is to help patients access the
appropriate level of health care and better manage
chronic conditions, avoiding emergency visits and
hospitalizations. The biggest challenge is that current Medicaid reimbursement doesn’t cover the full cost
of delivering the care, or the cost of additional case management support. That shortfall on every single
Medicaid patient combined with the increase in volumes is unsustainable in the long term.
The Valued Voice -- Page 6 -- 11/21/14
Continued from page 1 . . . U.S. Senator Baldwin Leads Bipartisan Letter Urging President Not
to Cut Rural Hospital Funding
said. “Critical access hospitals play a vital role providing access
to medical services, as well as economic security and jobs to rural
communities. That is why I am leading a bipartisan effort to stand
up for rural hospitals, their patients, and the local economies they
help support.”
The Wisconsin Hospital Association (WHA) and Rural Wisconsin
Health Cooperative (RWHC) both expressed appreciation to Sen.
Baldwin for her efforts and her long-standing commitment to
Wisconsin’s rural hospitals.
“The Wisconsin Hospital Association greatly appreciates Sen.
Baldwin’s efforts on behalf of rural Wisconsin hospitals,” said WHA
President Steve Brenton. “Rural and critical access hospitals provide
essential access to care across much of our state and the nation. We are grateful for those in Congress
who continue to stand up for our rural providers against ill-advised policy proposals.”
“Rural Wisconsin hospitals are very appreciative of the senators for their efforts in opposing unnecessary
and arbitrary efforts by the Administration that would jeopardize rural access to critical health services,”
said Tim Size, RWHC executive director. “Wisconsin has a number of critical access hospitals that would
likely be affected by the Administration’s plans. These hospitals are critical in the services they provide
to their communities and deserve our country’s support.”
The Green Bay Press Gazette editorialized on the joint Senate letter, expressing strong support for the
role rural hospitals play in their communities.
“We agree with the senators’ sentiment because we believe these rural hospitals play an important role
in their communities, both medically and economically. If this sounds familiar, it’s because it is. Just
over a year ago we urged Congress to defeat a similar proposal…Each [hospital] faces challenges in
accessibility, lack of health care providers, and a growing number of underinsured residents, according to
the National Organization of State Offices of Rural Health…We’re all for saving money in Medicare, but
not at the expense of health care for those who live outside of urban areas.”
Read the signed Senate letter: www.baldwin.senate.gov/download/?id=6c1ca798-ab56-44ae-aed2c6494b912d9e&download=1
Read Sen. Baldwin’s press release: www.baldwin.senate.gov/press-releases/us-senator-tammy-baldwinleads-bipartisan-support-for-rural-hospitals
Read the Green Bay Press Gazette editorial: www.greenbaypressgazette.com/story/opinion/
editorials/2014/11/19/reduce-funding-rural-hospitals/19299247/
The Valued Voice -- Page 7 -- 11/21/14