Transcript State Issues/Budget Update

HFMA Summer Conference
State & Federal Legislative Update
May 22, 2015
Jenny Boese
VP-Federal Affairs & Advocacy
State Issues/Budget Update
2015 WHA Advocacy Day
• 1100 attendees total
• 650 go to Capitol to
discuss…
• Medicaid DSH
• Workers Comp
• Licensure Compact
Disproportionate Share Hospital
What is DSH?
• Reimbursement program
• Created in last biennial budget
• Provides reimbursement based on
Medicaid volume at hospital
• $30 million
• Expires end of this FY (June 30)
The Case For DSH…
• Wisconsin’s Medicaid reimbursement is second
worst in nation (AHA analysis)
• WI hospitals reimbursed at 65% of cost
• Creates a “hidden health care tax” of $960 M
• Cost-shifts burden onto employers (higher h.c.
costs)
Step 1: Governor’s Budget
• Advocate directly to Governor for his budget to
include DSH funding
•
•
•
•
•
WHA briefs Governor’s health care policy team
WHA briefs DHS Deputy Secretary
WHA, System leaders meet with Governor Walker
Letters Sent to Governor Walker
HEAT Members sent close to 900 emails to
Governor
Results!
• Governor’s budget included:
– Hospitals one of very few areas of budget not cut
– Full cost-to-continue funding for Medicaid
– DSH program renewed for two more years
• $71.75 million AF; $30 million GPR
HOWEVER…
–
–
–
–
–
Massive cuts to UW System ($300 million)
Legislators want K-12 Aid (JFC provided add’l $200 M)
Legislators don’t like bonding for transportation
Legislators want more tax cuts, Walker says #1 priority w/ new rev.
Medicaid Cost-to-Continue – “MA crowding out other priorities”
Step 2: Legislature
• Dozens of meetings with legislators, more to come
• Meetings held with Leadership, more to come
• Focus Now: Joint Finance Committee Members
Senate JFC Members
Assembly JFC Members
Sen.
Sen.
Sen.
Sen.
Sen.
Sen.
Sen.
Sen.
Rep.
Rep.
Rep.
Rep.
Rep.
Rep.
Rep.
Rep.
Darling, Co-Chair – R
Olsen, Vice-Chair - R
Harsdorf - R
Vukmir – R
Tiffany – R
Marklein – R
Taylor – D
Erpenbach - D
Nygren, Co-Chair – R
Kooyenga, Vice-Chair - R
Loudenbeck - R
Knudson – R
Schraa – R
Czaja – R
Taylor – D
Hintz - D
State Budget: Update
Big Picture
- Keep in mind: Gov budget included DSH budget for two more years
- Joint Finance Committee has jurisdiction right now and is methodically
moving through entire budget, line-by-line
- Large items left until the end, including Medicaid funding, K-12,
transportation, etc.
WHA, Hospitals Priority for DSH? Prospects?
- Keep in the budget, make the program permanent
- 9 Assembly GOP members submitted motions to make DSH permanent
- Sen. Vukmir has been a leader in supporting permanent DSH
- Rep. Nygren states on permanent DSH; “I think we have the support so
we will try to move forward to make it permanent.”
- If this happens, not a small victory – considering revenue estimates
Next Steps:
• Joint Finance Committee
– Finishes votes on every provision in budget
– Right now heading it the major fiscal programs (MA, DOT…)
– Then will take one last vote on entire budget
• Full Assembly, Senate review/debate/vote
– June
• Final budget sent to Governor Walker
– He has broad veto powers
– Done by June 30
Main Goal:
Make DSH program
permanent
Behavioral Health Priorities
Development of Priorities
- Medicaid Workgroup developed areas of need, especially
with care coordination
- WHA Board approved agenda based off of the MA
Workgroup recommendations
What do the proposals look like?
- Behavioral Health Care Coordination Pilot
- Psychiatric Consult Reimbursement Pilot
- Online Mental Health Bed Tracker Program
Behavioral Health Care Coordination Pilot
Design of the Pilot
- Hinges on an integrated care setting and care coordination
activities
- Requires ED services, outpatient psych, outpatient primary care,
inpatient psych, general inpatient hospital and care
coordination/navigation services. Entity would need to provide or
subcontract for social services coordination after discharge.
- DHS would consider applications that test alternative payment
models
Fiscal Estimate of the Pilot
- $1.5 million All Funds ($600k GPR) over three-year pilot
- DHS has discretion to award pilots
Psychiatric Consult Reimbursement Pilot
Design of the Pilot
- Inter-professional psychiatric consultation reimbursement model
- Provides payment to psychiatrists providing consultations to
primary care providers
- Services current not reimbursed under Medicaid
- Could result in reduced number of clinic visits and ensures
patients receive services for mild to moderate mental health
needs
- Idea is to test one or more different models (i.e. lump sum, CPT
payment, etc)
Fiscal Estimate of the Pilot
- $500,000 All Funds ($200k GPR) over three-year pilot
- DHS has discretion to award pilots
Online Mental Health Bed Tracker
Design of the Program
- Online system to find real-time information on psychiatric beds
- Instead of calling psychiatric hospitals or units to find
availability, the system would allow online access to bed
availability
- Follows a MN model, which is a voluntary system for hospitals
to provide information and run by the Minnesota Hospital
Association.
Fiscal Estimate of the Program
- $50,000 startup costs and $30,000 annual operating costs
- $110,000 GPR Cost in FY 2015-17
Behavioral Health Priorities
Behavioral Health Care Coordination Pilot
Psychiatric Consult Reimbursement Pilot
Online Mental Health Bed Tracker
$600,000 GPR
$200,000 GPR
$110,000 GPR
Total: $910,000 GPR
WHA continues to work with Rep. Mary Czaja and Sen.
Leah Vukmir to effectuate this in budget process.
Other Major Budget Issues
Worker’s Compensation
Advocating against the Governor’s proposed recommendation to shift the
program from DWD over to the OCI
FQHCs
Joining WPHCA’s advocacy to oppose the proposed savings at DHS
resulting from a switch to PPS reimbursement from cost-based
WRPRAP/HPLAP
We have been told by the Senate Co-Chair’s office that several members
have requested the Governor’s budget change to save this program.
Feel confident it will happen.
State Employee Health Insurance
JFC passed (14-2) required legislative committee oversight for changes
to the state’s employee health insurance program. This was a WHAbacked amendment.
Interstate Physician Compact
Policy Overview
- Provides a process for expedited multi-state licensure
- Maintains authority for disciplinary action and medical practice
requirements in state
- Wisconsin bill draft requires that only compact licensees are affected
by the bill.
Compact Advocacy
- Rep. VanderMeer and Sen. Harsdorf are lead authors
- Over 70 co-sponsors to date, including key health care members
like Rep. Knudson, Rep. Kolste, Rep. Riemer, Sen. Carpenter and
Sen. Erpenbach
- Bill might be in Committees on Health or Interstate
Affairs/Government Operations
Wisconsin & the ACA
Wisconsin ACA Review: 2 Decisions
• Chose Federal Health Exchange
• Chose not to accept federal Medicaid $$,
But, instead…
 Moved individuals (parents/caretakers) with income
between 100-200% FPL off of Medicaid and into Federal
Exchange
 Expanded Medicaid (without taking Federal $$) to cover
childless adults with income up to 100% of FPL ($11,670
for a single person)
Coverage/Enrollment
As of March 2015
• Net 146,000 newly enrolled in Medicaid (childless adults with
income <100% FPL)
• 67,500 no longer receiving Medicaid compared to March 2014
(mostly parents/caretakers, some children)
o Of those disenrolled, 54% moved into Exchange or other private
insurance; Leaves 27,000 without insurance (based on DHS data from
June 2014).
• 207,349 selected a health plan on Federal Exchange (89%
receiving premium assistance) during open enrollment in 2015
Exchange Enrollment - 2015
Wisconsin
National*
207,349
8.84 million
Bronze
Silver
Gold
Platinum
n/a
n/a
n/a
n/a
21%
69%
6%
3%
< age 18
18-34
35-44
45-64
6%
26%
15%
53%
11%
28%
17%
47%
New enrollees
Re-enrollments
44%
56%
53%
47%
Total Enrollees
Official HHS data, March 10, 2015, ASPE Report, *States Using the FFM Platform
Exchange Enrollment - 2015
Total Enrollees
207,349
Percent with premium tax credit
89%
Average monthly premium before premium tax
credit
$440
Average monthly premium tax credit
$315
Average monthly premium after tax credit
$125
Average percent reduction in premium after tax
credit
72%
Official HHS data, March 10, 2015, ASPE Report, *States Using the FFM Platform
The Courts & ACA
Challenges
On March 4, 2015, the U.S. Supreme Court heard
arguments in the case, KING, DAVID, ET AL. V. BURWELL,
SEC. OF H&HS, ET AL.
Issue: Are federal tax subsidies available for purchase in
a federally-facilitated exchange?
Timing: decision in late June/early July
24
King v. Burwell & Wisconsin?
“Millions at risk of losing coverage in Supreme Court case”
Washington Post 2/17/15
• 207,000 enrolled via
exchange in WI
(89%=184,800
receiving subsidy)
• WHA engaged at state
and federal level
25
King v. Burwell - Issues
Enrollment: WI alternative to full Medicaid Expansion assumes those disenrolled from
Medicaid, plus all adults with income 100-133% FPL, have option to be covered through
the Exchange.
Loss of Affordability: Average premium in WI = $440/month, without subsidy.
Loss of the subsidy dollars affects people in every county. Avg subsidy in WI = $315/month
– that’s about $714 million in federal funding annually.
Higher Risk/Higher Cost: Without subsidy, coverage would become unaffordable -- many
become exempt from the individual mandate.
 The ruling would not impact other insurance requirements (guaranteed issue, rating
rules) = higher risk in the market as healthier individuals no longer purchase
coverage, and higher premiums for those who remain.
 Some insurers could exit the individual market altogether, leaving some consumers
with no feasible option for purchasing coverage.
 Studies have estimated that premiums could increase as much as 45%-75% for
those remaining.
Uncertainty: Ruling expected in June/July 2015 – in the middle of the 2015 benefit year.
Grace period??
26
King v. Burwell – Solutions?
1) Federal legislation – continue subsidies
-- Individual and employer mandate? Essential health benefits?
-- GOP split on this issue
2) Section 1332 Waiver (ACA innovation waiver)
3) State Exchange
- create own - timing
- feds certify (EO) unless state opts out
- contract with private vendor
- contract with feds?
27
Exchange Planning for 2016
Expected Date (2015)
Activity
April 15 – May 15
Insurers submit QHP (Qualified Health Plan*) applications
Filing 2 sets of rates (pending outcome of KvB)
May 18 – June 26
CMS reviews QHP applications.
June 29-June30
CMS sends first correction notice to insurer
July 10
Deadline for revised data to be submitted to CMS
July 13 - August 12
CMS reviews corrected applications
August 25
Final insurer data submission; Final deadline for state approval
August 26 – September 16
CMS completes re-review
September 21 – September 25
Insurers sign agreements with CMS; QHP data finalized
October 8 – October 9
Countersigned Agreements sent to Issuers
November 1, 2015 – January
31, 2016
Open enrollment
28
Federal Update
Sustainable Growth Rate – Review
What is it?
SGR cuts stopped 17 times and counting
These “patches” mean cuts elsewhere, like
to hospitals, systems…totaling $150 B
Current SGR patch expired 03/31/15
Where are we at…????
H.R. 2 – SGR Repeal/Replacement
 Repeals SGR
 Replaces with a system of stable updates
o 0.5% FY 2015-FY2019;
o 0.0% FY 2020-FY 2025
o 0.25% (non-APM), 0.75% (APMs) in FY 2026 and beyond
 Incents value (MIPS program, APM)
o
o
o
Merit Based Incentive Payment System
MIPS consolidates PQRS, EHR, Physician VBM
Performance threshold established (0-100) based on four
domains: Quality; Resource Use; EHR; Clinical Practice
Improvement
o
Beginning 2019, MIPS allows for +/- of: 4% in 2019; 5% in
2020; 7% in 2021; 9% in 2022 and beyond
H.R. 2 – SGR Repeal/Replacement
Extends CHIP funding 2 years
Includes important Medicare extenders like
MDH, LVA, therapy cap exceptions process,
Work GPCI among others
Two midnight – extends prohibition on postpayment audits through Sept. 30, 2015
Costs $212 Billion, $70 Billion is offset
o
Provider cuts relate to PPS (coding/documentation), post-acute
H.R. 2 – SGR Repeal/Replacement
 U.S. House approves 392-37
• Yes: Ryan, Duffy, Kind, Moore, Pocan, Ribble
• No: Grothman, Sensenbrenner
“As a leading state in the health care value movement, WHA has

U.S.
Senate
long
supported
theapproves
repeal of SGR92-8
and replacing it with a model that
rewards high quality, high value…in the context of a truly permanent
• Yes: Senators Baldwin and Johnson
solution to the SGR, WHA believes the package as a whole fulfills a
hard-fought effort to achieve a very important, long-term goal.
- Eric Borgerding, statement on final passage
May DC Agenda
SGR “thank you”, King
v. Burwell, 340 B, 96
hours, Value/Quality
Protecting 340 B
•Action
Drug
discounts
forStories
DSH, CAHs
Item:
Real Life
• Savings help “stretch scarce
WHAFederal
is assembling
a series
examples
of how Wisconsin hospitals are
resources
asoffar
as
using
these 304B
savings to
extend
services and increase access. If you
possible,
reaching
more
eligible
use the 340 B program, please think about examples of how your use
providing
this patients
program toand
benefit
patients more
and provide those to WHA.
comprehensive services”
- Provide 1-2 paragraph narrative of program
• Drug industry believes program
- Provide
of patients
grownnumber
too large,
beingimpacted
abused (if applicable) or extent of
on your region, community, types of patients etc
• impact
Regulation/guidance
is at OMB
- Consider finding a patient to provide a personal story about the
right now,
expectedthey
outreceived
by
impact
of care/services
summer
• Agenda
WHA
will provide
itemthese
during
examples
Hill visits
to our Congressional Delegation as
examples of how the 340 B program is working as intended!
Medicare Cuts
• Trade Adjustment Assistance (TAA)
– Sequester increase
•
•
•
•
Letter to Chair Ryan
Discuss with Ways & Means staff, Ryan staff
Discuss during all Hill meetings (May)
Continue to oppose additional Medicare
reductions
Other Priorities?
• Critical Access Hospitals
– 96 hour rule (HR 169/S 258)
– Watch for any mileage/distance proposals
– Rural GME flexibility (Delegation letter to CMS)
• RAC reform legislation
– HR 2156 (Medicare Audit Improvement Act)
• Stopping other cuts!
– Site neutral, bad debt, GME…
Offset Options that Continue to Come Up…
 Site Neutral Payments
o Targeted for years
o Equalizes difference between settings




IME/GME Cuts
Bad Debt Cuts
Rural Cuts
And always others…
All total, several cuts targeted
in the past would amount to
$2.77 billion in cuts over 10
years to Wisconsin hospitals.
Other Issues to Watch:
 Graduate Medical
Education
• WHA 8-page
letter to House
E&C
 ICD-10
• WHA letter
• DC advocacy
State/Federal Government
State/Federal Government Impact
Time period of heightened fiscal pressures
Legislators read the papers, magazines
Legislators hear from constituents
Legislators hear from other interest groups
Legislators control massive budgets (and there’s
never enough money)
Legislators regulate entire industries
All lead to legislation and regulations
Why Advocacy?
• Many changes occurring now are the direct
result of legislation, regulations
• When looking at an industry environment,
one of the external forces that impacts
health care (especially now) is government
• Advocacy is a lever to use within that space
WHA’s Approach to Advocacy
Hospitals
Education &
Advocacy
Team
WHA’s “grassroots” network of over 2,400
advocates
•
• Program provides timely information on
legislation impacting you, your hospital
• Regular opportunities to be involved
• Tools to become educated, to speak up:
…Grassroots Action Center
…Capitol Connection newsletter,
…HEAT Grassroots Handbook
…Invite-only webinars
HEAT Action Alerts!
• WHA develops multi-pronged
“grassroots” strategies on
important legislative issues
• HEAT Action Alerts are one
part of strategy
• WHA targets specific legislative
committees, regions or
legislators with HEAT Alerts
• Goal is to always bolster our
lobbying efforts in Capitol, show
legislators hospitals care about
issues enough to take action.
Strategies For Using HEAT Alerts…
• To show legislators there is local support on
hospital issues. (People vote, WHA doesn’t.)
• To show the magnitude of that local support.
• To stand with legislators who go out on a limb
on issues.
• To demonstrate an issue is important.
Example: HEAT Alert/Support DSH
• All total, 900 emails from across the state
sent to Governor to include DSH in his
budget bill.
• 900 emails lent support to our
comprehensive lobbying and advocacy
strategy on DSH.
Result: Governor included DSH in his budget.
Over the Years
Governor signs Rural Health Care Access Into
Law (2010)
HEAT grassroots
advocates sent well over
5,000
emails
Governor
signs
“Jandre”
Into
Law
(12/13/13)
Governor
signs
MentalBill
Hall
Care
Coordination”
Into Law (04/08/14)
to state/federal legislators,
helping build ground
support for priority issues!
Governor signs “DHS 124” Bill Into Law
(04/08/14)
Advocacy Day 2015
Largest ever!
1,100 hospital leaders, employees, trustees, volunteers,
corporate members in Madison!
Advocacy Day 2015
Does it make a difference?
Outcomes already…
• 650 attendees went to the Capitol to meet with
legislators on key issues like DSH!
• Issue: “Cosponsor” Interstate Physician Compact
legislation
• Result? To date, 70 legislators have signed on!!
That’s over half of the legislature
Take-Aways:
The health care environment is impacted by government
legislation and regulations. You can play a role.
1.
Advocacy is one of the levers you can impact
2.
HEAT is the program that unites, mobilizes
3.
Advocacy Day is a statement to legislators
“We in America do not have
government by the majority. We
have government by the majority
who participate.”
Thomas Jefferson
Jenny Boese
VP-Federal Affairs & Advocacy
608-268-1816
[email protected]