New Assembly Health Committee
Over the years I have had several opportunities to talk about Wisconsin health issues with Representative Gregg Underheim. His selection as the health committee chairman in some measure reflects the many hours he has already booked enthusiastically grappling with the complexity of multiple health agendas.
His support to end both the Cost Containment Commission and hold hearings to end the Wisconsin Health and Education Facilities Authority will probably trouble quite different sets of people. Representative Underheim is a practical politician but one not limited by conventional wisdom. As rural health often suffers from traditional "one-size-fits-all" policies, the new chairman may particularly welcome thoughtful but previously untried policies specifically tailored to rural realities.
Representative Underheim's Committee held his first informational hearing last Tuesday. Testimony was limited to invitational speakers, who discussed health care networks in rural and urban parts of the state. I used the opportunity to talk about RWHC, its future plans as well as some of the upcoming public policy issues of greatest concern to rural communities as large HMOs and systems compete to capture their primary care referrals.
Look to the Dutch for Market Reform
" 'Americans know too little about the implementation of market reform strategies in other countries,' says Alain Enthovan, whose work on managed competition has formed the underpinnings of the most recent health system reforms in the Netherlands. 'The Dutch are farther down the road to managed competition than we [Americans] are.' What is critical to the success of reforms, both in the Netherlands and in the United States, are risk adjustment mechanisms to prevent cream skimming - that is, to prevent plans from selecting the best health risks and avoiding those predicted to cost more. In a health system based on up-front capitation, health plans see it in their interest to attract persons whose costs will not exceed the amount paid to the plan for their care."
"...the implementation of good risk-adjusted capitation payments is a long way from theory to practice. Nevertheless, cream skimming is the Achilles' heal of a wide range of market oriented strategies in health care that are being discussed and implemented these days in many countries. Therefore, efforts aimed at the prevention of cream skimming deserve a very high priority from both researchers and policymakers."
The above item is taken from: "Risk-Adjusted Capitation: Recent Experience in the Netherlands," Health Affairs (Winter, 1994).
Public-Private Data Partnerships
Monday, Wisconsin took two additional steps forward in the development of the state data base needed to support competitive markets:
David Kindig's Wisconsin Network for Health Policy Research released the report Building a Public Foundation for Health Plan Performance Information: Issues and Options by Nancy Cross Dunham, the program's deputy director. She discusses key issues related to the use of a public data to evaluate private health care plan and system performance as well as the options available to the state government in expanding current public-private collaborations.
Jo Musser held an invitational meeting (at the new UW School of Business, Grainger Hall) to discuss "Meeting Future Data Needs.. A Public-Private Exchange." An eclectic cross section of folks with a specific interest in the topic spent the day with a process facilitator working through a number of key questions.
The advantages of expanding public-private cooperation were identified as improving the state's (1) outcomes/information, (2) data standards, as well as (3) the development of a level playing field. The three primary disadvantages noted were (1) the risk of developing inflexible standards rather than encouraging an individual plan's best performance, (2) problems related to confidentiality and proprietary information and (3) the cost for individual corporations to change already existing data systems.
Two Incomplete Visions of Government
"The two men who preside over Congress (Gore & Gingrich) are in a striking way, mirror images of each other. ...in their search for a successor to government as usual, they symbolize approaches that exactly reciprocate each other: a market-oriented public sector versus a non-market-oriented private sector. But in doing so, they each evade the very question they claim to be addressing: Where should we locate the borders between public and private?"
"Market-oriented bureaucrats and good-Samaritan citizens are wonderful things. But when they have to serve cunningly self-interested client groups, or stunningly self-destructive dependent individuals, the borders between the public and private sectors may still not be where they should. A public sector run according to market principles may yet perform way too many functions, while that part of the private sector activated by non-market principles may well be far too small to take over those functions."
(Andrew Stark, New York Times, 1/5/95)
Two Wisconsin Leaders Step Up
The following is a belated notice and congratulations for two already prominent Wisconsinites that have recently been elected to top national positions by their peers.
Representative Steve Gunderson has been elected co-chair of the Rural Caucus in the U.S. House of Representatives, the source in recent years of most legislative initiatives to assist rural health. (La Crosse area folks need to start and fund a grass roots "draft Gunderson" campaign to counter his stated intent to resign at the end of this term.)
OCI Commissioner Jo Musser has been elected recording Secretary of the National Association of Insurance Commissioners which in turn means she will be their vice-president in '96 and president in '97. Currently she also serves as the chair of NAIC's ERISA working group.
Rural Medical Centers In Action
The value of the rural medical center model was demonstrated recently as a RWHC member was cited in a State survey for not having two separate directors of nursing, one each for acute and long-term patients under the same roof (many, two ends of the same hall way).
When the question was asked, "isn't this what we are trying to address with the rural medical center initiative," further consultations were had and the State citation was withdrawn. Until we obtain the necessary federal waivers, it is likely that this situation will still receive a federal citation but the instance demonstrates in concrete terms what we are trying to accomplish with this major regulatory restructuring.
Save EACH/PCH Baby In Bath Water
I am often asked about "how to keep the ER without the 'hospital' " by rural hospital people in and outside of Wisconsin. As part of Wisconsin's alternative hospital model development, the Rural Medical Center project, we have looked closely at this issue and to the best of my knowledge the EACH/PCH waiver is the only option permitted by law, albeit currently limited to a few selected states.
There are a variety of perspectives about why EACH/PCH has floundered and has now been recommended for elimination in the President's budget. (I am not at this time writing to advocate for or against continuing the grant funding associated with this program.) My greater concern is that we are at risk of loosing an important piece of flexibility if authority for the EACH/PCH waiver is also eliminated.
Regardless of what happens to EACH/PCH funding, I believe it is absolutely critical to the ongoing development of a strong rural health infrastructure that we keep and expand to all states the option of an EACH/PCH Medicare waiver. This would allow rural communities the option of designing a delivery system that maintains an emergency room as part of a cluster of local services in situations where a traditional inpatient unit can no longer be sustained.
Rural Health Clinic Change On Horizon
Bill Finerfrock, Executive Director of the National Association of Rural Health Clinics was at the last meeting of the national Advisory Committee on Rural Health. During his discussion with the committee it became clear that significant changes in this increasingly popular program should be anticipated. It is expected that provider based rural health clinics (RHCs) will have a cap placed on their cost based reimbursement similar to that already placed on independent RHCs.
The new rules are seen as a reaction to general federal and state budget restrictions coupled with the explosive growth of RHCs in the last few years. Aggressive, proprietary chains seen as using RHC's to skim paying patients from local providers along with urban based systems use of RHCs for outreach colonization have also increased the call for reform.
Finerfrock speculated that the provider based and independent rural health clinic, a distinction based on ownership, would be replaced with a three part categorization based on the level of services rendered:
Level I: Basic Primary Care
Level II: Basic Primary Care with Ancillaries
Level III: Emergency Room Type Capabilities
New WI DOD Head Backs Rural Health
The new Secretary of the State Department of Development, Bill McCoshen, gave his unqualified support for promoting rural health as a key component of rural economic development in a recent meeting with the Rural Health Development Council. His visit with the Council, only weeks after taking office, along with a clear and forceful statement of how he intended to support the Council's work was particularly welcomed following the less than whole hearted support of some earlier department leadership.
Slow Start For Med School Dean Search
At the first meeting of UW's Search Committee for a Medical School Dean, UW-Madison Chancellor David Ward charged the committee to find a Dean who would be both visionary and manager, responsive to multiple internal and external constituencies. The interests of primary care and rural health were given significant emphasis. However, the challenges faced by the Medical School in southern Wisconsin's price competitive market received almost no attention in the Chancellor's remarks.
Of a particular note, was the announcement that the Board of Regents had appointed three Regents to "oversee" this search process. The nature of this oversight has not yet been established but apparently this unusual action is the result of Regent concern re the circumstances surrounding the "resignation" of the prior Dean.
From the perspective of most private or public organizations, this search process has not gotten off to a quick start. The need for a search has been known for over four months but announcement of the openiong is only now being distributed nationally. Whether or not intentional, it appears that the interim Dean has the maximum additional opportunity to make his mark before being compared with other internal and external candidates.
Medical Schools Not Off The Hook
Our medical schools must continue to address the shortage of physicians affecting many Wisconsin communities. A recent study by the UW Medical School ("Wisconsin's future requirements for generalist physicians," Wisconsin Medical Journal, January 1995) questioned the need to increase the supply of primary care physicians for the year 2015. The study makes a reasonable case for questioning some of our long range planning assumptions about the total number of physicians that we should be training. But while the study notes the need to improve the distribution of physicians throughout the state it understates the critical role to be played by medical schools.
Nationally, medical schools have found innovative ways to increase the number of their graduates that choose to work in rural and inner-city communities. Wisconsin must continue to hold its two medical schools accountable for similar initiatives. At least two common interventions need to be expanded in Wisconsin - recruiting qualified students from rural and inner-city communities and getting selected medical training off-campus into underserved communities.
WI MD From Amazon Seeks To Talk
Dr. Linnea Smith will be briefly back home in southern Wisconsin, May 12 to 20, from her work at the Amazon Medical Clinic in Peru. She is trying to identify potential speaking engagements, particularly if even a modest honorarium can be given to help her clinic. Call Dan or Judy Peterson at 608-767-3727 if you would like more information.
Paper Planes Bring Success
I rarely use this space to hawk another company's services but I know you all expect here a little of the unexpected. A friend from my Kellogg days, Chris Musselwhite in North Carolina, founded Discovery Learning, a group becoming well known for innovative human resource and organizational development.
One product is "Paper Planes, Inc., a simulation that quickly reveals barriers to organization success while providing insights into creative solutions. the simulation enables participants to experience the powerful effects of system re-engineering and process improvement. Employees of a plane manufacturing company have the opportunity to sell as many planes as they can manufacture, provided the planes meet customer specifications. As an employee, each participant has a specific role in the production process, which consists of a traditional functional division of labor."
"The simulation enables participants to experience the powerful
effects of system re-engineering and process improvement. participants
gain first hand knowledge about:"
Paper Planes is available for delivery through Discovery Learning or other trainers. For more information contact:
Discovery Learning, Inc.
P.O. Box 20304
Greensboro, NC 27420
FAX 910 273-4090
Typical Washington Overstatement
Story heard on my last WDC trip: "U.S. Senator Patrick Moynihan pulled out all the stops as he spoke against medical education reform during last year's debate - 'This is hubristic. This invites the wrath of the gods. This invites the death, the closing of a great moment of medical discovery, unprecedented on Earth. In the history of medicine, no such thing has happened in the advances in the last 30 years made in the United States. This is, if I may say - and I do not wish to introduce first amendment problems to this debate - but this is a sin against the Holy Ghost.' "
A Rare Washington Understatement
While Newt Gingrich suggested to the American Hospital Association that the Health Care Financing Administration should be abolished, the director of federal affairs for the American Association of Retired Persons suggested that the idea might be considered premature.