After 15 Years, A Name Adjustment
You may have noticed a difference in the above logo; after fifteen years we made a move from hospital to health. Our reason is simple - to better reflect the broader role of the Cooperative as RWHC rural hospitals (or rural medical centers) diversify their mission.
Progress On Medicare MD Equity
With the assistance of David Kindig in setting up the appointment, the President of the Wisconsin State Medical Society, Rich Roberts, met this month with HCFA administrator, Bruce Vladeck, to advocate for Wisconsin's application to have the state's eleven Medicare physician payment localities reduced to one.
Mr. Vladeck indicated that Wisconsin's application would be helped if they could show some support within the losing counties, not necessarily overwhelming support as indicated earlier. Consequently, the SMS Board has initiated a process to immediately poll their members in the seven counties that would no longer receive higher payments.
The amount rural physicians are currently underpaid has been estimated by Jane Thomas at the Rural Health Development Council. A negative number indicates those counties in which physicians are disadvantaged by the current eleven locality system. A positive number indicates those counties in which physicians are currently advantaged and would lose by a change to a single payment locality:
Competition, Or Is It Collaboration?
Cooperation and competition have never been mutually exclusive concepts and are now becoming an increasingly prevalent part of our daily work. For example, the Cooperative is asking the Federal Department of Justice to review our proposal to negotiate on behalf of our hospital members, fair contracts with large and powerful HMOs without being accused of violating an antitrust law. In this context, antitrust laws are seen as a possible limitation to developing rural health systems.
However, rural views on antitrust are complex as we also see the benefit to our own interests of strong antitrust enforcement. We have long been concerned about the predatory practices of the large health care and insurance systems. An interest in rural health requires a better understanding of both sides of this issue.
We have some guidance in the Statements of Enforcement Policy and Analytical Principles Relating to Health Care and Antitrust issued by the U.S. Department of Justice and the Federal Trade Commission on September 27, 1994:
"Because multiprovider networks are relatively new to the health care industry, the Agencies do not yet have sufficient experience evaluating them to issue a formal statement of antitrust enforcement policy or to set out a safety zone. The Agencies recognize, however, that guidance on antitrust issues raised by multiprovider networks is of vital importance to the health care industry." The Agencies went on to "describe the analytical principles that they apply in evaluating multiprovider networks under the antitrust laws, and address antitrust issues commonly raised in connection with the formation and operation of such networks: integration, joint pricing and joint marketing, market definition, competitive effects, exclusivity, exclusion of providers, and efficiencies."
In Wisconsin and nationally, the antitrust suit brought by Blue Cross against Marshfield has been the focus of substantial attention. Regardless of the ultimate outcome of this case, whether or not a rural area such as northern Wisconsin can or should be encouraged to sustain fully competitive markets is just one example of the policy discussions we should be having outside of the courtroom.
I believe that a challenge with this issue is related to deeply held
but conflicting values - we seek unduplicated use of scarce resources and
the "integrated", "seamless" delivery of health care
but we also prize consumer choice and competitive markets. Depending upon
which perspective one chooses, either a negative or positive spin can be
put on the following:
A legal doctrine, state action immunity, is widely seen as the major
rural health policy alternative or supplement to antitrust enforcement.
While it is not clear to what extent state laws based on this doctrine
can forestall a federal antitrust action it is known that the immunity
can only apply to activities that are subject to "active, substantive
state supervision." In conversations with the Wisconsin Justice Department,
the following questions arose about the refinement and implementation of
the State's current ability to forestall antitrust enforcement through
the use of a Certificate of Public Advantage (CPA) statute:
The whole policy debate yet to happen in Wisconsin around the implementation of our existing CPA statute quickly needs to address these and other questions. Several Wisconsin legislators are already beginning to draft amendments to our current (non-implemented) CPA statute so time is of the essence if we are to be of assistance.
RWHC Competition Is Outmigration
As part of the Cooperative's preparation to ask for an antitrust review from the Federal Justice Department, we have been looking at where people who live in the RWHC market area receive their care for services typically available at a local RWHC hospital. The results were encouraging - substantive use of RWHC facilities, minimal intra-RWHC competition and enough outmigration to show that people have an alternative.
Limits Of The New Federalism?
The following is excerpted from an article by E. J. Dionne Jr. in the
Washington Post, 3/7/95:
"If you think that the wave of the future is to package virtually all federal programs into block grants and ship them off to the states, consider how the public would react to repealing Social Security, giving the money now being spent on it to state governments and letting them decide who would get what. An absurd idea, you say? You're right, and you have just acknowledged the limits of the New New (or is it New, New, New?) Federalism that inspires many in this Congress."
"The truth is that for all the high-toned arguments, federalism and "the genius of the states" are almost always invoked more as tactics than as principles. Indeed, liberals and conservatives have shifted to and fro on federalism, depending on their needs at a given moment."
"The federalism debate is confusing because there are two distinct
American traditions on which partisans can draw. There is the happy "laboratories
of democracy" theory, which sees states as experimenting with all
manner of reforms. On this notion, the states try different things and
the best ideas can be adopted by other states and, where appropriate, by
the federal government. This tradition comes mostly from the Progressive
period after the turn of the century, when innovative states laid the groundwork
for national reforms."
"The less happy tradition is the "states' rights" proposition that was used by southern states first to defend slavery and, later, segregation. It took federal action to overturn both, and this bred into liberals a deep skepticism of devolutionist arguments. If the states were so wonderful, anti-devolution liberals ask, then why did it take the federal government to vindicate the rights of African Americans, women, the handicapped, the elderly, immigrants and the poor?"
"Almost all Americans are devolutionists in that they don't much like big, centralized bureaucracies. That's a healthy instinct. But an instinct is not a policy. John J. DiIulio Jr. and Donald F. Kettl of the Brookings Institution point out in Fine Print their new and supremely useful little book on the Republicans' contract, that "devolution is but a slogan." National policy, they rightly argue, is already entangled in a mishmash of competing federal, state and local administration. The danger of the current devolutionary thrust in Congress is not that it will lead to genuine devolution, but that it will merely use devolution as a public rallying cry for complicating that mishmash even more. Surely that's not what anybody voted for last November."
Medicare Share Continues To Slide
Medicare's share of charges paid to Wisconsin hospitals continues to slide downward. Data is from the Wisconsin Hospital Association for the third quarter of each of the last five years.
AHA Rep Visits With RWHC Board
John Supplitt, Director, AHA Section for Small or Rural Hospitals accepted Harold Brown's invitation on behalf of the Cooperative to meet with us on the 7th to discuss several concerns:
The most recent RWHC discussion re our understanding of AHA policies was stimulated by my attendance in November at a small invitational meeting with HCFA and several others sponsored by the Federal Office Of Rural Health Policy. The agenda was to explore ideas re Alternatives to Historical Costs in Pricing Health Care Services for Rural Areas. I was there as a member of the DHHS Secretary's National Advisory Committee on Rural Health. The AHA was represented by Debra Williams.
The observation for a number of us was that just about every time an issue related to the remaining inequities in Medicare payments was raised, the AHA representative aggressively disagreed that there were in fact any remaining problems.
We agree with the AHA position that the adequacy of payment for all hospitals is a growing problem but what is the AHA position re what we believe to be remaining Medicare rural-urban payment inequities ?
Specific areas of concern re ongoing discrimination against rural communities include:
Statewide Personnel Plan Proposed
Wisconsin's supply of primary care providers is inadequate to meet our current and future needs. The Cooperative has made a contribution of $5,000 as a challenge to other networks to support a new project of the Consortium for Primary Care in Wisconsin. If the Consortium can raise $35,000, it will initiate a long overdue planning process between those who employ primary providers and those who educate them. This nine month process will result in a highly publicized state work-force plan intended to focus the efforts of both the legislature and our academic institutions in meeting our needs for primary care physicians, physician assistants and clinical nurse specialists.
RMC Statute Out Of Budget Bill
While the Republican leadership removed "policy" items out of the State Budget Bill, the statutory language to fully implement the Rural Medical Center was booted out and now requires a separate bill. To try to get us back on track, Senator Schultz has already initiated the process of having a separate bill drafted. It is not expected that there will be opposition to this bill or that the basic work plan within the Division of Health will be delayed.
The Budget Bill was missing all changes made by the Rural Medical Center Advisory Committee in its last three meetings of 1994. Those changes have been identified and forwarded to Dale Schultz to be put in the new bill.
RWJF Project On Rural Networking
The Robert Wood Johnson Foundation is funding a quick project to assess policy issues and technical assistance needs for rural health networking and then do a "hill briefing" for Congress. I'll be with them in Washington, D.C. on 4/3-4 to address three issues from both a state and federal perspective:
I would very much appreciate be able to take your ideas and suggestions. (V: 608-643-2343; F: 608-643-4936; E: Tim.Size@together.org)
Earthquakes, Floods & Locusts
While the west coast has had more than its fair share of natural disasters, its loss may be our gain as Fred Moskol seems finally to have seen the error of his ways and it is hoped will be returning to our more forgiving country side after his leave from the WI Office of Rural Health.
Netscape: The Surfers' Choice
From DoIT NOW, 2/95 issue by Kurt Foss:
"For those who want to browse all those new home pages on the [World Wide] Web, there has been an important development: The dramatic acceptance of and apparent preference for one graphical interface to the World Wide Web (WWW) -Netscape. With Netscape's point-and-click navigation, one can easily explore the multimedia world of images, sound, video clips, and hypertext documents. You can download Netscape via anonymous FTP from ftp.mcom.com. For more information, including a Netscape FAQ and online handbook, go to http://home.mcom.com on the Web."
I'm using it and it makes the once highly touted Mosaic dowdy by comparison.