Eye On Health

Monthly Commentary from the Executive Director - March 9th, 1996

Policy Break For Presidential Year Politics

As we get closer to the November election, national political energies shift away from any pretense of concern about developing sound public policy and focus on skewering the other guy, or guy's wife. But a quick look at the trend of opinion polls shows Bill Clinton is not called the Come-Back Kid for nothing, with or without the help of the Republican primaries. In contrast is the steady increase in negatives for Hillary Clinton; for the first time, she is now showing higher disapproval ratings than her husband.

However, it doesn't seem that the apparently partisan attacks on the First Lady are having the assumed hoped for effect of hurting Bill Clinton's election year ratings. The same public attitude that didn't accept her health reform role (perceived by many as too close to being a non-elected "co-president") may work both ways, tending to shield President Clinton from most of whatever criticism sticks to her.

Technical Note: Bill Clinton's numbers are a summary of over 300 polls; each point on the graph represents the average of the most recent four polls. The intermittent number of polls asking about the First Lady's unfavorable rating are not averaged. Data is through 2/27/96 from the internet site Politics USA operated by the National Journal and the American Political Network; their address is:


A Dole-Powell Ticket

This week Governor Tommy Thompson sounded very definite when he told a number of us that Dole would ask Colin Powell to be his running mate and that Powell would accept. While a dream team for many, I suspect neither Pat Buchanan or Bill Clinton would be particularly pleased. In the event this scenario doesn't occur, he admitted to being in the next tier of possibilities; his public position was that an analysis of electoral college politics led him to believe that several other Governors were more likely to be tapped.

On a separate note, he agreed to provide national leadership for equitable Medicare HMO payments once his welfare and Medicaid reform agenda is resolved by Congress. Depending upon who you ask, this may not be any time soon.

Lust & Fear Enhances Gridlock

Just when we thought Congressional gridlock couldn't get any worse, consider how less cooperative Congressional House Democrats will be with any legislation as they eye the possibility of getting back majority status.

"The Democrats need a net gain of 20 seats to regain control of the House, and are growing increasingly confident about their chances. A packet titled Building a Democratic Majority was distributed Tuesday to members and pointed out that since 1946, the average 'swing' per election cycle is 24 seats. Moreover, the document notes that "landslide elections such as the 1994 midterm are regularly followed by an 'adjustment,' where the losing party [one election] cycle reverses these losses in the next election." PoliticsUSA, 2/29/96

Not Whether Rules But What Rules

Like the surgeon who sees surgery for every ailment, I might argue that understanding the politics of government is critical to understanding health care in general and rural health in particular. The just released They Only Look Dead, Why Progressives Will Dominate The Next Political Era by E. J. Dionne should be required reading for anyone responsible for a health care organization's development of alternative scenarios.

"The central issue in American politics in 1996 and beyond is not whether new rules will be written but what those rules will be and the extent to which they will make it easier or harder for the average American­p;and especially those in the Anxious Middle­p;to prosper in a new era." While Dionne argues on behalf of left leaning progressives more than the right leaning populism of Pat Buchanan, his book has the timely benefit of making sense of Buchanan's explosive arrival into the current Republican mud wrestling. Molly Ivans, the irreverent Fort Worth Star-Telegram writer stated (with some precognition) on the book jacket: "May all the too certain Republicans of the Universe, along with all the uncertain Democrats, read, learn and laugh."

From the book: "Our time combines social change with moral crisis, enormous economic opportunity with great economic dislocation and distress. It most closely resembles the period 1870 to 1900, which led to the Progressive Era. Then, as now, Americans were looking to forge new rules to realize a new era's potential while containing its threats. Progressives have always understood that while governments in authoritarian societies oppress, governments in democratic societies have the capacity to liberate. Unlike state socialism or pure, unregulated capitalism, the American Progressive tradition takes a pragmatic view of the possibilities of both government and the economy."

Actuaries Refute Insurer's Main Argument

Any chance at credible opposition to the bipartisan Kassebaum/Kennedy health care reform bill S. 1028 by the Health Insurance Association of America (HIAA) ran into brick wall built by their own technical experts, the American Academy of Actuaries. They concluded in a final report to the Senate Labor and Human Resources Committee that the bill would have minimal impact on the cost of individual health insurance premiums barring additional legislation by individual states. The following is from an Academy press release:

"Even in states that enact legislation, the Academy stated that premium rates would increase only 2 percent to 5 percent. This increase would occur over a period of three or more years, depending upon how quickly a state legislature responded to the federal health care legislation... Wilson Wyatt, Jr., executive director of the Academy, said, 'Individual health insurance premium increases under the Kassebaum/Kennedy Health Care bill have been subject to a great deal of debate. By analyzing the details of the legislation, the Academy work group, consisting of several prominent actuaries, has provided the American public and elected officials with unbiased premium increase estimates.' "

"Three Destructive Trends"

The following is taken from "Three Destructive Trends" by Daniel Yankelovich in the Fall, 1995 Issue of Kettering Review. He is chairman of Daniel Yankelovich Group, a firm that tracks social trends:

"The American people is in a foul mood. People are frustrated and angry. They are angry and off balance. They are pessimistic about the future and cynical about all forms of leadership and government. In 1992, the voters, in their frustration, threw out the Republicans. In last November's elections, in their frustration, they threw out the Democrats:"

"The United States and other industrialized democracies find themselves in the grips of powerful forces that no one understands very well and for which societies are almost totally unprepared. The forces are not bad in themselves, but they do require adaptations that our society is not making, at least not yet. My fear is that if we fail to adapt, the present mood will harden into class warfare, generational warfare, exacerbated racial tensions, polarization and political extremism, demagoguery, and instability as we careen from one over simplistic solution to another."

The trends are, first, that our economy is becoming increasingly lopsided: the majority of Americans are failing to participate in the benefits of economic growth. The second trend is that core values that Americans share in common are growing weaker. And third, a serious disconnect is growing between America's leadership and the citizenry.

Rural Medical Centers, Update

A Health Care Financing Administration (HCFA) $450,000 research and demonstration project grant included funding for a contract between a consortium of three rural Wisconsin hospitals, acting in cooperation with the Wisconsin Hospital Association and the Rural Wisconsin Health Cooperative (the Consortium), and WDHSS to implement a unified set of administrative rules, statutory language and pilot surveys to institutionalize the rural medical center as a new provider type.

In order to move the implementation of rural medical centers to the next phase, Wisconsin's Administrator of the Division of Health, Kevin Piper has asked the Health Care Financing Administration the following key questions:

"What steps must WDHSS take to obtain federal recognition of the rural medical center provider category for purposes of Medicare/Medicaid reimbursement?"

"What steps must WDHSS take to ensure that payment under Medicare and Medicaid are forthcoming to providers for services provided at or by a rural medical center?"

"If HCFA determines that it will not recognize the rural medical center as a reimbursable provider type, will HCFA nonetheless authorize reimbursement under Medicare and Medicaid for the actual health care services provided at a state-licensed rural medical center?"

"If HCFA determines that it will not recognize the rural medical center as a reimbursable provider type, will HCFA nonetheless recognize the survey results of the health care services provided at rural medical centers?"

"Will WDHSS be required to obtain any waivers, for example under § 1115 of the Social Security Act, from HCFA to implement a two-year consolidated survey of combinations of health care services at rural medical centers where the two-year framework for consolidated surveys runs counter to HCFA's existing timetables for individual facility surveys?"

A complete copy of the request to HCFA is available on the RWHC web site.

Public Health Or Health Of The Public?

On February 26th, the Wisconsin Office of Rural Health's quarterly forum focused on data available in Wisconsin relevant to local and regional community health assessments. Dr. Patrick Remington from the Wisconsin Bureau of Public Health hit a particularly resonant cord when he spoke of the need and opportunity for all of us to focus on "health of the public" rather than "public health." The phrase public health in the mind of too many is limited to the idea of government agencies rather than the partnerships we need to build among local public health agencies, health care providers, insurers and others. Suggesting a focus for such partnerships, Dr. Remington presented data from his paper, "Preventable causes of death in Wisconsin" published in theWisconsin Medical Journal, 1994.

"In this century, there has been a dramatic shift in the causes of death and disability. In 1900, the major causes of death were infectious diseases such as pneumonia, tuberculosis and diarrhea. Today, chronic diseases such as heart disease, cancer, stroke, and diabetes account for more than 70% of the deaths annually."

"Although information from death certificates has been used to document this shift, this data provides little insight regarding the preventable causes of death in the population. For example information concerning cigarette smoking and alcohol use is rarely mentioned on the death certificate, while the role of other important behavioral risk factors, such as diet and physical activity, is never recorded." As shown in the chart above, "approximately 50% of the deaths each year in Wisconsin result from nine preventable risk factors. For Wisconsin this represents approximately 21,100 deaths each year... Shifting the focus from disease as causes of death­p;to preventable risk factors­p;will hope focus prevention initiatives."

At the same Forum, Eleanor Cautley and Patricia Guhleman, also from the Center for Health Statistics presented a broad array of health information including summary data from Wisconsin's annual Behavioral Risk Factor Surveys, most recently reported in County and Regional Estimates of Behavioral Risk Factors and Health Screening Practices, November, 1995.

The chart on the following page is an attempt to get a feel for how their data relates to the communities served by RWHC providers. The non-metro counties within the Wisconsin Division of Health's Southern Region are used here as a proxy for RWHC counties. Estimates of the non-metro rates for adults appear to be differ unfavorably from state-wide estimates in three areas: safety belt non-use, being over weight and cholesterol screening. No surprise for parents that males and young people engage at a higher rate in health risking behaviors, particularly smoking, drinking and misuse of cars. On the other end of the age spectrum, we over forty-five win no commendations for weight control.

Technical Notes: Estimated rates with a confidence interval that falls below that of the "Wisconsin-All" estimated rate are shown shaded and bold. Southern Region Non-Metro rates were calculated as the weighted averages of data from several pre-defined county groups with the resulting confidence intervals inferred.

State Joins Anti-Marshfield Brief

The favored prediction is that the Marshfield antitrust suit will end with the Blue Cross appeal to the Supreme Court being denied. However, courthouse bookies shifted the odds, slightly, following the intervention of 26 State Attorney Generals. Their driving concern seems to be less about the specifics of the case than a concern for the effect of the Appeals Court precedent on their ability to enforce antitrust laws.

"Attorney General Jim Doyle has joined 25 other states in filing briefs asking the U.S. Supreme Court to review a federal appeals court decision on alleged anti-competitive practices by the Marshfield Clinic. If the decision stands, Doyle said, HMOs will be encouraged to consolidate, which could impair enforcement of antitrust cases and discourage competition in health care. The appeals court overturned a lower court ruling that ordered the clinic to pay $17 million in damages to HMO organizations that claimed the clinic held a health care monopoly in north central Wisconsin." (UP 2/15/96)

Go Next Door To NRHA National Meeting

The National Rural Health Association's annual conference draws more than 1,000 participants but like most health related conferences, you don't have to repeatedly ask, "but how does this relate to a rural provider or community?" The educational program is tailored to the needs of rural clinic and hospital administrators, physicians, nurses, educators, researchers and policy-makers. Call Mark Shapleigh, WI Office of Rural Health, 608-265-3603.

Value Beyond Beds

Harold Brown, CEO at Prairie du Chien (Wis.) Memorial Hospital has been talking for years about the need to better measure the services a rural hospital provides. Like many administrators, he was long tired of hearing his hospital described in terms of how many beds were used while the inpatient service was important but becoming less descriptive of the whole picture. He did something about it; since 1990 he has recorded "DUHS," daily units of health services, provided by his facility. The February 26 Modern Healthcare took DUHS national:

"Last month the facility had 379 acute-care patient days. In January 1995 the hospital had 514 acute-care patient days. However, its DUHS are up­p;11,701 vs. 10,204 in the same period... Those DUHS include child care, meals on wheels, meals to a local prison, home healthcare visits, outpatient surgeries and independent living residents. As Prairie du Chien Memorial increases its services, it increases DUHS, as well as measurable worth to the community."

Kritek In News

Dr. Phylis Kritek, longtime Wisconsin nursing leader self-exiled to Texas, is again on the national scene with a series in American Medical News from Renegotiating Health Care: Resolving Conflict to Build Collaboration, for which she is a contributing author. Her 1994 work, Negotiating at an Uneven Table, Developing Moral Courage in Resolving Our Conflicts is about to be re-released in paperback. Both books are highly recommended and available from Jossey-Bass.

Local History Via Internet

From the American Memory collection of the Library of Congress is this picture on the Wisconsin River near Merrimac [between 1890 and 1900] just up the river from the RWHC office. "American Memory consists of collections of primary source and archival material relating to American culture and history, the Library of Congress's key contribution to the national digital library"

"At this time, six photographic collections, one recorded sound collection, five textual collections, and a trio of early motion picture collections have been prepared for Internet access. A number of additional collections will be provided in the coming months."

Easy access to the Library of Congress via the RWHC web site.

HMO Market Shares In RWHC Counties

Eleven HMOs in 1995 insured 275,000 enrollees in the southern and central Wisconsin counties that form the core of the RWHC service area. Four HMOs account for 90% of the business: Dean, Physician's Plus, Unity and Group Health Cooperative. Market shares by county are indicated below. Rows don't equal 100% as HMOs with less than 100 enrollees in a county are not shown. Data: Wisconsin Office of the Insurance Commissioner.

Capital Financing For Small Projects

From Wisconsin Health and Educational Facilities Authority (WHEFA) Capital Comments, 3/96:

"WHEFA is pleased to confirm that its Small Project Financing Program is being utilized by healthcare and educational facilities throughout the state. This program has evolved into a program which helps small borrowers with smaller financing needs to a) develop a complete financial package and b) use that package to obtain multiple financing proposals. Through further analysis and negotiation, a final proposal is selected, documented and closed."

"Depending on the size of the project, financing terms desired, and the underlying creditworthiness, WHEFA can identify as many as 12 possible financing alternatives which are then contacted for proposals. WHEFA works with the borrower to identify all possible lending sources, including some which cannot utilize WHEFA as a conduit issuer. This broad distribution of requests for financing proposals assures the borrower that the best plan of finance has been identified and employed."

Call Larry Nines or Connie Carpenter at WHEFA, 414-792-0466 for more information.

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