RWHC Overview, Innovation And Action Since 1979

Incorporated in 1979 as the Rural Wisconsin Hospital Cooperative, RWHC has received national recognition as one of the country's earliest and most successful models for networking among rural hospitals. Today, the work continues as the renamed Rural Wisconsin Health Cooperative responds to the needs of its diverse members and their communities.

RWHC serves as a catalyst for regional collaboration and as an aggressive, creative force on behalf of rural communities and rural health. Owned and operated by 34 rural acute, general medical-surgical hospitals, RWHC's emphasis on developing an integrated network among freestanding entities distinguishes it from alternative approaches.

Vision (Future we want):

Rural Wisconsin communities will be the healthiest in America.

Mission (How we do it):

RWHC is a strong and innovative cooperative of diversified rural hospitals.

… is the “rural advocate of choice” for its Members.

… develops and manages a variety of products and services.

… assists Members to offer high quality, cost effective healthcare.

… assists Members to partner with others to make their communities healthier.

… generates additional revenue by services to non-Members.

… actively uses strategic alliances in pursuit of its Vision.

History

In 1979, RWHC was initiated by several hospital administrators in southern and central Wisconsin as a shared service corporation and advocate for rural health. The RWHC model was selected because it respected the autonomy of the sponsors and was a type of organization familiar to the community boards that would have to approve the individual hospital participation.

Over the years RWHC has made significant strides. RWHC was the major force behind the formation in 1983 of a then non-stock, not-for-profit insurance corporation, HMO of Wisconsin (now Unity Health Plans). At the same time community physicians organized themselves as an affiliated independent practice association, the Community Physicians' Network (CPN), to provide medical services for patients insured by the HMO.

In 1984, Mobile CT and Nuclear Medicine services were initiated through the development of private sector partnerships, and RWHC became active nationally as a vocal advocate for Medicare payment equity. RWHC was recognized for its work the following year by both the Wisconsin Legislature and the National Rural Health Association.

In 1987, major grant awards were received from the Robert Wood Johnson and W.K. Kellogg Foundations. RWHC established a pilot loan guarantee program for RWHC hospitals in cooperation with the Robert Wood Johnson Foundation and the Wisconsin Health and Education Facilities Authority. The program was in turn used as a model for the state's Hospital Loan Guarantee Program.

In 1990, RWHC played a significant role in the initiation of Wisconsin's Rural Health Development Council and its Rural Medical Center Initiative. In 1992, two Cooperative hospitals joined pilot sites in New York, Philadelphia and Phoenix to implement the Hospital Research and Education Trust's Community Health Intervention Project. In 1993, RWHC established a $1,000 Annual Rural Health Essay Prize, in honor of the memory of Hermes Monato, Jr., a December 1990 graduate of the University of Wisconsin, as well as to highlight the University's growing understanding of the importance of rural health. Hermes, at the time of his death, was an up and coming dynamic leader working with the Rural Wisconsin Health Cooperative.

In 1994, due to regional competitive pressures, HMO of Wisconsin was sold by its rural owners to United Wisconsin services (a BlueCross subsidiary) and subsequently merged with an HMO based at the University of Wisconsin. A joint venture among these entities governs the resulting HMO, Unity Health Plans. Community Health System LLC was created to represent the prior rural provider/owners of HMO of Wisconsin and RWHC was chosen to administer the LLC.

In 1995, RWHC served as a catalyst for statewide primary-care workforce planning. In the same year, RWHC initiated a newsletter and web site which has grown into a significant resource on the internet for rural health policy and networking at <www.rwhc.com>. RWHC also sponsors the only know rural health "political" cartoon series, with three new cartoon put online ea
U.S. Dept. Of Justice OK's Rural Network
From The 11/12/98 Business Advisory Letter:

"The network, to be called RWHC Network, Inc. ("the Net-work"), would be formed by hospitals that own and operate the Rural Wisconsin Health Cooperative ("the Cooperative"), which was formed in 1979 as a shared-services corporation and advocate for rural health services. The hospitals range in size from 8 to 78 beds, with an average size of 38 beds.""According to counsel for the Network, the individual members of the Network do not compete with each other, but rather with outmigration. That is, the alternative to using a local rural hospital is to travel to a larger, more sophisticated, regional medical center. The creation of the Network will allow these small local hospitals to contract more efficiently with health plans and other third party payers through a single agent.""The Network will employ a third party administrator, the Cooperative, to collect and analyze data from each hospital and aggregate this information in order to recommend contracting terms to the members. The administrator will initially negotiate contracts with payers based on a discounted fee for service schedule, but the goal of the Network is to eventually be able to enter into risk-sharing arrangements such as capitated fees. Members will be free to contract individually and to join other networks."

" 'The existence of the Network will allow managed care plans to contract with the 21 rural hospitals in an efficient and costeffective manner, thus ensuring that hospital services will continue to be available to consumers in rural areas,' said Klein. The letter states that the Department accepts the Network's contention that members do not compete, and thus their joint contracting efforts should not harm competition. They have taken steps to aggregate sensitive financial information so that no individual member will have access to any other member's costs or prices."
ch month.

In 1996, RWHC has incorporated RWHC Network (described later in more detail), to nego-tiate HMO and other in-surer contracts. Early in 1997, RWHC incorporated RWHC Network as a mechanism for its rural members to talk with each other and jointly negotiate with HMOs and other insurers without violating an-titrust laws. This critical step forwardwas consequent to an unexpected reversal of a preliminary position taken by the Fed-eral De-partment of Justice. On November 12th, 1996 Justice had accepted RWHC's initial proposal for a Business Advisory Letter--based on the presentation that RWHC rural hospitals don't compete with each other but with the problem of pa-tients leaving the local com-munity for care in large, re-gional medical centers. Conse-quently, RWHC hospitals can now work together to negoti-ate with HMOs and oth-ers without fear of violating strict federal an-titrust laws.

From the Justice's November 12th press release: "The Department of Justice today said that it would not chal-lenge a proposal by 21 small, rural hospitals in Wisconsin to form a network to contract with managed care plans and other third-party payers. The Department's Antitrust Division said the net-work, as proposed, would pose no threat to competition in the areas served by the members of the network. The Department's po-si-tion was stated in a business review letter from Joel I. Klein, Acting Assistant Attor-ney General for the Antitrust Di-vision, to counsel for the hos-pitals." (See box below for remainder of letter.)

RWHC and CPN developed mechanisms to begin to also more formally re-late to other regional players. As RWHC & CPN began to develop a closer working relation-ship with each other, they also have together begun to develop a closer working relation-ship with multiple HMOs and insurers within the region through the Rural Zones of Collaboration Initiative.

In 1997, RWHC received a Federal Network grant to implement this initiative; the following goals were successfully implemented:

In 1998, RWHC established a non-voting Affiliate Membership to enhance its relationships with regional, tertiary based, provider systems; current members include: University of Wisconsin Hospital & Clinics (Madison), Meriter Health Services (Madison), St Marys Hospital Medical Center (Madison), Gunderson Lutheran, (LaCrosse).

In 1999, RWHC (with the CPN) successfully renegotiated a second five year joint venture to govern Unity Health Plans along with United Wisconsin Services and the University of Wisconsin. As will be noted later, this led directly to the understanding of the need and opportunity for this proposal.

RWHC (along with other a cross-section of Wisconsin advocates) facilitates the state legislature's creation of a purchasing pool for small businesses. The RWHC executive director was appointed by the Governor to represent hospitals on the Employer Health Care Coverage Board. The Department of Employee Trust Funds are charged with implementing a health care coverage program for small employers by January 1, 2001. the substantial needs of Wisconsin's small employers is an open question.

Taking advantage of the departure (for family reasons) of RWHC's longstanding deputy director and a senior staff with long tenure, RWHC's staff leadership structure was "flattened," A Senior Staff Team was organized, led by the Executive Director and also comprising: the Director of Programs and Services, the Director of Financial Consulting Services, our Accounting Manager and a new position, the Director of Product & Member Development.
RWHC along with a "virtual organization," comprising the Wisconsin Department of Health & Family Services, identified "first generation" Critical Access Hospital applicants, the state Office of Rural Health and the Wisconsin Health and Hospital Association has rapidly implemented the Medicare Rural Hospital Flexibility Program. Wisconsin is thought to be unique in having created a "shared serviced" pool with a portion of the grant dollars to more effectively access the expertise needed by CAH hospitals. RWHC managed the RFP process for two key uses of the shared service fund: EMS and Telehealth/communication.

In 2000, RWHC began administering a federal Outreach grant on behalf of three county health departments and five rural hospitals located within the service areas of Adams, Juneau, and Sauk Counties. The collaborative initiative, known as Partners in Agricultural Health, is addressing the health promotion and disease and injury prevention needs of the farmers and agricultural laborers. The purpose of the project is to:

RWHC grappled with the Institute of Medicine (IOM) seminal report, To Err Is Human: Building a Safer Health System. In response, RWHC joined a coalition convened by MetaStar, the Medicare Peer Review Organization in Wisconsin, which includes: the Wisconsin Department of Health and Family Services, the Wisconsin Health and Hospitals Association, the State Medical Society of Wisconsin and the Employer Health Care Alliance Cooperative. The participants determined that the most effective immediate statewide intervention would be to address medication errors with a benchmarking initiative--(1) to determine the extent to which best practices for medication safety are being followed in Wisconsin hospitals and (2) to implement and evaluate strategies for increasing the use of best practices for medication safety in Wisconsin hospitals. Funding as a national pilot from HCFA has been requested; if not made available, MetaStar has committed to implementing the project by reprogramming federal funds in their core agreement.

RWHC initiated the RWHC Health Benefits Program as a mechanism for RWHC members who self-fund their employees health insurance to pool their cash for claims payments and to gain the benefit of group purchasing for their claims administration and reinsurance.

In 2001, RWHC assumed a leadership role on a national initiative to expand CAH reimbursement (described as REACH). Other advocacy/legislative achievements included active engagement with health care quality report cards in the state. The primary goal of this effort was to assure that the reporting of such data is fair and accurate. RWHC worked to develop alternative sources of blood products for rural hospitals in response to a series of unilateral changes by the then only regional source. RWHC dedicated significant time and effort to Wisconsin’s Private Employer Health Care Coverage Board and its ultimately unsuccessful effort to create an insurance pool for small employers. In addition, RWHC continued to focus on Medicare equity, patient safety, interfacility transfer standards, and workforce development.

In 2002, RWHC’s primary focus was on workforce development and information technology, including the implementation of shared data network thatallowed for secure T1 connections between the 29 member hospitals and a central data center. Following a grant-funded feasibility study in 2000, it was determined that RWHC should move forward on implementing a WAN/VPN hybrid to allow Members to share an assortment of clinical and business applications. RWHC applied for a series of federal grants to help fund the start-up of this data network (which allowed it to be fully operational by June 2003). In addition, RWHC has established or enhanced services in the areas of performance measurement, coding consultation, credentials verification and finance. RWHC’s executive director received the National Rural Health Association’s top honor, the Louis Gorin Award for Outstanding Achievement.

In 2003, RWHC partnered with the Wisconsin Office of Rural Health in the creation of a healthcare recruiter/workforce development manager responsible for promoting health careers and recruiting allied health professionals to rural Wisconsin. In addition to cultivating relationships with the universities, technical colleges, and staffing agencies, the RWHC/WORH healthcare recruiter began posting and monitoring job opportunities on a jointly-owned health careers web site and helped develop telehealth services for the members. Also, the breadth and scope of services available through the RWHC WAN was expanded to include mail filtering, virus scanning, and data protection.

RWHC partnered with the Wisconsin Primary Health Care Association on a grant from the Office for the Advancement of Telehealth that focused on teleradiology/PACS feasibility, distance education, and the development of a mental health/psychiatry telemedicine service. This initiative was sustained through the Wisconsin Telehealth Services Network, a loose collaboration of rural hospitals and clinics with regional providers in pursuit of ongoing telehealth relationships using videoconferencing technology.

RWHC received a research grant to address “How Can Rural Balanced Scorecards Best Incorporate Population Health Measures?” from the University of Wisconsin Health & Society Research Competition, funded by Robert Wood Johnson Foundation. RWHC was represented by its executive director on the Institute of Medicine’s Future of Rural Health Care Committee, within the National Academies of Science. After several years absence, the RWHC executive director was invited back for a rare second term on the National Advisory Committee on Rural Health & Human Services for the U.S. Department Health & Human Services.

In 2004, the Agency for Healthcare Research & Quality (AHRQ) awarded a “THQIT” (Transforming Healthcare Quality Through Health Information Technology) one year planning grant to RWHC for a collaborative of 19 Wisconsin healthcare organizations, both rural and urban, whose goal was to begin work toward applying existing technology to health care to reap rewards in improving the quality of care and efficiency of the delivery system in Wisconsin.  Activities during the planning phase included initial identification of stakeholders and interested parties, consensus building through monthly meetings and discussions about institutional needs and desires, education sessions related to EHR implementation and data exchange, and a survey of group readiness to implement EHR applications, as well as electronic exchange itself at different levels.

To address the Members’ basic IT needs, RWHC formed a separate association with our technology partners (Norlight Telecommunications, Digicorp, 5 Nines Data) that provides per diem IT staffing, technical support, application development, and assistance with hardware software purchases.

RWHC received a planning grant on behalf of a statewide collaborative for the “Wisconsin Academy of Rural Medicine,” a medical school within a medical school, from the Wisconsin Partnership Fund for a Healthy Future.

In 2005, RWHC hired a director of health information technology and began organizing a shared electronic health record (EHR) taskforce to determine whether a subgroup of RWHC members was interested in collaborating on a common integrated hospital information system. On the financial side, shared hospital information systems/EHRs have been shown to: (1) contain capital costs with a shared data center and server model; (2) contain operating costs with shared help desk and system administration; and (3) contain future investment costs with shared ongoing purchasing and negotiating power.  On the clinical side, robust integrated EHRs provide a clear migration path to: (1) a single sign-on, complete portal view of the patient chart; (2) advanced clinical systems such as E-MAR, CPOE, handheld rounding, decision support, and medication verification through the use of barcoding; and (3) an eventual paperless clinical environment.  In addition, with attention paid to emerging standards (and to which vendors are poised to adopt them), participants can position themselves for robust data exchange capabilities.  The benefits of a data exchange environment include: (1) improved continuity of care with tertiary centers; (2) facilitation of quality reporting, as well as eventual P4P reporting when/if reimbursements are tied to quality; and (3) public health and epidemiology support capabilities.

2005 was a major year of challenges for national rural health advocacy; RWHC joined with other rural voices to push back several major threats, including: the initial “Hospital Compare” Web Site, the Proposed Rural Hospital Building Ban and the DHHS Appropriations Bill.RWHC received a research grant for “What Policies Encourage Local Collaboration for Population Health in Rural Communities?” from the University of Wisconsin Health & Society Research Competition, funded by Robert Wood Johnson Foundation. RWHC was represented by the executive director on the planning committee for the Healthy Wisconsin Leadership Institute, initiated in late 2005.

In 2006, RWHC membership expanded to include 31 Active Members and six Affiliate Members, bringing a commensurate increase in demand for services.  The Cooperative responded to this by enhancing staffing and maximizing access to the research/resources available through the Advisory Board Company. (For 2007, RWHC will be adding the Advisory Board’s HR Investment Center to their membership offerings.)

In the area of recruitment and retention, RWHC continues to cultivate remote consultation agreements between regional providers/academic centers throughout the state, and those rural hospitals/community health centers that comprise the Wisconsin Telehealth Services Network.  In addition, the Cooperative began to issue exclusive “franchise agreements” with other states that wish to replicate Rural Health Careers in Wisconsin – a rural-specific, web-based job site that features both clinical and no-clinical positions. Currently, over 65 rural Wisconsin hospitals utilize the site. 

On the quality front, RWHC expanded their menu of patient satisfaction options to members and non-members alike by becoming an approved vendor for the Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey. The Cooperative currently collects and submits data to AHRQ/CMS on behalf of over two dozen rural hospitals located throughout the country.   

Financial support from Southwest AHEC and the Wisconsin Office of Rural Health helped drive RWHC-sponsored, statewide initiatives in the areas of shared HIT/EHR infrastructure, the financial impact of Critical Access Hospitals designation, and workforce development.  One project of note: Club Scrub – an interactive health careers program targeting middle school students.  In addition, grant funding was used to help purchase Mediasite technology - a media recording and publishing system that automates the capture, management and delivery of educational presentations that is already being used extensively for the live presentations, remote access, and archiving for later viewing.

Many regulatory issues touch rural health, and this year was no exception with RWHC making a positive contribution in diverse areas. With RWHC input, the Pharmacy Examining Board took action to allow remote dispensing demonstrations in a flexible manner to find the appropriate balance between developing new dispensing models to assure access while respecting a variety of quality and safety issues. The State Trauma Advisory Council agreed to accept from Trauma System Level IV hospitals either the Rural Trauma Team Development Course or Comprehensive Advanced Life Support training in place of Advanced Trauma Life Support training as more relevant to patients seen in these facilities. RWHC’s submitted an affidavit to defend the work of nurse anesthetists before the Wisconsin Medical Examining Board.

RWHC worked with the National Rural Health Association (NRHA) to highlight the problem of rural under-representation on Congress’s Medicare Payment Advisory Commission leading to significant support for a bill that, if passed, will require that MedPAC have rural representation equivalent to the percentage of rural Medicare beneficiaries. The newly authorized Medicare Advantage health plans will effect rural health in ways not yet understood by either the public or providers; RWHC led an analysis of this potential impact for both the National Advisory Committee on Rural Health and Human Services as well as NRHA.

Based on futurist Leland Keyser’s keynote at Wisconsin’s 2005 Annual Rural Health Conference, RWHC implemented one of Dr Keyser’s primary recommendations—that rural hospital Chief Executive Officers (CEOs) should routinely seek out and visit other hospitals in order to gain additional insights to enhance their organization’s performance. The inaugural RWHC Hospital to Hospital Program (H2H) was held in October at Grant Regional Health Center with an extraordinary session entitled “Creating Service Excellence: Through ‘Touching Lives.’

After almost two year’s preparatory work, RWHC was successful, in collaboration with others, in raising nearly a million dollars to support the Strong Rural Communities Initiative (SRCI). SRCI is a statewide collaboration among medical, business and public health sectors along with six rural communities pilots to make community wide prevention the norm locally and throughout rural Wisconsin. Of note, it is the first community based initiative to receive support from both of Wisconsin “BlueCross Conversion Foundations.” Also with “BlueCross” dollars, RWHC has been a key partner in the development of the Wisconsin Academy of Rural Medicine, a “rural medical school” with the University of Wisconsin School of Medicine and Public Health and helped it reach a key milestone in 2006—the offer of admission to the first medical student in the first class of WARM, starting Fall of 2007.

In 2007, RWHC and member hospitals founded the RWHC Information Technology Network, a 501(c)3 organization dedicated to providing member hospitals with shared HIS/EHR services.  Four RWHC facilities signed on as founding members.  Helping to support the initiative, three grants were awarded to RWHC:  (1) HRSA’s CAHHIT Network grant for $1.6 million; (2) FCC’s Rural Healthcare Pilot Program for up to $1.5 million; and (3) a federal appropriation through Senator Herb Kohl’s office for $181,000.

The Wisconsin Pharmacy Forum invited RWHC to their meeting to discuss collaborative approaches to addressing the rural pharmacist shortage.  This meeting led to the formation of three (3) workgroups to address this topic:  Academic, Research, Practice Models.  Since that time, RWHC has been meeting regularly with the UW Madison-School of Pharmacy to develop a plan of action to address the needs of our rural hospitals. These include RWHC attendance at the SOP Career Fair, working with the RHWC Pharmacy Roundtable to develop a practice model survey, ongoing discussions regarding needed change to the SOP curriculum, and the expansion of rural clerkship sites, which will include a listing of rural clerkship sites on the Rural Health Careers in Wisconsin web site (www.rhcw.org).

RWHC brought together over 30 individuals from around the state to present the Retirement and Departure Intentions Survey that was developed by the Fox Valley Healthcare Alliance.  The objectives of this meeting were to make this survey a state-wide initiative and to identify groups that would assist in implementing the survey.  Since this time, three (3) other regions in the state are is process of funding and implementing the Retirement and Departure Intentions Survey for their regional hospitals.  In addition to the Fox Valley Region, these regions include the Southcentral Regional Workforce Board, Southwest Regional Workforce Board, and the La Crosse Medical Health Science Consortium.  The information obtained from this survey will be of assistance in planning future healthcare workforce needs.

RWHC Nurse Residency Program was highlighted in the December issue of Hospital & Health Networks. “Residency programs help new nurses settle into their jobs and sharpen their skills. They also provide nurses with an immediate support group. But rural hospitals can find it hard financially to provide programs to the small number of new nurses they hire… The Rural Wisconsin Health Cooperative, Sauk City, is bridging this gap. Nurses drive to the cooperative—some as far as 100 miles—to attend 12 monthly, daylong programs. During the year, they are paired with a clinical coach at their facility and also create a professional development plan. During the classroom sessions, new nurses discuss cases, laying out how they cared for a patient whose condition pertains to that month’s topic… The retention statistics for the first and second years of the program are impressive. Eighteen months after the program ended its first year, retention was at 89 percent for 19 nurses. For the second year, 87 percent of the 31 nurses in the program were retained. Before the program, new nurses frequently left cooperative hospitals in their first year if a position at a larger facility was available, although she could not cite specific numbers.”

Other highlights of 2007 included:

At the very end of the year RWHC caught the attention of many rural health leaders by outlining what it saw as a related list of five “anti-rural” policy initiatives by the Centers for Medicare & Medicaid Services:

#1: CMS Bans Building/Remodeling by “Necessary Provider” CAHs—“Necessary  Provider” CAHs can not relocate one bed, even on campus, without CMS Regional Office permission; permission that will be denied if even one of the criteria used for its original designation, can no longer be met.

#2: CMS Quarantines New “Necessary Provider” CAH Services to Campus—CMS has banned "necessary provider" CAHs from operating any new offsite facilities not 35 miles from another hospital.
 
#3: CMS Freezes Rural Health Clinic Startups by Blocking Certification Surveys—CMS exempted rural health clinics from the prohibition on new CAH provider based off campus services but then classifies certification surveys of new Rural Health Clinics as a “Tier 4 survey” also known “as a practical matter, it ain’t ever going to happen” survey. 
 
#4: CMS Strips Rural Component from Quality Improvement Organizations’ Draft Contracts—In the evaluation of a CMS funded Quality Improvement Organization (QIO), the QIO will actually be hurt by working in rural areas because of the “inefficiencies” associated with the distance and lower population and provider density.

#5: CMS Prohibits CAHs from Submitting Data for Public Reporting—For 2008, CAHs will not be able to submit the outpatient measurement set to CMS and thus are excluded from Hospital Compare for this measurement set, a set specifically design for rural hospitals.

Membership Application Process

While the emphasis of RWHC is to better serve existing members, new members are welcomed. The application process is informal -- the Board engages in discussion to see if new membership will result in a mutually beneficial relationship. A special discount is available for new regular members' first year dues.

For Additional Information

Larry Clifford, Director of Product & Member Development
Rural Wisconsin Health Cooperative
880 Independence Lane
P.O. Box 490
Sauk City, WI 53583

lclifford@rwhc.com

(608) 643-2343 or (608) 643-4936 - FAX

Last Updated: 4/15/04

 

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