ASPS Advocacy Summit Update
By John LoGiudice, MD

Dear Colleagues,

Shortly before the July 4th Congressional recess, members of the American Society of Plastic Surgeons convened on Capital Hill to address issues facing our members as well as medicine as a whole.  I attended this event the last week of June as the sole Wisconsin representative.   For those unfamiliar, ASPS has organized “Fly Ins” to Washington, D.C. for a number of years allowing members to meet with their congressional representatives.   This inaugural Advocacy Summit is simply an evolution of the “Fly In,” allowing members to be educated about policy, while facilitating a forum to discuss new problems facing plastic surgeons, and coordinating meetings with respective representatives in the House and Senate for members to discuss matters impacting the practice of medicine.  Organized months in advance, it was fortuitous that the Advocacy Summit was scheduled while healthcare was the main topic of discussion on Capital Hill and nationally.

ASPS has identified five main federal policy issues that directly impact our constituents across the country. I will provide a brief summary.

1. Network Adequacy - In response to mandates by the Affordable Care Act (ACA), insurers have created products that have narrow networks particularly as it pertains to specialty care.  This has resulted in unexpected out-of-pocket costs to patients for out-of-network care. These plans may leave patients with limited options to see specialists in their own region or may limit the patient to access an unqualified specialist.  ASPS has proposed mandating transparency by payers, implementing available directories to patients to make choices about specialists with appropriate practice scope, and allow coverage of out of network care if a specialist is not available in a given region.
   
2. Ambulatory Surgical Center Quality and Access Act – Ambulatory Surgical Centers (ASC) have transformed the delivery of outpatient surgical care comparable to hospital based outpatient departments (HOPD) for considerably cheaper.  The cost of goods and services in ASCs and HOPDs is the same yet the rate of reimbursement is lower in ASC’s due to discrepant metrics to determine reimbursement.  Currently, Medicare reimburse an ASC 53% the HOPD rate for the same procedure.  Bipartisan legislation has been proposed to address this disparity. 
3. Protecting Access to Care Act – This is proposed legislation addressing the lack of medical malpractice liability reform nationally.  It proposes a statute of limitation from date of incident, a cap on non-economic damages, and limiting attorneys’ contingency fees.  Bipartisan bills have been proposed. 
4. Repeal of the Independent Advisory Board (IPAB) – Under the ACA, an IPAB would be formed if Medicare spending exceeds target growth rates.  This non-elected 15-member board would convene and ultimately yield power to adjust the Medicare fee schedule or access to qualified providers with no transparency to the process.  In essence, the IPAB can ration.  Interestingly a practicing physician cannot be on the IPAB but an insurance executive can be involved.  The IPAB would likely be convened this year due to higher medical cost inflation projected.  
5. Graduate Medical Education – This proposed bill addresses the limitations in Medicare funding of graduate medical education (residency positions) in the US despite an increase a nationwide increase in medical school training positions.  The number of funded residency spots has been frozen since 1997.

I had the opportunity to meet with Congresswoman Gwen Moore as well as members of Senators Ron Johnson and Tammy Baldwin’s offices.  With our neighbors in Michigan I also visited house and senate leadership representatives from that respective state.  Although Plastic Surgery isn’t foremost on these folk’s radar, it was effective to relay the problems that many of us encounter regardless of practice model.  Since we have the unique opportunity to work from head to toe in the young and old treating a broad spectrum of diagnoses with a variety of referring physicians, we see how the above issues impact delivery of care. 

Many have asked about the sentiment on Capital Hill regarding legislation to repeal and replace or modify the ACA.  Whether it be a lobbyist or a congressional staffer, the expectation is that any attempts at redefining healthcare will be a long process.  Our daily news sources remind us of this debacle.  Although these observations are not substantiated by any poll or data, there is a theme regardless of party.  Congress will likely not accept drastic cuts in coverage resulting in millions of uninsured.  Quality measures will be part of an equation to reimburse regardless of name (MACRA).  Legislation allowing an insurer to deny / cancel policies for pre-existing conditions or to institute lifetime caps is not popular.   If you watch the news none of this seems profound.  In the weeks after the GOP initially attempted to pass their version of healthcare law, it seems inevitable that the only way the ACA will be repealed or modified, it is going to have to be a bipartisan effort like it’s supposed to be.

Clearly, the federal policy issues that ASPS has identified are not the only problems we are facing in delivering care.  I would ask that you contact WSPS regarding practice issues that may be brought to the attention of our state and federal representatives.  

All ASPS members are welcome to attend these Advocacy Summits which take place throughout the year.  It is an efficient way to get “face time” with your congressional representatives.  WSPS plans to send a board member annually to an Advocacy Summit to represent our interests.  Many of us look at the political process that is impacting healthcare with great skepticism.  Other than our patients, nobody has a bigger stake in the outcome but us.  We feel that regardless of your practice model it is best stay involved. 

Best Wishes,

John LoGiudice, MD FACS
President, WSPS

July 6, Wisconsin Health News

An appeals court struck down a state law Wednesday capping the amount of money that injured patients can receive for some malpractice claims. 

The 1st District Court of Appeals ruled that a state law capping awards for noneconomic damages at $750,000 was unconstitutional. Noneconomic damages are intended to compensate for pain and suffering. 

Judge Joan Kessler, who penned the majority opinion, wrote that the law imposes "an unfair and illogical burden only on catastrophically injured patients, thus denying them the equal protection of the laws." 

The case involves Ascaris Mayo, who lost her limbs after she wasn't notified she had an infection after visiting a Milwaukee-area emergency room in May 2011. Mayo and her husband sued, and a jury awarded them $16.5 million for noneconomic damages.  

The state's Injured Patients and Families Compensation Fund, which is funded by hospitals and doctors and covers large medical malpractice claims, moved to reduce that amount to the $750,000 limit. The Mayos challenged that. 

Hospitals and doctors in the state were concerned about the Wednesday's ruling. Wisconsin Hospital Association CEO Eric Borgerding expects the state's Supreme Court to review the decision. 

"We believe the court will uphold the well-supported and bipartisan public policy balance set by the Legislature to help ensure accessible healthcare in Wisconsin," he said in a statement.

A spokeswoman for the Office of Commissioner of Insurance, which provides administrative staff to the 13-member board, didn't respond to a request for comment on whether the state would appeal the decision.

Dr. Noel Deep, Wisconsin Medical Society president, said the decision"endangers the long-term solvency of the Injured Patients and Families Compensation Fund and its ability to adequately compensate patients." He warned that it could incentivize "attorneys to file questionable cases in hopes of astronomical jury awards seen in other states without caps."

Dan Rottier, an attorney for the Mayos, called the society's claim regarding fund's solvency "ridiculous." The fund reported a net position of $879 million as of June 2016, according to an annual report.

Rottier said that pursuing such cases are difficult because "they're extremely expensive...these cases are not taken lightly.

Rottier said the court's decision has "implications for a few cases every year where there's horrendous injuries...it's those cases where the inequity is the most severe." He noted that applying a cap in this case would have reduced the jury award by more than 95 percent.

"I would call it 5 percent justice instead of 100 percent justice," he said.

Mark your calendars and plan to participate in Doctor Day 2018 on January 30, 2018 in Madison! 

Doctor Day began informally five years ago, drawing roughly 80 physicians to a joint legislative day involving the Wisconsin Medical Society and a handful of specialty societies. Now, Doctor Day has grown by more than 500%! In 2017, more than 480 physicians and medical students were registered for the event, which came together in an effort to maximize physician visibility in Wisconsin's legislative arena, and therefore enhance our collective ability to advocate on health-care issues. 

Unique in the nation, the equal-partnership, multi-specialty nature of Doctor Day has quickly become one of the largest Legislative Day events in Wisconsin. Plan to join your physician colleagues and participate in in Doctor Day 2018.

June 15, Wisconsin Health News 

The Senate approved the final two proposals that are part of a special legislative session on opioids that Gov. Scott Walker called in January. 

All 11 proposals that are part of that session have now passed the Legislature and await Walker's signature to become law. 

The bills were based on recommendations from an interim report released in January by the Governor's Task Force on Opioid Abuse, which was chaired by Lt. Gov. Rebecca Kleefisch and Rep. John Nygren, R-Marinette. 

"We have a lot of work left to do on a massive epidemic that's sweeping our state," said Ashland Democratic Sen. Janet Bewley, who served on the task force as well. "We are learning that it's even bigger and more profound than we ever thought." 

The Senate approved a proposal Tuesday that would provide limited legal immunity to overdose victims. Sen. Steve Nass, R-Whitewater, was the sole no vote.  

The chamber also approved a bill allowing for families and others to involuntarily commit a person with drug dependence. 

The Senate also voted down along party lines a Democratic amendment to the latter proposal requesting the attorney general to consider filing a lawsuit against opioid manufacturers. A few states, like Ohio, have filed lawsuits against drugmakers.  

Senate Majority Leader Scott Fitzgerald, R-Juneau, predicted that a class action lawsuit against drugmakers "is coming. It's just a matter of time...and I'm sure we'll be part of that at some point." He moved to reject the proposal as he didn't want it tied with the bill.  

See a list of the special session bills.

June 8, Wisconsin Health News 

Gov. Scott Walker's Department of Health Services officially asked the federal government Wednesday to allow Wisconsin to become the first state to drug screen adult Medicaid enrollees without children. The waiver amendmentalso caps eligibility, imposes work requirements and charges premiums to members living below the poverty line.

DHS pared back some of the changes after receiving more than 1,000 pages of comments on the proposal. 

That includes shrinking the income tiers for premiums from four tiers to two and not making anyone under 50 percent of the poverty level pay premiums. Childless adults with household incomes between 51 percent and 100 percent of the poverty level would pay $8 a month. Walker originally proposed a range of $1 a month to $10 a month for members making between 21 percent of the poverty level and 100 percent. DHS is also considering a grace period of 12 months for members that miss a payment. 

In addition, the application decreases a copay for subsequent visits to the emergency room. And members who skip a drug screening can sign back up for coverage as soon as they consent to treatment, instead of waiting six months. 

Walker called the application "a step in the right direction." "We're continuing to build on Wisconsin's legacy as a leader in welfare reform," he said in a statement Wednesday. 

Jon Peacock, research director for the Wisconsin Council on Children and Families, said the latest changes to the proposal were "modest improvements." But they don't "change the basic problem that the waiver would add new barriers to BadgerCare participation that increase administrative costs and keep people from getting the care they need." 

Last month, the state's budget committee voted to require that the panel approve the waiver amendment before it's implemented. At a Wisconsin Health News event Monday, Joint Finance Co-Chair Rep. John Nyrgen, R-Marinette, said he overall supported Walker's plan, but "there's still a lot of unanswered questions in the proposal." "For us to feel comfortable that we're moving in the right direction, we believe the proposal should come back to Joint Finance and we have the opportunity to vote it up or down," he said.

Rep. John Nygren, R-Marinette, and Sen. Alberta Darling, R-River Hills, the influential co-chairs of the Joint Finance Committee, will provide an update on the state budget, discuss a proposal to self-insure the state employee health plan, preview what's next for the Heroin, Opioid Prevention and Education agenda and highlight other healthcare legislation at a Wisconsin Health News Newsmaker Event.

The event is Monday, June 5 at the Madison Club (5 E Wilson Street, Madison).  Lunch begins at 11:45; conversation starts at 12:15pm and adjourns by 1pm.

Register now.

May 18, Wisconsin Health News

The management side of a council charged with developing changes to the state's workers' compensation system has proposed creating a fee schedule for healthcare services.

The Worker's Compensation Advisory Council, which consists of representatives from management and labor, crafts a bill that updates state law around workers' compensation every two years. Management and labor introduced their proposals at a meeting last week.

Management is calling for setting initial rates at 150 percent of Medicare rates starting in 2017. The schedule would adjust each year with the medical consumer price index.

The proposal differs from a measure that was pursued by the council four years ago but failed to make it into law, which was based on rates for surgeries and procedures negotiated by group health plans. 

"The goal is the same, which is to bring cost containment to the state," said Chris Reader, an advisory council member and director of health and human resources policy at Wisconsin Manufacturers and Commerce.

He said it's easier to construct the fee schedule using Medicare as it's difficult for the state to obtain average group health plan rates. More than 40 other states have fee schedules, he said.

Mark Grapentine, Wisconsin Medical Society senior vice president of government relations and liaison to the council, questioned why Wisconsin would want to mimic other states when it already has a successful system.

"The value of the current workers' comp system as it exists is by just about every measure fantastic," he said. "For whatever reason, the management side tends to have this fascination with sticker prices of individual procedures and not the overall cost of care."

Reader pointed to other proposals from management they believe could help with costs. That includes allowing employers to direct workers to healthcare providers and requiring providers to follow treatment guidelines.

If a provider decides to deviate from the guidelines, they would have to get prior approval. That ensures providers get employees back to work as soon as possible, he said.

"Let me be clear - most do an excellent job of getting workers back to work," he said. "But having strong treatment guidelines will ensure that everybody has to do that unless there's a good reason not to."

Grapentine said they're concerned about both proposals. Treatment guidelines could make it inefficient and frustrating for physicians to provide care to injured workers, he said.

The proposal relating to guidelines, he said, is coupled with the fee schedule approach. States with fee schedules aren't as efficient in providing care, and treatment guidelines can cut utilization. He compared it to pushing on both sides of a balloon at the same time.

"If you push on both sides of the balloon really hard, you know what happens," he said. "Why on earth would you do that to a system that people across the board think is a national model?"

Management and labor are set to negotiate over the coming months to craft an agreed-upon bill for introduction to the Legislature. 

Stephanie Bloomingdale, secretary-treasurer of the AFL-CIO and an advisory council member, declined to comment through a spokeswoman.

May 3, Wisconsin Health News

The Senate and Assembly passed a number of bills that are part of Gov. Scott Walker's special session targeting opioid addiction Tuesday.

The proposals originated from a preliminary report issued in January by a task force co-chaired by Rep. John Nygren, R-Marinette, and Lt. Gov. Rebecca Kleefisch.

"With the nine special session bills advanced today, the Senate has taken several great strides towards helping to combat our state's ongoing opioid crisis," Senate Majority Leader Scott Fitzgerald, R-Juneau, said in a statement. 

But Democrats questioned whether the bills go far enough. "After years of struggles, we're taking baby steps when we should be making major strides to improve outcomes and strengthen community safety," Senate Democratic Leader Jennifer Shilling, D-La Crosse, said in a statement. 

The Senate approved proposals that would:

• prohibit the dispensing of schedule V controlled substances containing codeine, dihydrocodeine, ethylmorphine and other substances listed under the section of law the bill targets.
• allow school district personnel and college and university residence hall directors to administer naloxone. 
• provide $2 million a year for alternatives to prosecution and incarceration for those with substance use disorders, $150,000 a year to expand those alternatives to more counties and $261,000 a year for an additional pilot program. 
• provide $50,000 to help establish a recovery charter school.
• provide $63,000 a year to expand graduate medical training on addiction. 
• provide $1 million a year to create more opioid treatment programs in the state. 
• provide $500,000 a year to establish an addiction medicine consultation program.
• provide $420,000 a year to hire four additional drug trafficking investigators at the Department of Justice.
• provide $200,000 a year to expand substance abuse screening by the Department of Public Instruction.

The Assembly approved the bills last month, so they now head to Walker's desk for his approval.  

The chamber also approved two additional bills Tuesday that are part of the package but haven't been taken up by the Senate. Those measures would: 

• provide limited legal immunity to overdose victims. 
• allow those with substance abuse disorders to be involuntarily committed. 

April 27, Wisconsin Health News

Doctors and acupuncturists oppose a bill that would allow chiropractors to perform physical examinations for student athletes and practice "chiropractic acupuncture" and "chiropractic dry needling" if they receive additional training.

The bill received a public hearing Wednesday before the Assembly Committee on Health.

Under the proposal, schools that require a pupil to have a physical examination to participate in sports and other activities will have to accept a physical examination completed by a chiropractor the same way it accepts those completed by doctors. The chiropractor would have to hold a certificate in health or physical examinations.

The same requirement would apply to the state's technical colleges or a two-year campus within the University of Wisconsin System that require physical examinations for students to participate in sports.

"With some additional training, doctors of chiropractic could provide a high quality exam," Mark Cassellius, a chiropractor practicing in Onalaska, told lawmakers.

Dr. Tosha Wetterneck, past president of the Wisconsin Medical Society, opposes the bill.

The physical examination isn't just focused on the athletics, but on at-risk behaviors, immunizations and other factors that might impact sports participation, she said. That requires extensive training.

"This is rocket science," she said. "This is difficult."

The bill would also allow chiropractors to practice "chiropractic acupuncture" if they complete at least 200 hours of instruction and the acupuncture examination administered by the National Board of Chiropractic Examiners.

The bill would also allow chiropractors to practice "chiropractic dry needling," which involves puncturing the skin with needles to treat "neuromusculoskeletal pain and performance," if they complete 50 hours of postgraduate study.

Shawano-based chiropractor Brian Grieves said the bill could help address the opioid epidemic by increasing access to alternatives pain treatments.

"We have very limited, proven, effective non-drug options to offer people for pain," he said. "Being able to augment that by offering chiropractic acupuncture would greatly expand that access."

Elissa Gonda, chair of the legislative committee for The Wisconsin Society of Certified Acupuncturists, opposes the bill.

"Acupuncture is a serious and rigorous profession," she said. "It's not a method or technique that can be employed on an occasional basis by another healthcare practitioner." 

Steve Conway, executive director of the Chiropractic Society of Wisconsin, said they're generally supportive of the bill but they're still vetting it. 

April 27, Wisconsin Health News

Wisconsin will receive $7.6 million from the federal government to combat opioid addiction, the Department of Health and Human Services announced Thursday night.

HHS is providing $485 million to all 50 states, the District of Columbia and six U.S. territories. The funding, made available under the 21st Century Cures Act, will go toward prevention, treatment and recovery services.

States were awarded funding based on rates of overdose deaths and unmet need for treatment. Florida received the most money at $27.2 million, while five territories received $250,000 each.

Gov. Scott Walker directed the Department of Health Services to seek the funding in an early January executive order. DHS can re-apply for additional funding next year.