continuum magazine (winter 2013)

7/28/2019 Continuum Magazine (Winter 2013)

1/13

A publication for Wisconsins Long-Term Care Profession by

Winter

Elections

Over.

Governing

Begins.

Including:

Ging r the Gl: Participating in the Natinal Quality Awar Prcess is a Win r Eery

Entitlement Rerm, the Fiscal Cli an their Eects n Lng-Term Care Priers

The Arable Care Act Care Act is Here t Stay - Nw What?

THE BUDGET ISSUE:


2/13

Clinical

Medication Mgmt.

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PatientScheduling

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MDS & Care Plans

MDS

BestReference

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TimeClock

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Improve Efciency Improve Morale Improve Quality of Care

Centralized Data

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WelcmeWisconsin Center for Assisted LivingWisconsin Health Care Association

Happy New Year!

Ater a long election year in 2012, Wisconsins stateand ederal political leaders will be getting back to thebusiness o governing in 2013. In February, GovernorScott Walker will release his version o the 2013-15Biennial State Budget. In the subsequent months, theWisconsin State Legislatures Joint Finance Committee,as well as the State Assembly and Senate will addressseveral important matters impacting all acets o thelong-term care continuum, notably the states Medicaid

budget and the uture o the Family Care program.

In the Winter 2013 Continuum, we oer an editionlled with useul inormation on issues acing memberso the long-term care provider community, including:

The state and ederal legislative landscape orlong-term care providers in the coming session;

The use o antipsychotic medications;

The implications o the Aordable Care Act orlong-term care providers;

The importance o providers participating in theAHCA/NCAL National Quality Award process;

The implications o the Wisconsin SupremeCourts Helen E.F. Decision or providers servingindividuals with challenging behaviors.

Traditionally, Wisconsins long-term care provcommunity has been politically alert and active. as we enter this legislative session, we must do so wintensied resolve and involvement. Members o provider community that have, in the past, watchrom the sidelines must enter the playing eld to assthe legislative and regulatory process acknowledunderstands and responds to their needs and concer

WHCA/WiCAL is truly proud to represent individual and collective interests o Wisconsins skinursing and assisted living acilities. In the year ahe

major issues impacting our states entire long-tecare continuum will garner greater attention in bin Washington and Madison. WHCA/WiCAL andmembership will be prepared to assure their voice amessage ring loud and clear throughout the discussiin which these issues are addressed and resolved.

Sincerely,

Thomas P. MooreExecutive DirectorWHCA

Why ?

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Brian PurtellExecutive Director

WiCAL

WINTER 2013


3/13

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CntentsWinter 2013

6CLINICAL CoRNER

Surveillance o Atypical Antipsychotic Drug Use is ComingRecent surveys have increased concern regarding the use o antipsychomedications. Are you ready or the implementation o CMS regulations? Fout the details.

MEdIA MATTERS

Going or the Gold:Participating in the Natinal Quality Awar Prcess is a Win r EeryneThe AHCA/NCAL National Quality Award process has a three-tiered systemparticipation that oers long-term care providers a series o measurable critto gauge their progress in providing quality long-term care. In 2012, GoldLivingCenters Continental Manor in Abbotsord, WI was one o two acil

in the country to be recognized with this impressive distinction. By participain the National Quality Award process, acilities truly go or the gold makina win or administrators, sta and, most importantly, the residents they care

CAPIToL CoNNECTIoN

At the Table or On the MenuEntitlement Reform, the Fiscal Cliff an their Effects on Long-Term Care ProviAs a proession, long-term care relies on ederal and state governments80 percent o its reimbursement. Yet, even ater all o the cuts long-term providers sustained as a result o sequestration, bad debt, health care reorm, sMedicaid cuts and more, Congress continues to look to the provider commuto sacrice. The head o AHCA/NCAL oers his perspective on how we musour lawmakers know about the impact their decisions have on those we care

CovER SToRY

The Budget Issue: Elections Over. Governing Begins.The conclusion o the November 2012 elections shited the political powerWisconsin State government back to the Republicans as they captured controthe State Senate, where hal o the seats were up or re-election, and maintaitheir majority in the State Assembly. Now attention turns to the states bienbudget process and eorts to oster job creation, review the states mining lacreate a venture capital und or entrepreneurs, and balance the Medicaid bud

STAkEHoLdER SPoTLIGHTThe Aordable Care Act is Here to StayNew Taxes an Fees Uner obamacareOn November 6, 2012, the American people re-elected Barack ObamaPresident o the United States or a second term, and with the re-election ca

the realization that the Aordable Care Act is here to stay. Are you ready orimplementation o CMS regulation?

LTC LEGAL LETTER

Balancing Rights and SaetyWhat the Helen E.F. decision Means for Laws Governing Challenging BehavTheWisconsin Supreme Courts decision in the Helen E.F. case relating totreatment o Alzheimers Disease in Wisconsin Statutes presents importlegislative challenges that are expected to be addressed in coming legislative sessWhat the Helen E.F. case and the Legislative Council Study Committee meansthe uture treatment o residents with challenging behaviors in long-term care.

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Continuumis publishe r the

Wisconsin Health Care Association

and the Wisconsin Center or

Assisted Living

131 W. Wilsn Street, Suite #1001

Maisn, WI 53703

Phne: 608.257.0125

Fax: 608.257.0025

www.whcawical.rg

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Publisher

dean Gille

Editor

Abbie Mcdwell

Account Manager

kris Hlen

Creative Director

Sara Rice

Layout & Design

dai Cx

Published by

1155 Wilburn Ra

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For more inormation in advertising in

Continuumcall 608.257.0125.

I you are planning on moving and

would wish to continue receivingContinuum, call 608.257.0125 and

inorm WHCA/WiCAL o your new

address.

2012 Bager Graphic Systems.

All rights resere. The cntents this

publicatin may nt be repruce by

any means, in whle r in part, withut

prir written cnsent the publisher.

PUBLISHEd dECEMBER 2012

WINTER 2013INUUM | www.whcawical.rg


4/13

Surveillance o AtypicalAntipsychotic Drug Useis ComingBy Patricia Boyer and Gail Robison

In July 2012, the U.S.Department o Health &Human Services Ofce o InspectorGeneral (OIG) released resultsrom a study indicating nearlyall records reviewed 99 percent ailed to meet one or moreederal requirement or residentassessments and/or care plans. Thesample was a total o 375 Medicarenursing acility records randomlyselected rom a previous OIG studyo 640 nursing acility records romJanuary-June 2007.

A previous OIG study reportedabout hal o the antipsychoticdrugs being utilized by skillednursing residents were not givenor medically accepted indicationsand one-fth o the drugs were notgiven in accordance with ederalsaeguards to protect residents romunnecessary antipsychotic drug use.

In Wisconsin, there have beeneorts to limit the utilizationo antipsychotic medications inlong-term care acilities. In 2010,legislation was signed into lawrequiring that skilled nursingacilities obtain written inormed

consent when an antipsychotic drugthat has received a ederal Food andDrug Administration black boxwarning is prescribed or a p atientwith a degenerative brain disorder.

While the prevalence o antipsychoticmedication prescriptions is wellunder the national average or short-and long-stay residents in Wisconsin,there is always room or improvement.

As a result o concerns about theutilization o antipsychotics, OIGrecommend CMS:(1) improve the detection onon-compliance with ederalrequirements or resident assessmentsand care plans or residents receivingantipsychotic drugs,(2) take appropriate action toaddress non-compliance with therequirements, and(3) provide methods or nursingacilities to enhance the developmentand useulness o resident assessmentsand care plans.

CMS concurred with all OIGrecommendations with some changesalready in place through a multi-dimensional improvement approach.

What specics did the study identiythat nursing homes can process orquality assurance and perormanceimprovements? Related to the RAIMDS requirements complianceidentied: 28 percent did not includequarterly MDS assessments, 12

Clinical Crner

percent did not include comprehensiveassessments, and 10 records lackedevidence o an RNs coordination othe RAP assessment.

The study reported 33 percento the oundational assessments(e.g. Braden, all risk assessment,nutritional assessment) were outo compliance: records withoutdocumented psychotropic drugRAPs (now CAAs) and 46 percent orecords indicated that an RN solelyconducting the assessment. Therewas only one example o documentedassessment by the appropriatelyqualied practitioner: psychiatrist,geriatrician and/or psychologistalong with only two care plansinvolving such practitioners.

Federal care plan requirements were notmet in 99 percent o records reviewed.Care plans were not developed by theinterdisciplinary team: 20 percento records indicating an RN, socialworker, or LPN was solely responsibleor developing the care plan. Lessthan 5 percent o records containedcare plans developed by at least ageneral physician and an RN. Asrequired to the extent practicable, 91percent o the records did not containevidence that the resident, amily/legalrepresentative or physician participatedin the plan o care process.

The decision-making processidentied conusion between residentassessments and care plans: 98records indicated they did not intendto develop care-plan interventions orpsychotropic drugs, but 54 percento the 98 records sta had developedthe interventions. However, 18percent o the records that listed careplan interventions or antipsychoticdrug use did not contain evidenceo the interventions. Monitoringo psychotropic drug interventionsin the care plans ound blank orincomplete in several cases.

The ndings cross over many aspects othe antipsychotic drug use managementcare system in the nursing homepractice. The response to the OIGissues included the ollowing:National CMS initiative to

improve behavioral health anddementia care and to reduceantipsychotic drugs in thenursing home by 15 percent.

CMS plans to strengthen theState Operations Manual relatedto documentation o residentand amily involvement inassessment and care planning.New surveyor guidance isexpected to emphasize medicalrecord compliance, and sta,resident or amily interviews.

CMS expanded the sampling oresidents receiving antipsychoticmedications in the QualityImprovement Survey process.

Clariying guidance/policy revisionsrelated to deciency determination,and enorcement remedies will beprovided in mandatory surveyortraining programs.

Public-private partnerships includingconsumer awareness, developmento consumer educational materials.

A new quality indicator (QI) willbe posted on the CMS NursingHome Compare website. Ashort-stay incidence indicatorwill be posted (would indicatethe number o residents whoadmit without an antipsychoticmedication that are startedon such medication ateradmission).

Enlistment o qualied health

proessionals, technical assistance,tools, resources and research to adviseand assist in improvement strategies.

The OIG study can be reviewedon the website under the listing:Nursing Facility Assessments andCare Plans or Residents ReceivingAtypical Antipsychotic Drugs.

On September 27, 2012, CMSollowed through on theserecommendations by publishingS&C: 12-45-NH InterimGuidance and revisions to StateOperations Manual, Appendix P Traditional Survey Protocol or LTC.These rules were eective December1, 2012. The changes in the surveyprocess has a lot o ocus on use opsychoactive drugs.

The areas impacted include:Education o sta in care o

dementia residents and howto address behavioral andpsychological symptoms odementia (BPSD).

How the acility monitors theuse o psychopharmacologicalmedications, specicallyantipsychotic medications.

Administrator will be asked or alist o residents who are receivingor have received antipsychoticmedications over the past 30 days.

This increased ocus on use oantipsychotic drugs allows thesurveyors to work toward meetingthe objective CMS has to reduce thepercent o drugs utilized.

How does this all apply to theAssisted Living environment?

Regulations may not be in plathey are in Skilled Nursing Facihowever, the ocus is the same.is played out in the bill that is bU.S. Congress. The introductia bipartisan bill that would cHHS to require inormed cobeore prescribing antipsycdrugs to nursing home and asliving residents. The bill (S. 3would also establish monthly rcards on each homes use o the d

So, no matter what area in whichwork, use o antipsychotic drugissue you need to be aware o antake steps to prevent inappropuse o antipsychotic drugs in yoacility.

Or Nion-Wie HelhcreConsling Services:

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Patricia J. Boyer

Percent o short-stay residents whonewly received an antipsychoticmedication. Lower percentages are better.

WI Average National Average

1.9% 3.0%

Percent o long-stay residents whoreceived an antipsychotic medication.

Lower percentages are better.

WI Average National Average

19% 23.7%

Patricia Boyer is the President oBoyer and Associates. Gail Robinsois a long-term care consultant.Ms. Boyer can be reached [email protected] Robinson can be reached [email protected].

Source: Medicare.gov

WINTER 2013INUUM | www.whcawical.rg


5/13

Going or the Gold:Participating in the Natinal Quality

Awar Prcess is a Win r Eeryne

By John J. Vander Meer

Do the difcult things while they areeasy and do the great things while theyare small. A journey o a thousand

miles must begin with a single step.Lao Tzu

Each year, the American HealthCare Association and theNational Center or Assisted Living

(AHCA/NCAL) receive applicationsrom hundreds o acilities rom acrossthe country applying or recognitionas a skilled nursing acility or assistedliving community that provides high-quality care or their residents.

Crated ater the prestigious BaldrigePerormance Excellence Program,the AHCA/NCAL National QualityAwards are organized into threecategories Bronze, Silver and Gold.In order to be considered or the nextaward category, one must completethe previous level. Consequently, theroad to receiving a Gold NationalQuality Award can be a long journey.

In 2012, Golden LivingCenter Continental Manor in Abbotsord,WI was one o only two acilities inthe countryto be recognized with theimpressive distinction o being a Gold

National Quality Award recipient.

It has been a long journey thatwe started back in 1999, saidTrudy Erickson, Nursing HomeAdministrator or Golden Living

Center Continental Manor(GLCM). The process keeps youso ocused on quality year ater yearthat it eventually leads to the kind oquality that youre aiming or.

Erickson said GLCM won the BronzeAward in 2000 and the Silver Awardin 2005, and began applying or theGold Award in 2009.

We knew all along that our stahad the ability to provide that levelo quality care to our residents,said Erickson, who said she includedGLCM sta in almost every aspect othe Quality Award process.

Ultimately, Erickson said it was the worko the sta that made attainment o theGold National Quality Award possible.

Theres always room or improvementno matter where you work, she said. Itsabout ensuring the sta that you employis made up o people who put their heartsand souls into caring or people.

By participating in the NationalQuality Award process, acilities cantruly go or the gold making it awin or the acility all the way around

administrators, sta and, mostimportantly, the residents they care or.

Theres an old saying nothingsucceeds like success. And, byparticipating in the National Quality

Award Process, acilities can improvethe quality o care their residentsreceive and administrators and stadevelop their acilitys reputation asthe community to be in i/when thetime comes.

It will be a great marketingopportunity or us, Erickson said.

Since the award, Erickson saidthe acility has been the subject oseveral articles in local and nationalpublications, and theres been a buzzabout it in Abbotsord, a communityo about 2,500 people.

What advice does Erickson oeracilities looking to go or the Gold?

WHCA/WiCAL and AHCA/NCAL notications we stay on topo that inormation, she said.

On behal o WHCA/WiCAL, I saythats good advice and congratulationsto Golden LivingCenters ContinentalManors clinical and administrativesta on this well-deserved award.

Meia Matters

John J. Vander Meeris the Director oCommunications

or the WisconsinHealth CareAssociation and theWisconsin Centeror Assisted Living.

He can be reached at: [email protected]

Congratulations to Golden LivingCenter Continenta

Manor in Abbotsford, Wisconsin for receiving the Go

AHCA/NCAL National Quality Award!

From the dedication of leaders and staff, to the processes built

quality care, to the family environment created through custom

and community focus, our goal is to achieve clinical results and

exceed expectations.

The minute you walk in the door, you know you have stepped in

a center where people care so deeply about one another that t

have become family. Golden LivingCenter Continental Manor

sharing our passion for improving quality of life through innovat

healthcare one person, one family and one community at a tim

Qualified applicants considered without regard to race, color, religion, gender, sexual orientation /gender identity, veteran status, national origin or disabDrug-Free Workplace GLS-00-0000

Golden LivingCenter - Continental Manor

600 East Elm Street

Abbotsford, WI 54405

715-223-2359

www.GoldenLivingCenters.com/ContinentalManor

Fr mre inrmatin n hw t apply

r the Natinal Quality Awar g t:

qa.ahcancal.org

Application Deadlines:

January 31: Brnze Quality Awar

February 28: Siler an Gl

WHCA/WiCAL is please t annunce the re-launch the member inrmatin serices n www.whcawical.org , an ur

new weely electrnic newsletter,CareConnection. Fr mre inrmatin n benefts membership call (608) 257-0125.

INUUM | www.whcawical.rg


6/13

At the Table or On the MenuEntitlement Rerm, the Fiscal Cli an

their Eects n Lng-Term Care Priers

By Gov. Mark Parkinson

Capitl Cnnectin

Ive said it many times: I truly believewe are in a time o extraordinaryopportunities and remarkable challenges.

Today, 10,000 Americans turned 65.By 2030, there will be 72 millionolder persons in this country. We havethe opportunity to care or millions

o Baby Boomers in our assistedliving and skilled nursing centers.Even though many centers are alreadyseeing increased demand or ourservices, it is only beginning.

At the same time, we ace some dauntingchallenges. We rely on ederal and stategovernments or 80 percent o ourreimbursement. In a healthy economywith productive state and ederalgovernments, this reimbursementsystem has protected us rom theperiodic economic fuctuations.Unortunately, the ederal government

is broken, and our national and stateeconomies are slowly recovering romthe worst recession since the 1930s.Everyone rom governments toindividuals is looking or ways to cutback spending. We are admonished todo more with less.

I have been asked time and time againwhether our proession can survive

these dicult times. My answer isalways the same: I am condentthat we will survive and thrive.The dedication o the people whowork in this proession is amazing.As individuals, as companies and asa proession we can emerge romthis stronger than ever. But it wont be

easy. We will have dicult choices tomake. We will have to commit to thehard work that is needed to succeed.

The rst thing we must do is becomethe cost and quality solution. We arealready making great strides in quality.The number o centers recognizedby CMS as a our- or ve-star hasincreased 30 percent since 2009.Nearly hal o all skilled nursingcenters nationwide are participatingin Advancing Excellence and 22percent o our members have earneda Bronze, Silver or Gold NationalQuality Award.

We know that providing quality care isthe right thing to do. But we also knowthat uture payment models will requireus to continuously improve quality.

The Quality Initiative we launched in

February 2012 will help us reach newheights in quality o care. We have setaggressive, measurable goals to saelyreduce hospital re-admissions, reachhigher levels o customer satisaction,retain more employees and reduce the o-label use o antipsychotic medications.When we get every member on the pathto showing better health outcomes at alower cost, we will thrive.

Continuous improvement in qualitycare is critical, but that alone is notenough. We also must be a politicalpowerhouse rom coast to coast. Inour state capitols and in Washington,D.C., we must become a powerullobbying voice that cannot be ignored.From scal cli negotiations to one-o pieces o legislation, we must letour lawmakers know about the impacttheir decisions have on those we careor, those we employee and those wesupport in our communities.

Long-term and post-acute care acesan ongoing threat o additional budgetcuts as the ederal government attemptsto reduce the decit and debt. Evenater sequestration, bad debt, healthcare reorm, state Medicaid cuts andmore, Congress continues to look toour proession to sacrice.

We are doing everything possibleto combat the current proposals.We launched a multi-week mediacampaign inside Washington, D.C.including radio, television and printadvertisements designed to reachmembers o Congress and theirsta. We hosted several fy-ins, soour state leaders can meet personallywith policymakers on Capitol Hill.And well continue to leverage therelationships we have built on the Hill.But sometimes the best messenger isthe one in the trenches.

To ensure we reach our goals, we needyour help. There are many ways youcan get involved.

Become a part o our Quality Initiative.You can nd more inormation aboutthe goals, resources or individualacilities and more online atqualityinitative.ahcancal.org.

Sign up or Advancing Excellence atwww.nhqualitycampaign.org.

Apply or an AHCA/NCAL QualityAward at qa.ahcancal.org.

Sign up or our grassroots eorts tocontact your Members o Congress.You can register in CapWiz online atwww.ahcancal.org/advocacy.

Contact your Member o Congress.Set up a meeting when they are inyour state, or come to Washingtonor a fy-in and meet with them onCapitol Hill. And then tell us aboutit: [email protected].

This summer, AHCA/NCAL createda new mission statement or ourorganization: improving lives bydelivering solutions or quality care.Our mission statement signals a newdirection or our proession. Wehave a renewed ocus on quality. Webring solutions to the table. We are apolitical and lobbying powerhouse.

The patients and residents we careor every year, their amilies and ouremployees are counting on us. Ourmission is much more than just wordson paper. Its a signal to our audiences state, ederal and everywhere inbetween that we are truly committedto surviving and thriving in theseextraordinary times.

Thank you or the work you do everyday. I look orward to working withyou to improve lives in 2013.

Governor MarkParkinson is the

President and CEOo the AmericanHealth CareAssociation and theNational Centeror Assisted Living.Beore leading

AHCA/NCAL, the native Kansan wasa successul businessman, state legislator,and most recently served as the 45thGovernor o the State o Kansas. Hecan be reached at [email protected].

Wisconsin Congressional Delegation

Ron Johnson (R) rn jhnsn.senate.g 202.224.5323

Tammy Baldwin (D) b al w in .s en at e.g 202 .224 .5653

Wisconsin Congressional District 1. Counties served: All Racine ankensha; prtins Walwrth, Wauesha, Milwauee an Rc

Paul Ryan (R) p au lr yan.hus e.g 202 .225 .3031

Wisconsin Congressional District 2. Counties served:All dane, GreeIwa, Sau an LaFayette, prtins Rc an Richlan.

Mark Pocan (D) pcan.huse.g 202.225.2906

Wisconsin Congressional District 3. Counties served: All Aams,Bual, Crawr, dunn, Eau Claire, Grant, La Crsse, Pepin, Pierce, Prtage, Trempealeaan vernn. Prtins Chippewa, Jacsn, Juneau, Mnre, Richlan an W.

Ron Kind (D) in.huse.g 202.225.5506

Wisconsin Congressional District 4. Counties served: MilwaueeCunty, incluing 1) that part the city Milwauee lcate in the cunty, an 2) theillage West Milwauee an the cities Cuahy, St. Francis an Suth Milwauee.Baysie, Brwn deer, Fx Pint, Glenale, Shrew an Whitefsh Bay.

Gwen Moore (D) g wenm re .h u se .g 202 .225 .4572

Wisconsin Congressional District 5. Counties served:All Jeersnan Washingtn; prtins dge, Milwauee an Wauesha.

F. James Sensenbrenner, Jr. (R) sensenbrenner.huse.g 202.225.5101

Wisconsin Congressional District 6. Counties served:All Clumbia,Fn u Lac, Green Lae, Manitwc, Marquette, ozauee, Shebygan an Waushara.Prtins dge an Winnebag.

Thomas E. Petri (R) petri.huse.g 202.225.2906

Wisconsin Congressional District 7. Counties served:All Ashlan,Barrn, Bayfel, Burnett, Clar, duglas, Flrence, Frrest, Irn, Langlae, Lincln,Marathn, oneia, Pl, Price, Rus, Sawyer, St. Crix, Taylr, vilas an Washburn;prtins Chippewa, Jacsn, Juneau, Mnre an W.

Sean Duy (R) uy.huse.g 202.225.3365

Wisconsin Congressional District 8. Counties served: All Calumet,Brwn, dr, kewaunee, Marinette, Menminee, ocnt, outagamie, Shawan anWaupaca; prtins Winnebag.

Reid Ribble (R) r ibbl e. h us e. g 2 02 .2 25 .5 66 5

LEGEND

US Senate

US House o Representatives

District 1

District 2

District 3

District 4

District 5

District 6

District 7

District 8

7

8

12

3

45

6

In our state capitolsand in Washington,

D.C., we must become apowerul lobbying voice

that cannot be ignored.

WINTER 2013 TINUUM | www.whcawical.rg


7/13

Medicaid

CommitteAssignments

2013-15Bud

get

JointFinance

Family

Care

Affordable

CareAct

AssemblyElections

The November 6, 2012 electionsshited the political power inWisconsin State Government back tothe Republicans as they captured controlo the State Senate and maintained themajority in the State Assembly.

In the 33-member State Senate, theRepublicans regained the majorityand will control the chamber, 18 to15. The Senate Republicans will be ledby Majority Leader Scott Fitzgerald(R-Juneau), while the Democratswill be led by Minority Leader ChrisLarson (D-Milwaukee).

In the 99-member State Assembly,Republicans maintained their majorityand will control the Chamber 60 to 39.The Assembly Republicans will be ledby Speaker Robin Vos (R-Rochester),while the Assembly Democrats willbe led by Minority Leader Peter Barca(D-Kenosha). It is important to notethat 25 o the 99 members o theAssembly are reshman Legislators and29 members will be serving in justtheir second term.

THE BUDGET

As the Legislative session begins,most o the attention will be ocusedon Governor Scott Walkers proposed2013-15 biennial budget bill tobe introduced in February. TheGovernor has indicated that his top 5priorities or inclusion in his proposedbudget bill will be job creation, taxcuts, transorming education andworkorce development, reorming

THE BUDGET ISSUE:

Elections Over.Governing Begins.By James McGinn

Cer Stry

government, and investing intransportation inrastructure.

As Governor Walker prepares hisbudget, scal inormation will beconstantly revised and updated asrevenues and expenditures change.

Legislators and most observers othe budget process will rely on theLegislative Fiscal Bureaus January2013 report on revenue estimatesand state agency budget requeststo accurately refect and project thestates scal condition.

The LFB is a nonpartisan serviceagency o the Wisconsin Legislature.The Bureau provides scal andprogram inormation and analysesto the Wisconsin Legislature, itscommittees, and individuallegislators.

The Bureau also serves as sta tothe Joint Finance Committee the16-member committee whichreviews and deliberates on legislationaecting state revenues andappropriations. The primary ocuso the Committees work, and thus,

that o the Bureau, in each legislativesession is the states biennial budget.

While the Governor will alsoconsider the Fiscal Bureaus analysis,the Department o Administrationsubmitted its own revenue estimatesand agency budget requestto his oce latelast year

one-hal year period, rom now untilJune 30, 2015, and there is greatuncertainty with the ederal budgetand payments to states.

All state agencies were instructedby Governor Walker to submittheir budget requests to SecretaryHuebsch maintaining spending at,or below, state scal year 2012-13levels. Secretary Huebsch reportedthat state agencies have requestedan additional $529 million in stategeneral purpose revenue (GPR-orstate tax dollars) in scal year 2013-14 and $540 million (GPR) in 2014-15, or $1.7 billion or the biennium.

DHS BUDGET PICTUREAreview o the Department o HealthServices budget includes a request oran additional $658 million (GPR)or the Medicaid program alone. TheDepartments request includes $248million due to a decline in ederalMedicaid matching rates rom thecurrent 60.32 percent to 59.02 percentin scal year 2014 and 58.79 percentin scal year 2015. The Departmentalso requested $410 million to refectthe cost to continue the Medicaid

program based on enrollmentprojections and estimated

expenditures per enrollee.

While the $410 million cocontinue request is substantialDepartment explained that important actor is the ondemand or long-term care servicseniors and people with disabIn state scal year 2011, longcare expenditures reached nearlybillion and accounted or 43 peo total Medicaid expenditureshould be noted the Departmunding request or Family Carother programs (PACE/PartneIRIS) assumes these programs rin existing service areas with no uexpansion into new counties.

Per past instructions, the Depardid not include in its requesadditional dollars or rate incor Medicaid providers. That deis made by the Governor Administration sta.

WHCA/WiCAL PRIORITIESThe top priority or WHCA/Win the 2013-15 biennial budto include a provision that dall o the unding derived romnursing home bed tax to supimprovement in nursing hresident care. In the current year, 2012-13, approximately million have been skimmed the nursing home bed tax andor other purposes.

Our message is to eliminateskim and return and rededicao the nursing home bed tax revto its original purpose, suppo

which included the ollowinganalysis.

In a November 20, 2012 letter toGovernor Walker and the Legislature,Department o AdministrationSecretary Mike Huebsch noted thatWisconsins budget is in a muchstronger position than two years agoand we are on track to end the 2011-13 biennium with a $348 milliongross ending balance. This is goodnews as just 2 years ago the 2011-12 Legislature was aced with a $3.6billion structural decit and wascalled into session immediately toaddress the decit and x our statesscal problems.

With respect to the next two scalyears, Secretary Huebsch expectsrevenue to increase by $518 millionin scal year 2013-14, and anadditional $502 million in scal year2014-15. Again, this is good news,but Secretary Huebsch cautions that

revenue estimates covermore than a

two and

In state fscal year

2011, long-term carexpenditures reachednearly $2.9 billionand accounted or43 percent o totalMedicaid expenditu



8/13

and improving the care or theelderly and disabled who reside inWisconsins nursing acilities.

The same biennial budget process hasbeen ollowed or years. GovernorWalker will introduce his proposedbudget bill in February, the billwill be reerred to the Joint FinanceCommittee or review and approvalby Memorial Day, and both Housestypically debate the measure in Juneand pass it by July 1. Both MajorityLeader Fitzgerald and Speaker Voshave stated that timely passage o abalanced budget is the top priority othe Legislature.

The biennial budget bill is themost important bill during the rst6 months o session. While the

Department o Health Services $8billion annual budget is the long-term care provider communitys toppriority, the budget also includesunding or K-12 public schools,the University o Wisconsin System,Corrections, Shared Revenues, stateemployee compensation and ringebenets, transportation unding androad construction, possible changes

in income tax and other tax policy,all with the goal o balancing thebudget and limiting state debt.

In addition to the return andrededication o the nursing homebed tax skim in the budget bill,WHCA/WiCAL will be advancinglegislation that:Permits the use o ormularies

by skilled nursing acilities andother qualied practitioners;

Allows a nursing home totranser licensed beds to anotheracility located anywhere inWisconsin i the transerringand receiving nursing homesnotiy the Department o theproposed transer within 30 daysbeore the transer occurs andthe Department reviews and

approves the transer;Requires the Medicaid program to

recognize and und its share o theadditional costs all long-term careproviders will incur as required bythe Aordable Care Act;

Addresses provider concerns withFamily Care program, including:provider contracts, rate changes,operational ineciencies, and anenorcement/appeals process.

MANY ISSUES FACING LEGISLATUREOther issues expected to be discussedand debated in the Legislatureinclude revisiting mining legislationthat ailed to pass the Senate bya single vote last year. Miningcompanies have expressed a stronginterest in revising state laws, theybelieve prevent the opening o aniron-ore mine in Iron and Ashlandcounties. Another initiative thatailed to pass last session and is apriority o legislative leadership isto advance a venture capital bill toencourage economic developmentand job creation. Also, since thecourts have blocked a requirementor photo identication or votingpurposes, Legislators have expresseda desire to modiy the photo IDlaw to comply with possible legalproblems with the law.

WHCA/WiCAL expects theWisconsin Legislature to have a busysession with a ocus on a balancedbudget bill, job creation eorts,and a watchul eye on WashingtonD.C. We will again be requestingthe membership to assist us to ensurethe concerns o all long-term careproviders are considered in Madison.

The WHCA/WiCAL LegislativeDay will be held on March 26, 2013at the Inn on the Park, located onthe Capitol Square. We encourageall members to attend this importantevent. Please stay tuned to CareConnection, WHCA/WiCALs weeklyelectronic newsletter, as details on

this event will be orthcoming.

James McGinnis WHCA/WiCALs Directoro GovernmentRelations.He can be reachedat [email protected].

WISCONSIN LEGISLATIVE LEADERSHIP

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Rep. John Nygren

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9/13

On November 6, 2012, theAmerican people re-electedBarack Obama as President o theUnited States or a second term,and with his re-election came therealization that the Aordable CareAct is here to stay.

The initial wave o changes broughtabout by the legislation includedreimbursements, tax credits andmandates intended to bring morerobust health care to the nationsinsured. The second wave is set to hitin 2014 with the dawn o exchanges,the individual mandate and employerplay or pay penalties requires adierent set o changes designed to payor this massive piece o legislation, itscoverage, subsidies, premium creditsand enhanced benets.

This article will discuss the varioustaxes and ees that will be imposedto achieve the ull realization o thislaw, including:Employer Pay or Play PenaltiesPCORI (Patient-Centered

Outcomes Research Institute) FeesReinsurance FeesAnnual Fee on Health Insurance

ProvidersMiscellaneous other taxes

EMPLOYER PAY OR PLAY

PENALTIESIn 2014, all employers, includinglong-term care acilities and nursinghomes, with 50 or more ull-timeequivalent employees will be requiredto provide minimum value healthinsurance coverage that is consideredaordable to ull-time employees

The penalty in this situationwould be either $2,000 per ull-time employee minus the rst 30or $3,000 per subsidized ull-timeemployee, whichever is less. Penaltiesare not paid on part-time employees.

PCORI FEES FOR HEALTH

INSURANCE PLANSHealth insurance plans will be requiredto pay ees to help und the Patient-Centered Outcomes Research Institute(PCORI). The PCORI is a private,non-prot corporation that will assistpatients, clinicians, purchasers andpolicymakers in making inormedhealth decisions by advancing thequality and relevance o evidence-

based medicine through research.

The ees are eective or plan yearsending on or ater October 1,2012. For example, or calendaryear policies and plans the ee isapplicable or the plan year startingJanuary 1, 2012 and endingDecember 31, 2012. The ee is $1per average number o covered livesor plan years ending beore October1, 2013. The ee increases to $2 in2014 and will be increased thereaterbased on a projected per capita rate.The ees will be treated like taxesand will be due on July 31 o everyyear or the preceding plan year.

The ees are imposed on the insurancecarriers (ully insured plans) or plansponsors/employers (sel-unded plans).

REINSURANCE FEES

The ACA establishes a transitionalreinsurance program in each stateto assist in stabilizing premiums or

(30+ hours per week) or pay apenalty. In order to hit the thresholdo 50 or more ull-time equivalentemployees, employers should includeull-time employees (30+ hoursper week) and part-time employees(total monthly hours/120). Seasonalemployees working 120 days or lessare excluded.

Based on current inormation,employers are subject to the penaltyi at least one ull-time employeein their population qualies orsubsidized coverage in an exchange.

I an employer oers no health plancoverage (or oers coverage, but suchcoverage is not minimum essentialcoverage), the penalty is $2,000 perull-time employee minus the rst 30employees. I the employer continuesto oer coverage the coverage mustmeet a minimum value standard(coverage o 60 percent o the costswhich has not been urther dened)and be aordable. Employerswould determine aordability bycomparing 9.5 percent o the ull-time employees W2 income to thecontribution amount required orthe lowest-cost single coverage which

provides minimum value.

The Aordable Care Actis Here to StayNew Taxes an Fees Uner obamacare

By Karen J. W. Breitnauer, J.D.

Staehler Sptlight

Pay or Play Penalty Example

No Health Plan Oered Penalty = $2,000/FTE 30 employees

Employer Continues toProvide Plan

Penalty = Lesser o $2,000/FTE 30employees OR $3,000/subsidizedemployee

coverage in the individual market orindividuals with higher cost needs toobtain coverage during the rst threeyears o exchange operation (2014-2016).

All health insurance carriers (ullyinsured plans) and Third PartyAdministrators (TPAs or sel-undedplans) will make payments to supportthe reinsurance payments to individualcarriers. This applies only to majormedical plans. States will have theoption to establish the reinsuranceprogram. I the state does not establisha reinsurance program, the U.S.Department o Health and HumanServices will establish the program andperorm the unctions or that state.

HHS has proposed initial paymentso $5.25 per covered lie per month(or $63 annually) in 2014.

ANNUAL FEE ON HEALTH

INSURANCE PROVIDERSThe ACA imposes an annual ee onhealth insurance providers eectivewith respect to premiums writtenin 2013. Fees are based on the totalamount o premiums each insurerwrites compared to other insurers.These ees are imposed only onhealth insurance carriers and not onemployers that provide sel-undedbenets to employees.

The total amount payable by healthinsurance providers subject to thetax will equal $8 billion in 2014,$11.3 billion in 2015 and 2016,$13.9 billion in 2017 and $14.3billion in 2018. Ater 2018, theamount o excise tax is indexed tothe rate o growth o the premiums.Health insurance providers will owea percentage o the annual dollaramount based on the providers netpremiums written or the precedingyear and divided by the net premiumswritten by all o the health insuranceproviders subject to the tax or thepreceding year.

Cadillac Tax on Highplans in 2018 40 percent tax on high cost plans currdened as $10,200 annualon individual plans and $27annual limit on other

individual plans.

The Aordable Care Act is here toUnderstanding the various ees,penalties and other costs assocwith it will be crucial as the provo this law continue to unwind.

ADDITIONAL TAXESUnder the ACA the ollowingadditional taxes will be imposed:Medical device excise tax on the

sale o certain medical devices bythe manuacturer, producer or

importer o the device. The taxapplies to sales ater December31, 2012. The tax is 2-3 percento the price or which themanuacturer or importer sellsthe taxable medical device.

Individual mandate tax o$95 annually to person who ailsto maintain minimum essentialcoverage. The cost rises to $695per uninsured person in 2016.

Increase o Medicare payroll taxo .09 percent on individualswho earn $200,000 or more peryear or amilies that earn morethan $250,000 per year.

Increase o unearned income taxto 3.9 percent on individualswho earn $200,000 or more peryear or amilies that earn morethan $250,000 per year.

Karen Breitnauerleads M3sGovernmentalCompliance Unitwhich researches areports on regulatoand legislative issuto clients and M3

sta. She is licensed to practice law iWisconsin and is a member o the SBar o Wisconsin, Health Law SectiShe can be reached [email protected].

WHCA/WiCAL AFFORDABLE CARE ACT PREPARATION SEMINAR

WHO:Robert Semandel, ESQ. o Jackson-Hewittand Sean LaBorde, RHU o M3 Insurance Solutions or Business.

WHEN: February 6, 7 and 8, 2013

WHERE:

Appleton: Holiday Inn, 150 Nicolet Road - 920-735-9955

Eau Claire: Holiday Inn, 2703 Craig Road - 715-835-2211

Brookfeld: Midway Hotel Brookeld, 1005 S. Moorland Road -262-786-9540

REGISTER: www.whcawical.org

ACA PROJECTED HEALTH INSURANCE PROVIDER FEES(IN BILLIONS $)

$8B

2014

$11.3B

2015

$11.3B

2016

$13.9B

2017

$14.3B

2018

4

6

8

10

12

14

16



10/13

51. Since her disability was likely to bepermanent, she was thereore a propersubject or protective placement andservices under Chapter 55. The Courtalso analyzed the purpose o the statutesand ound Chapter 55 presented a betterbalance o Helens interest in liberty andthe Countys interest in protecting thepublic and providing Helen with care.

Three specic eatures o Chapter55, not ound in Chapter 51 include:placement options, the involvemento a Guardian ad Litem, and the needor long-term care versus short-termtreatment and rehabilitation. TheCourt concluded that the eatures oChapter 55 are more appropriate orindividuals with Alzheimers or relateddementias, and that Chapter 51 bereserved or individuals with mentalillness or purposes o treatment. Oparticular note, however, was thatthe Court did not rule on whether anindividual who has a dual diagnosis oboth mental illness and dementia couldbe involuntarily committed underChapter 51. Instead, the Court let thisissue or another day.

FALLOUTFollowing the Helen E.F. decision, mostcounties have modied their proceduresin the area o situations involvingaggressive or dangerous individualswith Alzheimers or related dementias.Providers are increasingly conrontedwith inormation rom county ocialsthat law enorcement or others are notauthorized to initiate an emergencydetention or an individual who clearlyhas dementia. The application o thesedecisions varies slightly throughout thestate with some counties using a moreexpansive interpretation, particularlywhen an individual may have both someunderlying mental illness and dementia.

LEGISLATIVE COUNCIL COMMITTEEA Joint Legislative Council Committeereviewed the options and possiblelegislative changes to address some

ultimately results in modicatioChapters 51 and 55 remain to bebut it is imperative that the procommunity communicate their to their legislators.

While it is only a small subindividuals that present signibehavioral challenges, providers awith such instances will certainlythat they consume a disproportiamount o time, energy and resoto protect the resident and othis hoped that the legislative chwill aord a sae and eective oor individuals with Alzheimerdementia to receive the necessaryand treatment so as to protect themothers around them.

For more inormation, or to keep ao developments in this area visLegislative Council webpage localegis.wisconsin.gov/lc/commistudy/2012/alz, or write me usincontact inormation listed below.

o the issues raised in the Helen E.F.decision. This Committee exploredthe development o modicationsthat would address the inadequacieso Chapter 55 or acute emergencysituations. Those amiliar with Chapter55 recognize that while the Chapterprovides additional protections andprocedures or individuals in need oprotective placement or services, thisalso comes at a cost o time whichmay be crucial or acute situations.I Chapter 55 is a more appropriateavenue or individuals exclusively withAlzheimers or related dementias giventhe additional protections aorded,modications are necessary in order toshorten the timerames to allow this tobe a viable option when an emergencyexists.

Additional stumbling blocks exist withregard to the denition o an inpatienthealth care acility where a protectiveplacement would be made. WhileCommittee members generally agreedthat it may be better or individualswith Alzheimers and dementia tobe placed in a setting exclusive to

this client population, the realities ohospitals or other similar providerscreating dedicated and separate unitsto provide such services and treatmentmay be impractical or cost-prohibitive.

It is hoped that the Committeewill advance recommendations orlegislation to be considered during thenext legislative session. Whether this

Brian Purtell isWHCA/WiCALs

Legal Counsel,Executive Directoo the WisconsinCenter orAssisted Living,and is a member

o the Legislative Council StudyCommittee on Legal Interventionsor Persons with Alzheimers Diseaand Related Dementias. He can bereached at [email protected].

Wisconsins long-term careprovider community providestremendous care and services to a widevariety o individuals, in various settings,throughout the state. A very small butimportant subset o individuals servedpresent unique challenges, particularlywhen, due to underlying conditionsor progressive deterioration, causesan individual to create a danger tothemselves or others.

Historically, the avenue o last resortmay have been a Chapter 51 emergencydetention or involuntary commitmentwhen the provider was unable to addressthe needs o the individual. Whilethis process was sparingly used orindividuals with Alzheimers or relateddementias, it was an option prior to theHelen E.F. case.

BACKGROUNDFond du Lac County v. Helen E.F. wasdecided by the Wisconsin Supreme

under emergency detention pursuantto Section 51.15. Fond du Lac Countythen initiated a proceeding underChapter 51 to have Helen involuntarilycommitted or treatment. Acommitment was ordered and the courtissued an involuntary commitmentorder in a locked psychiatric unit, whichwas appealed.

The Court o Appeals determinedthat Helen was not the proper subjector commitment or treatment underChapter 51 because Alzheimers diseasewas not a qualiying mental condition.Notably, the Court o Appeals alsostated that since rehabilitation is thepurpose o Chapter 51, the treatmento an Alzheimers disease patient underthis Chapter is inappropriate becauseindividuals with Alzheimers diseasecannot be rehabilitated.

The Court o Appeals decisionwas heard by the Supreme Courtand the Court stated that becauseHelen was not medically capable obeing rehabilitated, she could not beinvoluntarily committed under Chapter

Court in the Spring o 2012, which heldthat a person with Alzheimers diseasedoes not have a Chapter 51 qualiyingillness, and is more appropriatelytreated under the provisions o Chapter55. This decision has created muchconusion and discussion about themost appropriate way to addresssituations when individuals withAlzheimers or related dementias presentacute situations in which they pose arisk to themselves or others.

Helen was an 85-year-old womansuering rom Alzheimers disease,with symptoms including progressivedementia and memory lags. She lived ina nursing home in Fond du Lac or sixyears and began to exhibit agitated andaggressive behavior. She was transportedto a hospital emergency room wherethe behavior persisted and was placedin the hospitals behavioral health unit

LTC Legal Letter

Balancing Rights and SaetyWhat the Helen E.F. decisin Means r

Laws Gerning Challenging Behairs

By Brian Purtell

This decision has createdmuch conusion anddiscussion about themost appropriate wayto address situationswhen individuals with

Alzheimers or relateddementias present acutesituations in which they

pose a risk to themselvesor others.

Brian Purtell, WHCA/WiCALs Legal Council, listens to testimony before the Legislative C

Study Committee on Legal Interventions for Persons with Alzheimers Disease and Related Dem



11/13

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