For the past eight years, I have worked as an Advanced Practice Nurse Practitioner (APRN) in the State of Wisconsin and have operated my own independent clinic. My passion for affordable, accessible healthcare has permeated nearly every aspect of my hectic life, including my new role as a state legislator.

Over the course of my time as a nurse, the healthcare industry has changed drastically. I have worked for large health systems, small ones, clinics, and everything in between. At the end of the day, I got in to nursing so that I can care for my patients, not feed a massive healthcare system. That is why I started my own business: so that I can provide healthcare to those who may not fit into the large systems, if they have astronomical deductibles, or if they do not have insurance at all.

I believe this model of small clinics, operated by nurses, can be replicated across the state and dramatically cut healthcare costs for folks who need it the most. For example, all of the prices for procedures and appointments are posted directly on my clinic’s website – there is not some mystical formula that only the system can understand. The logic is simple: you would never go through a McDonald’s drive-thru for them to only tell you at the end your burger costs $25. You would go down the road to Burger King or Wendy’s, where the prices you know are more competitive. This is how we can bring some sanity back to the healthcare field – the more competitive it is, the market will do its job to cut costs. Just imagine having dozens of these clinics in our area.

One obstacle in the way of this, however, is the fact that nurses in the State of Wisconsin have their hands tied. They are required to pay astronomical prices for collaborating physicians to even have their doors open – and if that physician dies or disappears, they need to immediately shut down. Collaboration is not the issue. I collaborate every day with specialists in nearly every aspect of healthcare for the good of my patients. The issue is the price and risk of having to close my doors because of someone who I may not even talk to on an annual basis somehow vanishes. This has turned off many fellow APRNs from replicating clinics like mine throughout our cities and rural areas.

Currently, 24 states and 2 territories have full practice authority (FPA) for Nurse Practitioners (NPs). Wisconsin made steps towards this goal when Governor Evers issued his COVID-19 emergency order, which eliminated the restrictions placed on NPs to practice without that collaboration requirement. Unfortunately, after the emergency orders were overturned by the Wisconsin Supreme Court, all restrictions were re-instated on the profession. During the COVID-19 pandemic, we learned NPs can have FPA without the negative consequences that some feared. In fact, studies have shown that an NPs outcomes for management of acute and chronic disease are equivalent if not better than a physicians.

Assembly Bill (AB) 396/Senate Bill (SB) 394 brings Wisconsin up-to-date with 24 other states to give Nurse Practitioners FPA. Passing these bills will allow NPs to continue to prioritize patient care and allow NPs to continue excellence in their nursing practice without unnecessary and undue restrictions.

Those opposing these bills have raised concerns about the unlikely event an NP goes “rogue” and attempts to practice outside of the scope of their training. As nurses, this is not how reality works. I have collaborated with physicians and other professionals in every instance that is deemed necessary. To do

otherwise would open me up to severe liability issues and lawsuits, just as it would for a physician who practices outside of their scope.

At the end of the day, all nurses are asking for is a level playing field. We want the freedom to do what we do best: care for our patients.

State Representative Rachael Cabral-Guevara (R-Appleton) represents the 55th Assembly District in the Wisconsin Legislature. Her Assembly district is in Winnebago County and includes the City of Neenah and parts of Appleton.

NOTE: The views and opinions expressed in this article are those of the author and do not reflect the official policy or position of WiAHC. Furthermore, the opinion piece allows WiAHC to gain a better understanding of a health care-related bill from the author’s perspective, but in no way indicates support for or opposition to the proposal.

A group of Republican state lawmakers – including Sen. Pat Testin (R- Stevens Point) and Representative Rachael Cabral-Guevara (R-Appleton) – recently introduced an advanced practice registered nurse bill (AB 396 / SB 394). The proposal creates a new license issued by the Wisconsin Board of Nursing for advanced practice registered nurses (APRNs), which includes Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Certified Nurse Midwives.  

The bill’s authors and supporting nursing organizations claim the legislation and is necessary to help address Wisconsin’s health care provider shortage and provide clarity to the scope of practice of APRNs. They believe it will help provide regulatory flexibility and assist with removing barriers to allow these providers to practice within their scope in underserved areas of the state.

However, other health care provider groups, including the Wisconsin Medical Society have raised concerns over numerous provisions in the bill. They believe the legislation will improperly expand the APRN scope of practice by eliminating the requirement for these practitioners to collaborate with physicians and allow them to diagnose and treat patients independently from a physician.

The legislation, which was introduced earlier this month and is currently under consideration by the Assembly and Senate Health Committees, is supported by the Wisconsin Nurses Association, the Wisconsin Association of Nurse Anesthetists, WPS Health Insurance, and United HealthCare Services. Opposition to the proposal includes the state medical society and the Wisconsin Society of Anesthesiologists.

By Hoven Consulting – WiAHC’s Government Affairs Firm

The Legislature's Joint Finance Committee (JFC) has finished its work on reshaping Gov. Tony Evers' 2021-23 state budget proposal. While the Finance Committee completed their work on time, it was a challenging budget process with numerous moving pieces, including split government, billions of dollars in federal COVID-19 relief aid, and a projected $4.4 billion state budget surplus.

The budget bill must still be approved by the full Legislature and signed into law by Evers, who could also veto the legislation in part or in whole. However, both houses of the Legislature are likely to adopt the budget approved by JFC with minimal changes. 

While the Finance Committee did not include Medicaid Expansion in its spending plan, it did include over $1.5 billion in total funding the state’s Medicaid program and increased spending on several specific initiatives. In addition to the 10 percent Medicaid rate increase for home health care skilled nursing services added to the budget bill, the committee approved increases for personal care and direct care workers as follows:

• Direct Care Workforce Funding: Provide $53.8 million in 2021-22 and $50.4 million in 2022-23 to increase funding for the direct care workforce funding supplement.  
• Personal Care Reimbursement: Provide $18.9 million in 2021-22 and $59.3 million in 2022-23 to increase hourly rates paid for personal care services to $20.69 on January 1, 2022, and to $22.35 on January 1, 2023. 

Please find below an overview of additional Department of Health Services and Medicaid-related provisions included in the JFC-approved version of the budget bill:

Medicaid

• Medical Assistance Cost-to-Continue Estimate: Provide funding of $1.3 billion in 2021-22 and $1.25 billion in 2022-23. In addition, adjust the cost-to-continue re-estimate to provide $25,900,000  in 2021-22 and $51,400,000 in 2022-23, reflecting the impact of the Department's proposed rate increase to managed care organizations providing services under Family Care, PACE, and Partnership, subject to approval by the federal Centers for Medicare and Medicaid Services.  
• Nursing Home Reimbursement: Provide $82 million in 2021-22 and $170 million in 2022-23 to increase reimbursement rates paid to skilled nursing facilities and intermediate care facilities for individuals with intellectual disabilities. 
• Postpartum Eligibility Extension: Provide $2.5 million in 2022-23 to reflect the estimated cost of extending benefits, for women enrolled in MA as pregnant women, until the last day of the month in which the 90th day after the last day of the month that the end of the pregnancy falls, instead of the 60th day under current law.
• Outpatient Mental Health and Substance Abuse Services and Child-Adolescent Day Treatment Reimbursement: Provide $6.6 million in 2021- 22 and $13.2 million in 2022-23 for a 15% increase to reimbursement rates for outpatient mental health and substance abuse services. In addition, provide $1.3 million in 2021-22 and $2.6 million in 2022-23 for a 20% increase to reimbursement rates for child and adolescent day treatment services.  
• Medication-Assisted Treatment: Provide $1.2 million in 2021-22 and $2.4 million in 2022-23 to increase MA reimbursement rates for opioid treatment providers by 5% and increase rates for opioid-related patient evaluation and management provided by primary care providers by $5 per visit.
• MA Dental Reimbursement: Provide $15.4 million in 2021-22 and $30.8 million in 2022-23 to increase MA dental reimbursement rates by 40%. 
• Home Health Reimbursement Rate: Provide a budgeted sum of $473,300 as the state share of payments, and provide the matching federal share of payments, in 2021-22, and by a budgeted sum of $960,200, as the state share of payments and provide the matching federal share  of payments, in 2022-23, for the Department to increase the Medical Assistance rates paid for nursing care in home health agencies for dates of services beginning January 1, 2022. Specify that funding is to support licensed practical nurses, registered nurses, and nurse practitioners in home health agencies that are licensed under s. 50.49 of the statutes.

Public Health

• Community Health Center Grants: Increase grant funding for federally qualified health centers (FQHCs) by $1,000,000 annually.  

• Grants to Free and Charitable Clinics: Increase grant funding for free and charitable clinics by $1,000,000 annually.  

• Lead Screening and Outreach Grants: Provide $50,000 annually to increase a grant for lead screening and outreach activities provided by a community based human service agency that provides primary health care, health education, and social services to low-income individuals in the City of Milwaukee, from $125,000 to $175,000. 

Community Based Behavioral Health

• Child Psychiatry Consultation Program: Provide $500,000 in 2022-23 to increase from $1,500,000 to $2,000,000 the funding for the child psychiatry consultation program.

• Medication-Assisted Treatment Expansion: Provide $500,000 in 2021-22 and $1,000,000 in 2022-23 in the Joint Committee on Finance supplemental appropriation for medication-assisted treatment.  

• Methamphetamine Addiction Treatment Grants: Provide $150,000 in 2021-22 and $300,000 in 2022-23 in the Joint Committee on Finance supplemental appropriation for training for substance use disorder treatment providers on treatment models for methamphetamine addiction.    

• Substance Use Disorder Treatment Platform: Provide $300,000 in 2022-23 in the Joint Committee on Finance supplemental appropriation for development of a substance use disorder treatment platform that allows for the comparison of treatment programs in the state.  

• Behavioral Health Bed Tracker: Provide $50,000 in 2021-22 and $20,000 in 2022-23 to expand the purposes of the current psychiatric bed tracking system to include information on the availability of space for peer run respite beds and crisis stabilization beds.  

• Behavioral Health Trainee Provider Grants: Provide $250,000 in 2022-23 in the appropriation for treatment program grants to increase total funding for the program in that year to $750,000. Modify the program to: (a) specify that the Department may expend any available federal moneys received for this program; (b) require the Department to distribute a total of $750,000 per year, beginning in 2022-23; and (c) renumber the appropriation so that it is included as an appropriation under mental health and substance abuse services instead of under public health.  

The power of advocacy can help make change happen. That is something we often hear, but seldom see in action. Fortunately, the entire WiAHC membership can now say they have witnessed firsthand the benefits of a comprehensive advocacy effort to deliver a long-overdue policy change to boost the skilled home health care industry in Wisconsin.

On Tuesday, June 15, the state Legislature’s powerful budget-writing committee, which is tasked with shaping the state’s two-year budget, voted to include a provision in the budget to increase Medicaid rates for home health care skilled nursing services by 10 percent. WiAHC has been advocating for this important change for nearly two years.

The budget bill must still be approved by the full Legislature and signed into law by Gov. Tony Evers, but approval of the increase by the budget committee was an extremely important step, as the budget created by the committee is highly likely to be adopted by the Legislature with minimal changes.

Due to in part to current Medicaid rates in Wisconsin, home health agencies struggle to attract sufficient nursing workforce. As growth in the utilization of home health care services continue, today’s workforce challenges will only worsen without a rate increase. The committee’s actions mark a significant step forward in addressing this issue.

“The skilled home health care industry is very grateful for the budget committee’s commitment to the services we provide and the patients we serve,” said WiAHC Board Chair Lisa Kirker. “We specifically want to thank Senator Mary Felzkowski (R-Irma) and Representative Amy Loudenbeck (R-Clinton) for their leadership on this issue. Their work was invaluable in ensuring a rate increase passed the committee.”

Under the provision approved by the budget committee, the state will provide more than $1.4 million in additional state funding – along with the federal match – over the upcoming two-year budget cycle to increase the Medicaid rate paid for nursing care in home health agencies. The rate boost would begin on January 1, 2022. The additional funding will support care offered by licensed practical nurses, registered nurses, and nurse practitioners in home health agencies.

The WiAHC Government Affairs Team will continue to work with lawmakers and the Governor’s office throughout the remainder of the state budget process to help make sure the provision is ultimately signed into law. 

The power of advocacy can help make change happen. That is something we often hear, but seldom see in action. Fortunately, the entire WiAHC membership can now say they have witnessed firsthand the benefits of a comprehensive advocacy effort to deliver a long-overdue policy change to boost the skilled home health care industry in Wisconsin.

On Tuesday, June 15, the state Legislature’s powerful budget-writing committee, which is tasked with shaping the state’s two-year budget, voted to include a provision in the budget to increase Medicaid rates for home health care skilled nursing services by 10 percent. WiAHC has been advocating for this important change for nearly two years.

The budget bill must still be approved by the full Legislature and signed into law by Gov. Tony Evers, but approval of the increase by the budget committee was an extremely important step, as the budget created by the committee is highly likely to be adopted by the Legislature with minimal changes.

Due to in part to current Medicaid rates in Wisconsin, home health agencies struggle to attract sufficient nursing workforce. As growth in the utilization of home health care services continue, today’s workforce challenges will only worsen without a rate increase. The committee’s actions mark a significant step forward in addressing this issue.

“The skilled home health care industry is very grateful for the budget committee’s commitment to the services we provide and the patients we serve,” said WiAHC Board Chair Lisa Kirker. “We specifically want to thank Senator Mary Felzkowski (R-Irma) and Representative Amy Loudenbeck (R-Clinton) for their leadership on this issue. Their work was invaluable in ensuring a rate increase passed the committee.”

Under the provision approved by the budget committee, the state will provide more than $1.4 million in additional state funding – along with the federal match – over the upcoming two-year budget cycle to increase the Medicaid rate paid for nursing care in home health agencies. The rate boost would begin on January 1, 2022. The additional funding will support care offered by licensed practical nurses, registered nurses, and nurse practitioners in home health agencies.

The WiAHC Government Affairs Team will continue to work with lawmakers and the Governor’s office throughout the remainder of the state budget process to help make sure the provision is ultimately signed into law.  

First elected to the state Assembly in 2012, Representative Dan Riemer (D-Milwaukee) is serving his fifth term representing the 7^th Assembly District, which includes portions of the cities of Milwaukee and West Allis, as well as the Village of West Milwaukee.

Rep. Riemer holds a law degree from UW-Madison and is a full-time lawmaker. He currently serves on the Assembly Health Committee, and during his time in the Legislature has worked on numerous health care-related proposals.

Rep. Riemer took a few minutes to talk with us about a handful of topical health care issues facing Wisconsin and what health care policy priorities he believes should be pursued during the 2021-22 legislative session:

Question 1

As a long-time member of the Assembly Health Committee and a legislator who has worked on numerous health care-related polices during your time in the Legislature, what do you believe are the largest health care-related challenges facing the state? In addition, what policy solutions do you believe are needed to address those challenges? Lastly, what key health care policy proposals is the Assembly Democratic Caucus focusing on for the 2021-22 legislative session?

Answer: The single biggest health care challenge facing Wisconsin is the failure to expand Medicaid. This would increase the number of Wisconsinites with health insurance, and lower health care costs for newly Medicaid-covered individuals between 100%-133% of the Federal Poverty Line. Medicaid provides better benefits than Affordable Care Act plans or other plans and provides Wisconsin’s government with over one billion additional dollars, some of which could be devoted to other health care priorities.

As I have done for many years through legislation, Governor Evers has also repeatedly proposed Medicaid expansion. The Assembly Democratic Caucus has again made this a priority, as have Democrats in the State Senate. The time has come for the Republican majority in the Wisconsin Legislature to agree. That’s the simple solution to our biggest health care challenge.

Question 2

The cost of healthcare continues to rise, for both individuals and employers. In fact, a recent survey by the Kaiser Family Foundation and the Purchaser Business Group on Health found that 85 percent of large employers believe the government must take a bigger role in managing healthcare costs and coverage. Another survey found that 55 percent of small business owners say the cost of providing health insurance to their employees is the biggest challenge they face. What types of policies or future legislation do you believe are necessary to help drive down the overall costs of health care?

Answer: In addition to Medicaid expansion, which will reduce what Wisconsin’s taxpayers and government must pay for health care for a large sector of our population (a form of lowering costs), I strongly support other measures to lower the overall cost of healthcare in Wisconsin.  One step that I support would be to require that the Wisconsin State Employee Health Plan (WSEHP) be used as the vehicle by which all government employees obtained health insurance. 

A careful analysis of WSEHP by University of Wisconsin-Madison La Follette Professor of Economics John Mullahy and others compared the WSEHP’s experience in Dane County vs. Wisconsin’s other 71 counties. The study showed that  when a very large percentage of the employees in a county are offered a choice among competing health care plans, they have incentives to enroll in the lower-cost plans, because while higher-cost plans are always available, they must pay a modest additional premium to enroll in higher-cost plans. Given the choices, health care premiums and costs are held down.

If WSEHP served as the vehicle for enabling all government employees to obtain health insurance in the same way, it should be possible to replicate much of WSEHP’s unique success in Dane County in constraining health care premiums and costs.  One of the benefits of this is that, as the Dane County story suggests, it is not only the WSEHP and those it helps obtain health insurance for who experience reduced costs.  The model’s incentives put pressure on the competing plans to become more cost effective in general, which helps private employers as well.

Question 3

Skilled home health care offers a wide range of health care services, which are provided by skilled non-physician practitioners, such as nurses in a patient’s home. Not only does skilled home health offer patients with greater convenience, increased quality of life, and better outcomes, it is also typically less expensive than care delivered in a hospital or other facility. Unfortunately, despite the many benefits of home health care, the Wisconsin Medicaid reimbursement rate for home-based skilled nursing has not been increased in over a decade. With that in mind, would you support increasing the Medicaid reimbursement rate for home health skilled nursing services by 10 percent?

Answer:  I certainly would be concerned if the current Medicaid reimbursement rate for home health skilled nursing services is resulting in a reduction in the number of providers or the quality of care.

This is not an issue, however, that I know much about. I would welcome the opportunity to learn more.

The views and opinions expressed in this interview are those of the individual that was interviewed and do not necessarily reflect the official policy or position of the organization.

Governor Tony Evers has called a special session of the legislature to take up a proposal to expand the Wisconsin Medicaid program, which would capture an extra $1 billion in federal funds and cover more than 90,000 additional Wisconsin residents under the program.

The legislation would also use $850 million of the additional federal dollars for numerous economic development-related projects and transfer the rest to the state’s budget stabilization fund.

The Republican-controlled Legislature has said they would immediately gavel out the special session without taking up the proposed legislation.

As was reported in previous editions of the WiAHC Advocacy Newsletter, the Association has launched a Legislative Key Contact Program, which can be a highly effective grassroots advocacy tool to help build and nurture strong on-going relationships between WiAHC members and lawmakers in Wisconsin. Ultimately, the program can help us help shape new policies important to our members.

We are happy to report the program is now live on the WiAHC website and members can easily and quickly sign-up as a Key Contact.

As a Key Contact, you can help influence the legislative process at both state and federal levels by cultivating relationships with elected officials. By taking advantage of existing relationships and making new contact with members of the Wisconsin Legislature and the Wisconsin Congressional  Delegation, you can help us educate lawmakers on industry issues and influence legislation.

But the program will not succeed without strong member participation, so please take a few moments to read more about it – and learn how simple it is to “enlist” and participate as a Key Contact. The time commitment is minimal and your responsibility as a key contact depends on your level of comfort and willingness to engage.

Remember, lawmakers are often eager to hear input from their constituents, and as an expert in your field, you can make a real difference in the policy process as a Key Contact. CLICK HERE to sign-up by filling out and submitting a brief online survey.

The U.S. Treasury last week issued guidelines for state and local governments on how they can access their share of the $350 billion in COVID-19 aid for state, local, tribal, and territorial governments included in the American Rescue Plan Act (ARPA).

It was also announced the state of Wisconsin will receive $700 million less in ARPA funding than originally anticipated – from and an anticipated $3.2 billion to an actual $2.5 billion. In addition, the direct federal funding to the state will be split into two payments a year apart. The reduction in funding is due to improvements in the state’s unemployment rate, which has returned close to pre-pandemic levels.

Governor Tony Evers (D) who has full control over the allocation of the federal aid had planned to put $700 million toward the state’s ongoing response to the pandemic and $2.5 billion toward economic recovery. That will now need to be revisited with less funding coming into Wisconsin.

Evers, along with Wisconsin U.S. Senator Tammy Baldwin (D) has sent a letter to the Biden Administration asking Treasury to reconsider the split payment approach.

The newly released rules provide guidance on allowable uses of the federal relief funding. The federal government’s funding objectives for the relief aid includes:

• Support urgent COVID-19 response efforts to continue to decrease spread of the virus and bring the pandemic under control.
• Replace lost revenue for eligible state, local, territorial, and Tribal governments to strengthen support for vital public services and help retain jobs.
• Support immediate economic stabilization for households and businesses.
• Address systemic public health and economic challenges that have contributed to the inequal impact of the pandemic.

State and local governments may use these funds to:

• Support public health expenditures, by, for example, funding COVID-19 mitigation efforts, medical expenses, behavioral healthcare, and certain public health and safety staff.
• Address negative economic impacts caused by the public health emergency, including economic harms to workers, households, small businesses, impacted industries, and the public sector.
• Replace lost public sector revenue, using this funding to provide government services to the extent of the reduction in revenue experienced due to the pandemic.
• Provide premium pay for essential workers, offering additional support to those who have and will bear the greatest health risks because of their service in critical infrastructure sectors.
• Invest in water, sewer, and broadband infrastructure, making necessary investments to improve access to clean drinking water, support vital wastewater and stormwater infrastructure, and to expand access to broadband internet.

Within these overall categories, recipients have broad flexibility to decide how best to use the funding to meet the needs of their communities.

For more information, please visit the U.S. Treasury website.

Although much of the focus in the State Capitol is on development of the 2021-23 state budget bill – the $91 billion two-year spending plan for the state – lawmakers are also acting on stand-alone, non-budget legislation, including many that impact the delivery of health care in Wisconsin. Legislation of interest to health care professionals across the state that have been introduced and are currently being considered by the Legislature’s Health Committees include the following:

• Assembly Bill 66 - Relating to community health center grants and making an appropriation.
• Assembly Bill 86 - Relating to providing complementary and alternative health care practitioners with exemptions from practice protection laws, requirements and prohibitions for individuals who provide complementary and alternative health care services.
• Assembly Bill 184 - Relating to application of prescription drug payments to health insurance cost-sharing requirements.
• Assembly Bill 281 - Relating to registration of pharmacy technicians.
• Assembly Bill 290 - Relating to reimbursement of pharmacist services under the Medical Assistance program.
• Assembly Bill 295 / Senate Bill 308 - Relating to licensing and regulation of pharmacies and remote dispensing sites under the pharmacy practice law and the practice of pharmacy.
• Assembly Bill 296 - Relating to funding for free and charitable clinics and defining telehealth.
• Senate Bill 337 - Relating to prohibiting businesses from discriminating against customers due to vaccination record.
• Senate Bill 340 - Relating to reimbursement rates for behavioral treatment services under the Medical Assistance program.
• Senate Bill 342 - Relating to prohibiting the state or other governmental entities from discrimination based on whether the person has received a COVID-19 vaccine.

For a full list of bills currently being considered by the Assembly and Senate Health Committees, CLICK HERE to view Assembly bills and HERE to view Senate bills. You bill be able to read the bills in full and track their status as they move through the legislative process.