The APRN bill still sits in a stalemate with no movement since our last report, although some action in the Assembly is expected soon. The APRN bill establishes an Advance Practice Registered Nurse credential in Wisconsin.  WISCA has been closely monitoring AB 154/SB 145, as one of the biggest sticking points within that new credential relates to pain management procedures and the collaborative agreements surrounding nurse anesthetists. 

An amendment to the bill was introduced requiring CRNA’s have a collaborative agreement with a physician who has a pain management background.  WISCA has pushed back against this amendment arguing that it would hurt our ability to provide services, especially in more rural areas, where there are fewer physicians with a pain management background.  The bill has passed the Senate without this amendment and is being considered in the Assembly.  In addition to our concerns, it appears the Governor still has certain issues with the bill, and it is unclear how and if it will become law.  

Outside of APRN legislation, bills related to price and access have been introduced by Republicans and Democrats that are making their way through the legislative process.  Most of them are unlikely to find consensus and become law without compromise.  These include a price transparency bill to align Wisconsin law with the federal law as it relates to hospitals posting their pricing; a proposal to make several changes to how pharmacy benefit managers (PBMs) are regulated; legislation to allow for direct primary care in Wisconsin; and a bill to create a provisional license for international physicians. 

Lastly, the Surgical Black Box bill has been introduced in the Assembly.  AB 870 would allow for patients to have their surgeries recorded.  WISCA has opposed this bill in the past and will do so this session. 

In what many predicted after Wisconsin’s Supreme Court flipped from conservative to liberal in April of 2023, the new State Supreme Court found Wisconsin’s current maps unconstitutional and ordered new legislative maps to be drawn in time for the 2024 elections. 

The court set a deadline of January 12 for the various parties to the case to submit proposed remedial maps. The court also appointed two “referees,” political science academics who have worked as redistricting consultants in other states, to help the court evaluate the proposals. In a letter to the court, the referees explain how they will analyze the proposals by using demographic and election data to assess the following factors based on the court’s directive:

·         Population equality

·         Political subdivision splits

·         Contiguity

·         Compactness

·         Federal law compliance

·         Community considerations

·         Political neutrality

The referees are to return their evaluations to the court by February 1.

While there are only a few months left in Wisconsin’s 2023-24 biannual legislative session, there could be a lot packed into the remaining calendar days before both houses wrap-up their work for the year in March.

One of the most pressing issues will be whether the Legislature and Governor Evers can come to an agreement on Wisconsin’s $7 billion budget surplus.  They failed to come to an agreement during state budget negotiations and have yet to make progress since.  The legislature wants to fund a significant tax cut while the Governor wants to see money go toward childcare and a smaller tax cut.  There are other spending priorities for both sides, but a deal will have to be cut or we can expect to start the next budget process with a fat surplus once again. 

In addition to the surplus, some other hot-button issues remain.  Speaker Robin Vos has said he is going to bring a medical marijuana bill to the floor.  Wisconsin is nearly surrounded by states that have legalized recreational marijuana, but most legislators in the Badger State are not supportive of full legalization.  Vos’s bill could be a compromise.

In recent interviews, Majority Leader Devin LeMahieu has mentioned two of his priorities being a bill that would allow Wisconsin to access $84 million in federal funding to build Electric Vehicle Infrastructure, as well as a bill that would give Wisconsin companies the first option to build transmission lines in Wisconsin.  As of today, each of these proposals has had at least one public hearing with more action in both houses expected soon. 

Other issues that the legislature may address include PFAS (forever chemicals), abortion, election reform and artificial intelligence.  On the health care front, we’ll expect to see some activity surrounding the Advanced Practice Registered Nurse (APRN) bill and price transparency and pharmacy benefit manager bills. 

Visit ASCA's ASCQR Program requirements webpage for information on changes to ASCQR Program requirements in 2024, and the Ambulatory Surgical Center Quality Reporting Specifications Manual for more information on all measures. Additional resources, such as reporting dates and measure resources, can be found on CMS' ASCQR Program Resources webpage.

• ASC-1: Patient Burn; ASC-2: Patient Fall; ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant; ASC-4: All-Cause Hospital Transfer Admission are outcome measures that were previously suspended as of January 1, 2019, but data collection resumed in CY 2023 for reporting via the HQR Secure Portal in CY 2024. Data for these measures must be collected for all patients, not just fee-for-service Medicare beneficiaries, and must be submitted by May 15, 2024.
• ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients is a web-based measure that is reported via the HQR secure portal. This aggregate data must be reported by all Medicare-certified ASCs, regardless of specialty or case mix. If your center does not perform colonoscopies, select the box under the measure name and description that states: “Please enter zeros for this measure as I have no data to submit.” Data collected in 2021 must be submitted via the HQR secure portal by May 15, 2024.
• Facilities do not need to report data for ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy, as the data will be pulled from claims previously submitted by the hospital that the patient visits within seven days of the colonoscopy.
• ASC-13: Normothermia Outcome is used to assess the percentage of patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration who are normothermic within 15 minutes of arrival in PACU. Like ASC-9, this is a sampling measure. If your center does not perform procedures related to this measure, select the box under the measure name and description that states: “Please enter zeros for this measure as I have no data to submit." Data collected in 2021 must be submitted via the HQR secure portal by May 15, 2024.
• ASC-14: Unplanned Anterior Vitrectomy is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy. If your center does not perform procedures related to this measure, select the box under the measure name and description that states: “Please enter zeros for this measure as I have no data to submit." Data collected in 2021 must be submitted via the HQR secure portal by May 15, 2024.
• ASC-17: Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures data is pulled from claims previously submitted by the hospital that the patient visits within seven days of the orthopedic procedure.
• Facilities do not need to report data for ASC-18: Hospital Visits after Urology Ambulatory Surgical Center Procedures as the data is pulled from claims previously submitted by the hospital that the patient visits within seven days of the urology procedure.
• Facilities do not need to report data for ASC-19: Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers as the data is pulled from claims previously submitted by the hospital that the patient visits within seven days of the general surgery procedure.
• ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel data is submitted quarterly via a web-based tool, the National Healthcare Safety Network (NHSN). The 2024 reporting deadlines are February 15, 2024 (2023 third-quarter data), May 15, 2024 (2023 fourth-quarter data), August 15, 2024 (2024 first-quarter data) and November 15, 2024 (2024 second-quarter data).
• Please note that ASC-15 a-e: Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey measures are available for voluntary reporting in CY 2024, with mandatory reporting beginning with the CY 2025 reporting period for CY 2027 payment determination. CMS has added two approved survey modes: electronic with phone and electronic with mail. ASCs must use an approved OAS CAHPS Survey vendor: and pre-register via the OAS CAHPS website. For more information, visit our OAS CAHPS Survey page.

The Centers for Medicare & Medicaid Services (CMS) has provided more information regarding the new recommendation process for the ASC Covered Procedures List (ASC-CPL). This process enables interested parties to submit codes for consideration to be added to Medicare's ASC-CPL. The submission period will start on January 1, 2024, and conclude on March 1, 2024, for 2025 rulemaking. ASCA will continue to advocate for the addition of complexity-adjusted code combinations and alignment with the Hospital Market Basket to update reimbursement rates. More information about the recommendation process will be available in January in ASC Focus Magazine’s Digital Debut.  If you have specific procedures you would like ASCA to advocate for, please contact Kara Newbury.

This month’s ASCA Report includes information on ASCA resources to support ASC quality reporting, updates on recommended changes to the covered procedure list (CPL), a correction on previously reported clinician reimbursement rates and update on federal price Transparency legislation.  A special thank you to ASCA from WISCA for all of their leadership and support of ASCs through the year, and for sharing these valuable updates.

Federal Regulatory Update

ASCA’s ASC Quality Reporting Program Resources Updated for 2024: ASCA has updated our ASC Quality Reporting (ASCQR) Program home page to reflect 2024 measures and deadlines. You can also visit ASCA's updated ASCQR Program requirements webpage for information on how to comply with ASCQR Program requirements in 2024, and the Ambulatory Surgical Center Quality Reporting Specifications Manual for more information on all measures. Facilities should also be sure to check out the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey page which provides more information on the OAS CAHPS survey which will become a mandatory component of the ASCQR Program in 2025. If you have specific procedures you would like ASCA to advocate for, please contact Kara Newbury.

Pre-Proposed Rule CPL Recommendation Process: The Centers for Medicare & Medicaid Services (CMS) has provided more information regarding the new recommendation process for the ASC Covered Procedures List (ASC-CPL). This process enables interested parties to submit codes for consideration to be added to Medicare's ASC-CPL. The submission period will start on January 1, 2024, and conclude on March 1, 2024, for 2025 rulemaking. ASCA will continue to advocate for the addition of complexity-adjusted code combinations and alignment with the Hospital Market Basket to update reimbursement rates. More information about the recommendation process will be available in January in ASC Focus Magazine’s Digital Debut. If you have specific procedures you would like ASCA to advocate for, please contact Kara Newbury.

Clinician Reimbursement Correction Notice: Medicare reimbursement for clinicians is set to decline by 3.37 percent unless Congress acts. Several major specialties that operate in ASCs, such as orthopedic surgery, ophthalmology and vascular surgery, are expected to see negative impacts. ASCA has been active in advocating for relief from these cuts, most recently signing on to a letter with 53 other health organizations requesting congressional action. Representatives Mariannette Miller-Meeks (R-IA), Ami Bera (D-CA), Larry Bucshon (R-IN), and Kim Schrier (D-WA) circulated a “Dear Colleague” letter to members of the US House urging quick legislative action to prevent the 3.37 percent reimbursement cut scheduled for January 1, 2024. In previous years, a correction notice has been issued to resolve this issue. ASCA expects the Centers for Medicare and Medicaid Services (CMS) will release additional information in the next few weeks. In addition, CMS did not release the drug and biological rates with the final rule release. Therefore, ASCA expects information to be included in the January update.

Update on Federal Price Transparency Legislation.

On December 11, the Lower Costs, More Transparency Act (H.R. 5378) passed the US House of Representatives by a vote of 320–71. As previously reported, language pertaining to ASCs under Sec. 104 of H.R. 5378 is identical to the price transparency legislation that ASCA lobbied against in July. On Thursday, December 14, the companion bill, S. 3548, was introduced in the US Senate. Section 5 (5)(B)(i-ii) of the legislation nearly matches the language of H.R. 5378. ASCA has been working closely with committee staff to improve the legislation and will report on any updates. If passed, implementation would begin in January 2026. Pertinent takeaways from Sec. 104 (Ambulatory Surgical Center Price Transparency):

• ASCs must publicly disclose all of their standard charges for all items and services they offer.
• This information must be free and accessible without subscription.
• ASCs must also disclose their prices for a minimum of 300 shoppable services, including all Centers for Medicare & Medicaid Services (CMS)-specified shoppable services they provide and additional ASC-selected shoppable services to reach the 300 minimum; if an ASC offers less than 300 shoppable services, it must disclose prices for all of the services it does offer.
• For CMS-specified shoppable services not offered, ASCs must clearly indicate their nonavailability.
• PENALTIES: This legislation allows CMS to issue penalties of $300 per day for noncompliance.

More information is available in ASCA’s Digital Debut. Contact David Opong-Wadee at dopongwadee@ascassociation.org with any questions.

WISCA will host monthly legislative updates open to all members starting in 2024.  Updates will be held  the first Thursday of each month at 12pm.  Updates will be presented by the WISCA lobby team and provide an opportunity for Q&A and discussion on topics of interest to ASC leaders across the state.  Sign up today for the next legislative update (register).

WISCA works closely with our national association partner – the Ambulatory Surgery Center Association (ASCA) – on advocacy and other issues important to our members. In fact, the WISCA Government Affairs Team joins a national ASCA state chapter call twice a month for a federal regulatory and legislative briefing and closely follows their published Government Affairs Updates. Here is the latest federal government affairs news from ASCA:

·        Medicare Physician Fee Schedule

On November 2, CMS released the Medicare Physician Fee Schedule (MFPS) final rule. The rule finalizes a 2024 conversion factor of $32.74, a roughly 3.4 percent reduction from 2023. Notably, CMS finalized the implementation of a new g-code, G2211, beginning on January 1, 2024. This code was first proposed in the 2020 rulemaking cycle but has been delayed due to the Consolidated Appropriations Act of 2021. The code is contentious because it triggers a significant budget neutrality adjustment that is the main factor in the overall negative conversion factor reduction. CMS estimates that G2211 is driving 90 percent of the negative 2.2 percent budget neutrality adjustment. ASCA opposed its implementation in comments responding to the CY 2024 MPFS proposed rule. There will likely be a significant lobbying push from the physician community to oppose the implementation of the code before the end of the year. On November 6, ASCA was one of 54 health organizations that signed-on to a letter (see below) to Congressional leadership opposing the implementation of G2211:

o   On behalf of the 54 organizations representing physicians and other health care providers across the United States, we write to urge Congress to stop the 3.4% cut in Medicare physician payment that the Centers for Medicare & Medicaid Services (CMS) recently finalized in the Calendar Year 2024 Medicare Physician Fee Schedule (PFS) final rule. The agency acknowledges in the final rule that, due to budget neutrality requirements, the majority of the cut is created by the decision to increase payments for primary care services through the creation of the new G2211 code.  

We acknowledge policymakers’ desire for additional investments in primary care, however these increases are being paid for by an across-the-board cut to all clinicians. It is imperative that Medicare patients have access to the full range of essential health care services, including primary and specialty care. Further, clinicians are facing these cuts when they are expecting a 4.6% increase in medical practice cost inflation in 2024, as measured by the Medicare economic index. 

Therefore, in the absence of long-term reform, Congress must stop the full 3.4% cut.

·        General Update on 2025 Proposed Payment Rule

The Centers for Medicare & Medicaid Services (CMS) has provided more information regarding the new recommendation process for the ASC Covered Procedures List (ASC-CPL). This process enables interested parties to submit codes for consideration to be added to Medicare's ASC-CPL. The submission period will start on January 1, 2024, and conclude on March 1, 2024, for 2025 rulemaking. ASCA will continue to advocate for the addition of complexity-adjusted code combinations and alignment with the Hospital Market Basket to update reimbursement rates. If you have specific procedures you would like ASCA to advocate for, please contact Kara Newbury.

A bill that would require ASC’s to visually record a surgery at the patient’s request has been circulated but not yet introduced.  The bill’s authors reference surgeries in Wisconsin that resulted in fatalities as the foundation for why patients need this type of protection. WISCA, in conjunction with the WI State Medical Society and the Wisconsin Hospital Association has opposed this legislation in the past and will continue to do so this session. 

The APRN bill establishes an Advance Practice Registered Nurse credential in Wisconsin.  WISCA has been closely monitoring AB 154/SB 145, as one of the biggest sticking points within that new credential relates to pain management procedures and the collaborative agreements surrounding nurse anesthetists. There has been an amendment requiring CRNA’s have a collaborative agreement with a physician who has a pain management background. WISCA has pushed back against this amendment arguing that it would hurt our ability to provide services, especially in more rural areas, where there are fewer physicians with a pain management background. The bill has passed the Senate without this amendment and is being considered in the Assembly.  In addition to our concerns, it appears the Governor still has certain issues with the bill. and it is unclear how and if it will move forward.