State fiscal effect - The rule does not mandate any changes to fees charged to outpatient mental health clinics, increase the number of State surveyors, or otherwise create new or different requirements for the department. The rule does not change the provider requirements for who may bill Medicaid for outpatient services. In addition, the rule does not propose to change the services that are Medicaid reimbursable as an outpatient mental health service. Therefore, no increases or decreases are anticipated in the Medicaid budget as a result of the rule changes.

Summarized below is the analysis of the potential fiscal impact the rule may have on county and private sector outpatient mental health clinics:

1. The proposed rule has no specific space, design, or organizational requirements for outpatient mental health clinics. The capital costs for the clinic are based on individual preferences, such as the number of staff, staff service time, and location of offices. The number of support staff would also be related to the size of the operation.

2. Ongoing operational costs would include the cost of contracting for services from a psychiatrist, psychologist or other mental health professional for the purpose of clinical collaboration on treatment. The proposed rule has added alternatives to reduce this cost over the existing rule. Specifically, the current rule requires clinical supervision from a psychiatrist or psychologist at an average reported cost in the survey of clinics of $701/month and $593/month, respectively. The proposed rule permits an oversight model of either clinical supervision or clinical collaboration, which has an average reported cost of $551/month.

3. Ongoing transaction costs would include normal clinical data keeping which is factored into the hourly fee charged to the client. Typically, a therapeutic hour is calculated to be 45 minutes with the remaining 15 minutes used for documentation related to the therapy session and other record keeping. The cost of preparing for the actual compliance review would assume that the psychotherapist has a full schedule of therapy sessions, and would need to disrupt the normal schedule. However, most clinics do not function on a full 40 hours of therapy per week, a typical schedule would be 50% direct face-to-face time.

4. Start-up costs would vary with the skills of the individual. The tasks would include creation of policies and procedures, design of documentation and filing systems.

The expected average compliance cost may range from $500 to $1,000 depending on the size and nature of the operation. Other costs to consider:

1. Ability to finance compliance costs: The cost of compliance is primarily composed of individual time. There are no capital costs required by the rules.

2. Financial hardship: The rule is designed to reduce cost over the existing rule.

3. Competitiveness of enterprises and sectors: When a clinic elects to be certified under the existing or proposed rules, they have access to additional funding which would not otherwise be available. This includes funding from mandated insurance under WI Stats. 632.89 and Medicaid. The funding provides up to $500 of coverage for those individuals with insurance or Medicaid. There is also the advantage of being recognized as complying with standards established by the state mental health authority.

4. Barriers to entry and expansion: The individual clinic seeking certification is required to meet minimum standards of compliance. This requires compliance with accepted standards of service. The primary barrier would be the therapist's ability to comply with the accepted standards. There are no restrictions on the number and locations of agencies. The addition of staff which is the principal method of expansion simply requires the notification of the certifying agency of the qualifications of new staff. The same is true for adding additional branches to the clinics. The clinical operation is in control of the type and style of office they wish to a create or add.

Employment effects: There should be no effect on the present employment within clinics. The rules have been structured to allow qualified staff of existing operations to continue. There may be minimal effect on those operations, which were marginally operating under the existing standards. The proposed rules allow the hiring of additional staff for specific functions within the clinic. There are provisions to allow persons who are in the process of training and those with alternative qualifications to be employed by the clinic.

Specific cost saving changes: The proposed rules only apply to those clinics who choose to be certified. Individuals who are licensed to provide psychotherapy can apply their trade as permitted by their license. The proposed rules only apply to those clinical operations electing to be approved as an outpatient clinic as defined by the rules.

The following changes have been made to improve the quality of care and at the same time reduce costs and the burden of regulation.

1. The location of service delivery has been changed to be more flexible. Under the existing rule, services could only be provided at the clinic offices unless it was demonstrated there were specific barriers to care. This should increase the profitability of the clinic by increasing the numbers of persons that can be accessed.

2. “Deemed status" from a national accrediting organization is recognized. This would not duplicate costs to the agency for staff time to prepare for a survey by both the national accrediting organization and Department staff, potentially saving money during the certification period.

3. A waiver or variance of a requirement is permitted to allow clinics alternatives to rules when compliance is difficult due to availability of staff, remote geographic locations, or strict enforcement of the requirement would result in unreasonable hardship on the outpatient clinic or consumer. The waiver or variance would not be allowed if quality of care is adversely affected.

4. The personnel requirements have been changed to allow alternatives to the existing rule to reduce costs and difficulty of obtaining staff. Existing rules require a minimum of two hours of clinical treatment by a psychiatrist or psychologist for each 40 hours of psychotherapy provided. The new rule eliminates this requirement with a minimum savings of $19,000 per year of cost for the small clinic. Larger clinics will save proportionally increased amounts.

5. Under the existing rule, clinics are required to provide supervision by a psychiatrist or psychologist at the rate of 30 minutes for every 40 hours of therapy provided. The cost for a small clinic would be approximately $5,000 per year. The new rule allows clinical collaboration with other licensed staff to provide for this function.

6. Service requirements have been extensively reduced to recognize the wider variety of clinics and methods of providing care. The existing rules were written for publicly operated clinics. Private clinics have been allowed to apply for certification if they agree to comply with the rules. The proposed rules have eliminated the requirements that clinics provide, or provide access to residential facilities, partial hospitalization, pre-care for hospitalization, rehabilitation services, habilitation services, and supportive transitional services. The services under the proposed rule may be provided, contracted or provided by agreement. It is assumed that the therapist would expedite services as required for individual clients. The time and cost of procuring these services or agreements has been eliminated.

7. The existing rule requires that every consumer must have a referral from a physician for psychotherapy services. The proposed rule allows the licensed therapist to make the recommendation for therapy, which reduces cost to the consumer and increases accessibility to services. This would be an estimated cost savings to the consumers (who are not Medicaid recipients) of $100.

A copy of the full text of the rules and the fiscal estimate can be obtained at no charge from the Wisconsin Administrative Rules Website at http://adminrules. wisconsin.gov or by contacting the person listed below.

Dan Zimmerman
Department of Health and Family Services
Bureau of Mental Health & Substance Abuse Services
Room 455
1 W. Wilson St.
Madison, WI 53707
zimmeds@dhfs.state.wi.us
(608) 266-7072

NOTICE IS HEREBY GIVEN that pursuant to ss. 146.50 (4) (c), (5) (b), (6) (b) 2., (8m), (13), and 227.11 (2), Stats, Stats., and interpreting ss. 146.50 (1) (d) to (g), (4) (c), (5) (b) and (d), (6), (9), (10), (13) and 146.53 (5) (g), Stats., the department proposes to modify rules relating to licensing emergency medical technicians and affecting small businesses.

The hearing site is fully accessible to people with disabilities. If you are hearing impaired, do not speak English or have circumstances that might make communication at a hearing difficult; you require an interpreter or a non-English large print or taped version of the proposed rules, contact the person at the address or telephone number given below at least 10 days before the hearing. With less than 10 days notice, an interpreter may not be available.

Written comments may be submitted at the public hearing or submitted to the contact person listed below. Comments may also be made using the Wisconsin Administrative Rule Website at http://adminrules.wisconsin.gov.

The deadline for submitting comments to the Department is 4:30 p.m. on July 31, 2006.

Wisconsin has two levels of emergency medical services. They are basic life support and advanced life support. These two levels are distinguished by the skills and medications that can be used by emergency medical services personnel when performing pre-hospital care. At the basic life support level, the department licenses individuals as emergency medical technician-basic (EMT-basic) and emergency medical technician-intravenous (EMT-basic IV) and certifies individuals as First Responders. At the advanced life support level, the department licenses individuals as provisional emergency medical technician-intermediate (provisional EMT-intermediate), emergency medical technician- intermediate (EMT-intermediate), and emergency medical technician-paramedic (EMT-paramedic). The requirements for basic life support are codified in chs. HFS 110 and HFS 113. Requirements for advanced life support are codified in chs. HFS 111 and HFS 112.

The training and competency requirements for the EMT-basic IV license are identical to the training and competency requirements for the provisional EMT- intermediate license. But because the EMT-basic IV requirements are codified in the basic life support code, ambulance service providers are reimbursed at the basic life support level of care instead of the advanced life support level of care. The ambulance service provider industry report that this situation is having a negative fiscal impact on ambulance service providers that use EMT-basic IV licensees to provide emergency medical services and may eventually cause a reduction of services in the communities that they serve.

To maintain the level of emergency medical services that are currently being provided and to avoid confusion about the skills and level of care provided by the EMT-basic IV licensee, the department proposes to change the name of the EMT-basic IV license to EMT-intermediate technician and move the licensing requirements to ch. HFS 111. No changes to skills and competency requirements are being proposed. The department also proposes to modify the continuing education requirements under ch. HFS 110 to allow ambulance service providers flexibility in providing refresher training to EMT-basic licensees. This change will reduce financial and scheduling burdens on providers by allowing them to use their training dollars more cost effectively, and it will create uniformity between the basic refresher requirements and the refresher requirements that are in place for the other skill levels.

The department will implement these changes in a substantially identical emergency rule to become effective on July 1, 2006, because under current s. HFS 111.045, individuals who are licensed as provisional EMT-intermediate licensees will become EMT-basic IV licensees effective July 1, 2006. If this occurs, it's likely that the currently reported negative affects on the ambulance provider industry will increase.

In Wisconsin there are approximately 430 ambulance service providers. Approximately 80% are volunteer (not for profit) or owned by private for profit entities. The remaining 20% are government owned. A total of 129 ambulance service providers and 2812 licensed individuals in 48 counties currently provide emergency medical services at the EMT-basic-IV (74) or EMT-provisional intermediate (55) level to approximately 2.65 million Wisconsin residents.

The provider industry estimates that these ambulance service providers are losing approximately $1.5 million dollars in reimbursement revenues annually due to the codification of the EMT-basic IV services in ch. HFS 110 as basic life support. The loss is likely to increase when the provisional EMT-intermediate is renamed EMT-basic IV effective July 1, 2006, and an estimated 95% of the individuals who are currently licensed and titled as provisional EMT-intermediate will be renamed EMT-basic IV. Consequently, the level of emergency medical services provided in over half of the state's 72 counties may be reduced or become non-existent unless the proposed changes are implemented.

The department believes the proposed changes will have a positive fiscal effect on ambulance service providers as the proposed changes are likely to increase revenues through increased reimbursement. The proposed rules do not do not require any additional reporting or record keeping, or other requirements that may increase costs or decrease revenues.

Pursuant to the foregoing analysis the proposed rules will have a positive fiscal effect on ambulance service providers, including those that may be small businesses.

Small Business Regulatory Coordinator

Rosie Greer

608-266-1279

Currently the department sets standards for different categories of Emergency Medical Technicians (EMT) in rule. By amending this administrative rule, the Department proposes to eliminate the category of EMT-basic IV, retain the category of provisional EMT- intermediate (which is due to sunset on June 30, 2006), and rename both categories of providers as EMT-intermediate technicians. This change will allow providers with specific skill levels, including advanced life support, to be classified appropriately. This change in rule allows these categories of EMT providers to be placed in the appropriate rule, which defines their scope of practice more adequately. As a result, ambulance service providers will be able to charge for the more complex skill sets at a higher rate based on the treatment modalities that are utilized and individual ambulance providers will be able to increase their revenues. The addition of more flexible renewal requirements will allow services to better budget and use their training dollars more efficiently. This is a significant issue with regard to reduced local budgets.

Ambulance service providers report that they cannot continue to cover the costs of training and operating at the advanced life support level of care while being reimbursed at the basic life support level of care. The provider industry estimates that Wisconsin ambulance service providers are losing approximately $1.5 million dollars in reimbursement revenues annually due to the codification of the EMT-basic IV services in ch. HFS 110 as basic life support rather than in ch. HFS 111 as advanced life support. The loss of revenue would increase if the current provisional EMT-intermediate were renamed EMT-basic IV when the category of provisional EMT-intermediate sunsets, as would happen under the current rule. However, this rule change will reclassify both categories as EMT-intermediate technicians, which will allow ambulance service providers to charge for both at the higher rate of reimbursement. Medical insurance providers and other entities responsible for health care costs may see some increase in expenses as a result of this change.

In many cases now, Medicaid reimburses ambulance providers for the actual level of services required. As a result, there are not likely to be significant increased expenses for Medicaid as a result of this rule change. Without this rule change and the potential for rate increases, some EMT providers may not be able to continue to operate. The level of services provided in some communities would be likely to decrease or disappear. This rule change will help to ensure that an adequate emergency medical services system remains in place in Wisconsin.

A copy of the full text of the rules and the fiscal estimate can be obtained at no charge from the Wisconsin Administrative Rules Website at
http://adminrules.wisconsin.gov or by contacting the person listed below.

Dan Williams

Department of Health and Family Services

Division of Public Health - Emergency Medical Services

1 West Wilson Street Room 118

P.O. Box 2659

Madison, WI 53701-2659

608-261-6870

NOTICE IS HEREBY GIVEN that pursuant to ss. 227.11 (2), 250.04 (1) and (7) and 254.47, Stats., interpreting ss. 254.47 and 254.85, Stats., the Department of Health and Family Services will hold a public hearing to consider the Department's proposal to repeal and recreate ch. HFS 172 relating to pools and water attractions, and affecting small business.

Two public hearings will be held, as follows:

Wednesday, August 9, 2006 Time: 10:00 AM	Dept. of Health and Family Services 1 West Wilson Street Room B 139 Madison, WI 53703
Thursday, August 10, 2006 Time: 10:00 AM	Marathon County Health Dept. 1200 Lakeview Drive Room 200 Wausau, WI 54403-6797

The hearing site is fully accessible to people with disabilities. If you are hearing or visually impaired, do not speak English, or have circumstances that might make communication at a hearing difficult and if you, therefore, require an interpreter or a non-English, large print or taped version of the hearing document, contact the person at the address or phone number given above at least 10 days before the hearing. With less than 10 days notice, an interpreter may not be available.

Written comments may be submitted at the public hearing, or in lieu of attending a public hearing written comments can be submitted by regular mail or email to:

Tracynda Davis

1 W. Wilson Street, Room 150

Madison, WI 53702

Phone: 608-266-8924

Fax: 608-267-3241

Email: davistl@dhfs.state.wi.us

Written comments may also be submitted to the Department using the Wisconsin Administrative Rules Internet website at http://adminrules.wisconsin.gov.

The deadline for submitting comments is 4:30 p.m., on Friday, August 17, 2006.

The Department of Commerce has authority related to the design and construction of public pools and water attractions, including plan approval and supervision of construction. When a facility has been properly designed and built, the Department of Health and Family Services (DHFS) then reviews the pool for operation, safety and maintenance and gives the pool a permit to operate if all conditions of ch. HFS 172 are met.

DHFS proposes revisions to ch. HFS 172 based on recent scientific research and extensive input from pool designers and operators. The rule will generally not have an effect on standard rectangular pools and whirlpools that have not made changes resulting in increased risk. Waterslides that were previously regulated by the Department of Commerce, are included in these rule revisions, requiring permitting, either separately or as a pool appurtenance, and annual inspection by DHFS for operation and safety. A certified structural engineer will be required to evaluate the physical condition of the slide every 5 years for bolt degradation and physical stress load capabilities.

The rule also proposes changes related to lifeguard and attendant staffing, to add flexibility in these plans.

Chapter HFS 172, Wis. Adm. Code, is proposed to correspond to the recent changes made by the Department of Commerce in ch. Comm 90, Wis. Adm. Code.