The following video is the first in a two-part series of interviews conducted with a couple of the forum’s esteemed speakers. IHA had the chance to speak with Herb Kuhn, President and CEO of the Missouri Hospital Association (Jefferson, MO), on how health care reform will impact states like Iowa and Missouri.

Part two of the series will be posted next week and will feature David Swenson, Associate Scientist, Dept. of Economics at Iowa State University.

YouTube link: http://www.youtube.com/watch?v=nWSOlXI7qiA

Due to a flawed formula, many who use the Medicare Part D prescription drug program do not receive the needed level of benefits leaving them on the hook for much of hte cost of prescription drugs.  The health care reform bill included rebates to beneficiaries affected by this and hopes to offset some of the cost.

The president will also take questions from seniors across the country as well as discuss efforts to combat senior scams and fraud in advance of the first mailing of the rebate checks.  An estimated four million seniors nationwide will receive rebate checks.

The event will be broadcast on C-SPAN and can be seen from the following locations in Iowa:

National Council on Aging
Iowa City Johnson County Senior Center
28 South Linn Street
Iowa City

Alliance for Retired Americans
Machinists Hall
2000 Walker
Des Moines

Alliance for Retired Americans
Black Hawk Labor Temple
1695 Burton Ave
Waterloo

Alliance for Retired Americans
IBEW 405
1211 Wiley Blvd. SW
Cedar Rapids

Cedar Falls Senior Center
528 Main Street
Cedar Falls

Buchanan County Senior Center
400-5th Avenue
Independence

Marshall County Senior Center
20 ½ E. State Street
Marshalltown

Kimball Ridge Senior Center
2101 Kimball Avenue
Waterloo

The two scientists go on to point out several factual errors and misrepresentations in the article.  Among the errors: the Times claims Dartmouth data does take into account quality of care; Fisher and Skinner show that the atlas does indeed contain quality data.  The article also claims that “neither patients’ health nor differences in price are fully considered by the Dartmouth Atlas”; the scientists respond that risk adjustments are included in their studies.  As for price, they point out that because their investigations focus on actual measures of utilization, price adjustments are not necessary, though fully price-adjusted expenditure data is also available on the Dartmouth Atlas Web site, just the same. 

Rather than the Times article, which cites “critics” of Dartmouth’s work but fails to present any substantial criticism (or at least none that can hold up to scrutiny) and Skinner and Fisher describe as “superficial,” the researchers urge readers to take the time to read their initial but very thorough responses to the reporters’ questions, which the Times posted as a sidebar. 

In an article that ran in the Dartmouth campus newspaper, Fisher reiterated that the Dartmouth Atlas findings – essentially, hospitals that spend more on high-intensity health care “are less likely to deliver safe and effective care” – remain largely undisputed in the scientific community.  

“All of this research and all the findings they cite [in the Times’ article] are consistent with ours,” Fisher said. “The Times is not helping advance the public’s understanding of what’s going on.” 

Fisher went on to say that the potential remains to save “about 20 to 30 percent of health care spending” if more hospitals engage in “better performance measures, greater accountability and payment systems that reward improved performance.”

Like the scientists at the Dartmouth Atlas, IHA and Iowa’s hospitals are committed to understanding variations in health care delivery for the purpose of ensuring access to high-value health care.

 The New York Times, meanwhile, appears less interested in improving health care and more interested in creating controversy where there is none.

Dartmouth is a natural for this sort of endeavor primarily because it is home to the Dartmouth Institute for Health Policy and the Dartmouth Atlas of Health Care, which have been studying variation in health care delivery and spending for a couple of decades.  But while the Atlas gives Dartmouth the data, the college’s home state, New Hampshire, isn’t exactly a shining example of health care value. 

At more than $7,800 per Medicare recipient per year, New Hampshire spends nearly 20 percent more than Iowa ($6,686).  Of course, that’s not nearly as bad as nearby Massachusetts ($9,568) or New York ($9,995), both of which should provide convenient laboratories for what not to do for value-based health care delivery. 

This is worth noting because of something Dartmouth’s president, Jim Yong Kim, mentioned when the center was announced over the weekend.  According to Associated Press coverage of the story, Kim and state leaders have “discussed using the center to make New Hampshire a model for innovative health care.” 

This brings one thought immediately to mind: Why not Iowa? 

Obviously, Dartmouth has every right and reason to focus on its home state.  But this deserves serious consideration in Iowa, where IHA has made “value” a health care watchword.  Certainly, the tools and the people are there. The Iowa Healthcare Collaborative has united hospital and physician interests under the value flag and, like the Dartmouth Atlas, has become a vast data collector.  

The University of Iowa (UI) and Des Moines University both offer excellent schools of health care administration and medicine with easy access to not only urban medical centers but also nearby rural referral centers and Critical Access Hospitals, many of which are on the cutting edge of innovative health care delivery models.  The schools of engineering at UI and Iowa State, along with major businesses (including hospitals) that have adopted ideas like Lean and the Toyota model of process improvement, offer expertise and laboratories for systems analysis. 

What Iowa doesn’t have is seed money, like the $35 million that was anonymously donated to fund the Dartmouth center.  Perhaps if we can broaden our state leaders’ views on what drives a healthy economy (hint: it’s more than wind turbines and gambling halls) and quality of life (more than good schools and smooth roads) to realize the impact of high-value health care, some investment capital might emerge.

The rules do not go into effect until September 23, although several insurance companies across the nation, including Wellmark Blue Cross and Blue Shield of Iowa, have elected to implement the policy earlier.

Trends show that patients in the young adult age group are less likely to have insurance, which places burdens on hospitals in areas with high volumes of young adults. Mike Tretina, CFO at Mary Greeley Medical Center in Ames, home to Iowa State University, says that the hospital has budgeted $670,000 in uncompensated care to offset the cost of treating students or other young adults who do not have insurance.

Tretina hopes that the new provision will help to encourage parents to add their children to their coverage to reduce the number of young adults who are uninsured, and thereby reduce uncompensated care costs for hospitals.

Since 2008, Iowa law has allowed young adults up to age 25 to stay on their parents coverage.  The new federal provision adds an additional year, but it’s up to parents and young adults to take advantage of these benefits.

Nationwide, according to a White House fact sheet, estimates show that young adults comprise the largest percentage of uninsured of any age group, with an estimated 1 out of every 5 uninsured American falling in this age group.

Donald Berwick

Bringing real value to government-supported health care will be Dr. Berwick’s foremost challenge.  And with health care reform set to trim billions of dollars from the Medicare program while adding millions of new enrollees to Medicaid, it is a formidable challenge, indeed. 

But Dr. Berwick has two things going for him.  First, he knows what he is talking about.  His work and leadership at the Institute for Healthcare Improvement (IHI), which he cofounded nearly 20 years ago, has led to changes in the way hospitals provide health care that have saved lives, lowered costs and improved quality.  IHI’s current initiative, it’s “Improvement Map,” is perhaps its most ambitious.  

The Improvement Map is an interactive, Web-based tool designed to bring together the best knowledge available on key process improvements that lead to exceptional patient care. It offers clear guidance through the often confusing health care landscape, helping hospitals set change agendas, establish priorities, organize work and optimize resources.  The Improvement Map is also a testament to IHI’s dedication to shared learning, which it established from its beginning through collaboratives, learning networks and mentor hospitals (among these are Mercy Medical Center and St. Luke’s Hospital in Cedar Rapids, University of Iowa Hospitals and Clinics in Iowa City and Buena Vista Regional Medical Center in Storm Lake). 

But leaders succeed only when they energize followers, and that is Dr. Berwick’s other strength.  Throughout the medical world, Dr. Berwick is highly respected not only for his ideas but for his ability to bring key players to the table and keep them there.  Time and again, Dr. Berwick has been described as “a visionary.”  Hospital leaders in Iowa continue to be pleased about his nomination: 

“I was very excited to hear of the nomination of Dr. Don Berwick as the administrator for CMS,” said Jim FitzPatrick, CEO at Mercy Medical Center-North Iowa in Mason City.  “Dr. Berwick has spent his career on a quest for improving quality in the nation’s health care system.  His passion for improving processes for our patients and keeping focus on the ‘big dot’ issues to eliminate defects in care makes him the perfect leader for CMS. 

“Dr. Berwick’s appointment to CMS would be very positive for the health care industry,” said Eric Lothe, administrator at Iowa Lutheran Hospital in Des Moines.  “He has a long history of setting transformational goals for health care quality and then achieving great results.  Dr. Berwick would continue the focused work of IHI to help physicians and hospitals improve quality, reduce errors and eliminate adverse events.” 

The real question is, can Dr. Berwick’s ability to unite diverse interests come through in a U.S. Senate that remains bitterly divided over health care reform?  Can he show that not only can Medicare and Medicaid lead the way in improving care, but they can do it at less cost?  And can he hold his ground should talk of “rationing” and perhaps even “death panels” rear its ugly head? 

Answers should come fairly quickly, as Dr. Berwick’s first stop will be in front of the Senate Finance Committee and its ranking Republican, Iowa’s own Chuck Grassley.

IHA President and CEO Kirk Norris joined Jim Swift, Chairman and CEO of Holmes Murphy and Associates, an insurance brokerage firm with more than 500 employees and Jennifer Vermeer, Director of Iowa Medicaid, which is the third largest provider of insurance in Iowa.

Watch the video here.

IHA’s take on the bills as passed by the House:

Overall: The legislation passed by the House and Senate have addressed many of the concerns that affected hospitals in the original proposals.  The resulting legislation will bring about positive reforms for the health care industry by increasing access to health insurance coverage for citizens while also holding the immediate and long term potential of increasing the historically low payments for Iowa hospitals and physicians.

Insurance Coverage: Having millions more people covered by insurance is good news for hospitals.  Hospitals across the state have seen a notable increase in charity care cases, often because people have lost their jobs and their insurance.  The cost of that care eventually impacts those who do have insurance.  The larger the pool of insured people, the lighter the impact.  And when people have insurance, they are more likely to receive routine care – i.e., check-ups, immunizations, etc. – and avoid serious and expensive illnesses.  This legislation provides access to coverage to 30 million Americans.  Iowa currently enjoys a relatively low uninsured rate, but this legislation seeks to make health insurance more portable, while also making important reforms to the insurance industry.

Cost: We believe the legislation holds the potential to reduce costs by insuring more people (as explained above) and improving the way health care is provided.  The bill emphasizes providing care at the primary level (by providing higher Medicare payments to primary care physicians, for example).  Together with greater numbers of insured, the emphasis on primary care should help establish “medical homes” for more people, a model of care based on the primary care physician that improves quality of care and reduces cost.

Geographic Variation: Iowa’s congressional delegation has made a bi-partisan effort to address geographic inequities in hospital payments across the U.S.  Iowa will benefit from the negotiations as the legislation contains critical reforms that will increase payments to hospitals and physicians that have remained stagnant for decades.  For the first time, the Medicare program will finally recognize value over volume and incent and reward providers that provide the highest-quality of care at the lowest cost like that provided in Iowa hospitals.

IHA will remain actively engaged in the process as the reconciliation bill now moves to the Senate for debate, and applauds the work done thus far by Iowa’s Congressional Delegation that worked to address the issues surrounding geographic variation that negatively impacts payments to hospitals and physicians in Iowa.

The health care system in this country has really been more of a “sick care” system. Too much emphasis has been on mending bodies after health has left them. We have shielded folks from the true cost of health care through the proliferation and misuse of health insurance. The personal responsibility for maintaining optimal health has not been incented in the system. Although a growing number of Americans are health conscious, it is hard to deny the obvious epidemic of poor health. 

The “sick care” issue is at the foundation of health care reform.  It is one of the reasons health care and health insurance costs have risen.  We live in a very healthy society and most of us take it for granted, even though it was only 70 or 80 years ago that thousands of Americans were killed by accidents and diseases that scarcely exist today.  Advances in medicine, safety and nutrition keep people out of the hospital.  And when they go to the hospital, advances in treatment – like minimally invasive surgery – mean procedures are safer, recovery is faster and the likelihood of complications is greatly reduced. 

Our good health also comes with our good insurance coverage.  Since World War II, we have been a well-covered society.  On the up side, this has given broad access to the health care system and increased both the quantity and quality of life.  On the down side, as Todd notes, it has shielded health care users from the real cost of care and incented providers to offer more but not always better care. 

People don’t like going to the hospital and today they almost never have to.  But when they do go unexpectedly, it can be quite serious and very expensive.  For those with insurance, there is little incentive to prevent these occasions – the relatively low out-of-pocket cost and the fact that even very sick people are healed is what most of us see and remember.  For those without insurance, the result is often even more serious illness as they delay treatment. 

Certainly, we need to make sure as many people as possible are insured.  But how our society “uses” health care must also change and hospitals are helping make that happen with a focus on prevention and wellness.  This has been going at Grinnell Regional Medical Center in many ways and for several years, as Todd mentions.  In fact, every Iowa hospital provides services and programs that support prevention and advance wellness.  But hospitals are doing more than putting out the water and waiting for the horses to come around.  They are actively working to change our health care culture, to change our society’s mindset and put a focus on wellness. 

But cultural shifts don’t happen overnight.  It will take all of us, as health care consumers and providers, to create a true “health care” system.

“I believe the United States Congress owes the American people a final vote on health care reform,” Obama said.  He continued by mentioning a myriad of other bills that were passed with a simple majority rather than the currently required “super-majority” of 60 votes needed in the Senate to pass legislation.

The Democrats held onto a 60 vote majority until the election of Republican Scott Brown in Massachusetts.

Republican lawmakers insist that using the reconciliation procedure would cause outrage in the public and further the intense partisan gridlock facing the Congress.  Regardless, Obama requested that Congress take action in the next few weeks.  The president also highlighted the Republican ideas that he has agreed to include in his proposal and again told Republicans that starting over is not an option.

IHA will continue to monitor the process along with the new budget numbers and coverage estimates that result from the president’s new proposal.