IHA continues to work on resolving and coordinating efforts to address the serious concerns surrounding the controversial “clarification and restatement” of the direct physician supervision requirements included in the outpatient Prospective Payment System/ambulatory surgical center final rule for 2010.  The key issue being addressed surrounds the Centers for Medicare & Medicaid Services’ (CMS) requirement that a supervisor be immediately and physically present throughout the duration of outpatient therapeutic services.

IHA has been meeting in-person with each of the offices of Iowa’s congressional delegation and has drafted a delegation letter to CMS urging immediate action on this issue.  To date, Senator Tom Harkin, and Representatives Leonard Boswell, Steve King, Tom Latham, and Dave Loebsack have all confirmed their support on the issue and have agreed to sign onto the letter.  Staff from the offices of Senators Chuck Grassley and Harkin have also been in contact directly with CMS to outline their concerns and staff for Senate Finance Committee Chair Max Baucus have been in communication with CMS on this issue as well.

Earlier this week, CMS hosted a rural health open door forum conference call and spent most of the time discussing physician supervision.  CMS acknowledged the arising complications and encouraged hospitals to continue reaching out to help CMS understand the “real-world” impact of its policy.

CMS verbally qualified its position by stating that physicians or other allied professionals, recognized in the outpatient rule should be “fairly immediately available” and recognized that the rule doesn’t anticipate clinicians “hanging around the emergency department” with no knowledge of anticipated patient arrivals.  CMS stated that determination of “immediately available” is essentially at the discretion of the hospital.  CMS also acknowledged that this billing policy predominantly creates an issue with observation status, which is currently billed as a therapeutic service.  However, CMS stopped short of backing away from the rule as written, but confirmed that further written guidance will be provided on this topic.

IHA will continue working with Iowa’s Congressional Delegation, the Senate Finance Committee staff as well as the American Hospital Association to seek clarification and resolution of this issue.  Pending further guidance from CMS, IHA will survey Critical Access Hospital members to further refine its understanding of the scope of the problem and potential solutions.

The editorial page of the Boston Globe provides a brief item on the importance of evidence-based medicine with regard to reducing costs and improving health care.  The editorial points to two examples: A 2007 study that showed that drugs work just as well as stents in treating chest pain and a 2002 study that showed generic drugs work just as well as name brands. 

The central point of the editorial is that neither of these cost-saving approaches has been as widely adopted as one might expect.  Why?  Because the insurance companies – both public and private – have provided few, if any, incentives to adopt them. 

This is yet another illustration of how health care spending is being driven by something other than value.  Instead, it is driven by a system that rewards quantity – a physician who does more testing and procedures will be paid, even if those tests were not the best or possibly even unnecessary. 

The Globe emphasizes evidence-based best practices and notes that “Medicare should have the authority to weigh both comparative effectiveness and cost in steering doctors to the best practices.”  In other words, Effectiveness + Cost = Value. 

In Iowa, we are fortunate to have a health care system that, particularly in the community hospital setting, is dominated by a culture of patient-centered primary care.  This means care tends to be provided in a coordinated fashion with the primary care physician at its foundation.  Patient-centered primary care works when best practices are emphasized.  And when that happens, real value in health care is the result.  

This is why Medicare would save billions of dollars every year if it demanded, as the Globe editorial suggests, the same value from others that Iowa already provides.

Iowa’s already-struggling mental health care system has taken another hit , as Ellsworth Municipal Hospital (EMH) in Iowa Falls announced that, within the next two months, it would be closing its inpatient behavioral health service and its chemical dependency program. 

This was not an easy decision for EMH leaders to make.  Only a handful of mental health programs like these exist in Iowa and the services at EMH are heavily used by patients from all over the state.  In fact, only 15 percent of the hospital’s inpatient behavioral health patients come from Hardin County.  This is no surprise; after all, 83 of Iowa’s 99 counties are considered mental health professional shortage areas.  With only about seven practicing psychiatrists for every 100,000 residents, Iowa ranks 47^th in the nation for access to mental health care. 

In Iowa Falls, EMH has done all it could to keep its inpatient program functioning.  The hospital streamlined the program, reduced staff and discontinued its transportation program.  But because of lagging reimbursement, particularly from Medicare and Medicaid, the program has been a drain on overall hospital finances.  This is a problem for all Iowa hospitals offering behavioral health services, but the impact is much greater for small facilities like EMH, which do not have the patient volume to make up for the losses.  This is why only a handful of these small hospitals offer any kind of behavioral health program (inpatient or outpatient). 

The good news for people in and around centrally located Hardin County is that inpatient behavioral health services in Des Moines and Waterloo are relatively close by.  For much of the rest of Iowa, particularly in the western half of the state, the distances are much greater.

What needs to be done?  IHA is advocating for programs that would attract more psychiatrists to the state, such as student loan repayment programs.  Expanding telemedicine services through high-speed Internet would allow more patients to utilitize online counseling rather than having to travel to urban areas where behavioral health programs and practitioners are concentrated.  IHA has been steadfast in pushing to keep the state’s mental health institutes in Cherokee, Clarinda, Independence and Mount Pleasant open – Iowa needs more access to mental health services, not less. 

IHA also continuously advocates for increasing Medicare and Medicaid payments to hospitals and doctors.  Hospitals lose millions of dollars each year because these programs do not cover the full cost of care.

Featuring hospital and health care headlines from the media and Web from December 12-December 18.

Iowa Headlines

Harkin takes to radio, TV to back bill
The Iowa Democrat has been dispatched to ease the concerns of liberal groups and leaders who have voiced their frustrations with compromises the Democratic leadership has made to hold together its tenuous coalition. (December 18, Des Moines Register)

Union membership to decide whether to back Culver, leader says
Whether Iowa’s largest public employee union will work to help Democratic Gov. Chet Culver in his re-election bid will be up to the members of the union, its leader said Friday. GOP challengers are lining up for the chance to take on Culver, who is expected to seek his second term next year. Support for Culver from at least one union is not yet assured. (December 11, Waterloo-Cedar Falls Courier)

Official: UIHC turns financial corner
University of Iowa Health Care officials say the hospital has “turned the corner” after months of financial woes, and they are prepared to move forward with work on a new outpatient clinic in Coralville.  (December 17, Iowa City Press-Citizen)

Allen Child Protection Center to open next year
Each year more than 100 sexually or physically abused Black Hawk County children are sent to Cedar Rapids for a forensic interview and treatment. Nina Thomas has made that journey to the St. Luke’s Child Protection Center with several young people. She has seen the extra stress placed on the families and the child. (December 14, Waterloo-Cedar Falls Courier)

We should shoot for higher Iowa health ranking
Just as the Hawks were a few plays from maybe making the Top 5, Iowans could be a few calories or a couple of packs of cigarettes away from sliding further down the rankings.  (December 14, Dubuque Telegraph Herald)

Iowa set to get Mercy Capitol keys
The people of Iowa are about to become the new owners of an old hospital. The east-side Des Moines facility, most recently known as Mercy Capitol, “is not the greatest building,” said Ray Walton, director of the state Department of Administrative Services. But it’s in a valuable location, just northeast of the Statehouse, and it could house about 400 government employees now using rented space elsewhere. (December 14, Des Moines Register)

Experts weigh in on health care reform
If Mid-Iowa is to get meaningful health care reform, there has to be a focus on what’s causing spiraling costs, and Iowa must get a better level of Medicare funding, according to experts who addressed the Ames Chamber of Commerce Friday. Four panelists from the fields of medicine, politics and private health insurance spoke to a group of about 50 people at Mary Greeley Medical Center. (December 12, Ames Tribune)

Broadlawns’ Hall fights audit release
The chief pharmacist at Polk County’s public hospital wants a judge to block release of documents related to allegations the pharmacy was mismanaged.  Mark Hall has asked for an injunction to prevent Broadlawns Medical Center from giving The Des Moines Register copies of the documents, including an internal audit of how the pharmacy tracked drug supplies. (December 17, Des Moines Register)

U.S.  Headlines

Hospital, physician lobbyists fought Medicare buy-in plan
The proposal to allow people ages 55 to 64 to buy insurance through Medicare — one of the most significant ideas to emerge from the Senate’s side of the debate — appeared and vanished in a mere six days.  (December 16, Washington Post)

Unified, yes; united, no
As the new nursing union behemoth – the National Nurses United – is unveiled, some of its new members aren’t exactly jumping for joy. (December 16, Modern Healthcare)

California hospital vote pits upstart union against colossus
Hundreds of workers at Santa Rosa Memorial Hospital are scheduled to go to the polls in a closely watched union vote pitting the giant Service Employees International (SEIU) against an upstart rival. The balloting at has drawn scrutiny in labor circles nationwide because of the nasty underlying conflict between the SEIU and its breakaway competitor, the National Union of Healthcare Workers. (December 17, Los Angeles Times)

Public cooling to health-care reform as debate drags on, poll finds
Anew Washington Post-ABC News poll finds the public generally fearful that a revamped healthcare system would bring higher costs while worsening the quality of their care. A bare majority of Americans still believe government action is needed to control runaway healthcare costs and expand coverage to the roughly 46 million people without insurance.  (December 16, Washington Post)

Top 10 health care issues in 2010
Some might say that there’s no juice left to squeeze from the cost of providing care, but a new report from PricewaterhouseCoopers’ Health Research Institute says health leaders are going to have to try.  (December 18, HealthLeaders Media)

Smoking rate drops in Massachusetts, drawing attention
When Massachusetts began offering virtually free treatments to help poor residents of the state stop smoking in 2006, proponents hoped the new Medicaid program would someday reap benefits. But state officials never expected it would happen so soon. (December 17, New York Times)

New hospital debuts in Minnesota; patients wanted
The construction crews have gone. Balloons and bouquets dot the lobby, and fish swim placidly in an aquarium near the lounge. Now the Twin Cities’ newest hospital just needs some patients.  (December 16, Minneapolis Star Tribune)

Massachusetts ER policy passes checkup
A new Massachusetts policy requiring crowded hospital emergency rooms to accept all patients delivered by ambulance has not worsened conditions, as some doctors had feared. According to an analysis by state public health officials, the average time patients spent in 75 of the state’s emergency rooms remained about the same since the rules went into effect in January 2009. (December 14, Boston Globe)

Immigrants lose lawsuit against Atlanta hospital
Efforts to force the public hospital here to continue providing free dialysis treatment to a group of immigrants, most of them illegal, suffered a setback on Tuesday when a judge dismissed a lawsuit challenging the recent closing of the hospital’s outpatient renal clinic. (December 15, New York Times)

The issue of geographic payment disparity in the Medicare program is once again in the headlines, and it’s good news for Iowa that this fight continues to be fought. 

As many Iowans know, our state’s hospitals spend far less (and receive far less) Medicare funds than most other states.  The Dartmouth Atlas of Health Care has documented that higher-spending hospitals and states are not providing any better care and, in fact, much of that extra spending is simply wasted.  The White House and much of Congress is in agreement, and this is making some high-spending hospitals nervous, the New York Times reports: 

The issue pits hospitals in more rural states like Iowa and Minnesota, where spending tends to be lower, against those in areas like New York City and Los Angeles, and revolves around a question that has bedeviled the medical establishment for decades: how much money do hospitals need to provide adequate care for patients…

Urban hospitals are countering that they serve poorer, sicker patients.  But that does not explain why similar hospitals – such as highly regarded academic medical centers in urban areas – have extraordinary differences.  Take a look at the table below (this information all pertains to Medicare patient averages during the last two years of life): 

Hospital	Physician visits	Medicare spending	Days in the hospital
Barnes-Jewish Hospital (St. Louis)	61	$63,281	27
Cleveland Clinic	63	$55,333	24
Hospital of the University of Pennsylvania	72	$80,727	31
Johns Hopkins Hospital	57	$85,729	29
Massachusetts General Hospital	75	$78,666	29
New York-Presbyterian Hospital	83	$91,113	39
UCLA Medical Center	101	$93,842	32
UCSF Medical Center	63	$78,046	22

 

These hospitals all happen to appear at the top of U.S. News & World Report’s “Best Hospitals” list and they all serve very urban populations.  Yet the differences are stark and raise many questions.  Why, for example, are patients spending 10 more days at UCLA Medical Center then its sister institution in San Francisco?  Why are 26 more physician visits needed at New York-Presbyterian than Johns Hopkins? 

Now, just for perspective, here are the numbers for Iowa’s major medical centers, along with the overall U.S. average: 

Hospital	Physician visits	Medicare spending	Days in the hospital
Alegent Health Mercy Hospital	58	$40,831	20
Allen Memorial Hospital	47	$39,386	18
Covenant Medical Center	57	$41,998	18
Finley Hospital	56	$38,696	19
Genesis Medical Center	58	$39,964	25
Iowa Methodist Medical Center	66	$44,068	25
Jennie Edmundson Memorial Hospital	65	$40,357	22
Mercy Hospital	47	$31,229	20
Mercy Medical Center-Cedar Rapids	52	$36,590	20
Mercy Medical Center-Des Moines	73	$42,091	24
Mercy Medical Center-Dubuque	47	$32,403	16
Mercy Medical Center-Mason City	43	$37,920	14
Mercy Medical Center-Sioux City	57	$42,272	22
St. Luke’s Hospital	50	$37,263	20
St. Luke’s Regional Medical Center	59	$37,581	19
University of Iowa Hospitals & Clinics	51	$48,427	24
U.S. Average	70	$52,838	25

 

One last thing:  Though it’s convenient from a media perspective, this is not necessarily an urban vs. rural issue.  There are, as the tables above show, urban hospitals that are providing value to the Medicare and there are rural facilities that are extreme outliers when it comes to Medicare spending.  The point is it is time for Medicare, as a health care consumer, to seek out and reward value – wherever it is found.