An Iowa hospital is in the national spotlight this afternoon in an Associated Press story focusing on “medical homes.”

The story focuses on Dr. Don Klitgaard and his colleagues at Myrtue Medical Center in Harlan and their use of the medical home model, which focuses on primary care and coordinating the care of patients at that level:

Put primary care doctors like Klitgaard on the front end, the theory goes, and they could make sure patients see the right specialists, avoid duplicative tests, get proper medications and prevent the worst complications of chronic illness, such as diabetes-related blindness.

The problem is, health care payment systems, including Medicare and Medicaid, don’t line up with the Medical home model:

Klitgaard is wondering if Congress will do enough for primary care doctors, the ones expected to carry out the transformation. Medicare, the government health program for seniors, doesn’t pay for the care coordination, monitoring, and coaching of patients that are part of his model.

The practice model at Myrtue is nothing new, at least in Iowa.  It is one of the reasons why Iowa spends far less on Medicare patients than nearly all other states, yet retains extremely high quality of care, as the Commonwealth Fund noted in its most recent report.

Unfortunately, while Iowa’s practice model limits wasteful tests and visits to multiple specialists, keeps patients out of hospitals and ICUs and promotes hospice care, the model in other hospitals in many other states tends to do quite the opposite.  The result forces Iowa to effectively subsidize the wasteful ways of those hospitals.

The good news is stories like this one, which notes that the medical home model is getting more and more attention from Congress and the White House.

The other good news is that Iowa hospitals and practitioners are ready to show the world how and why the medical home model works.  On-point in that effort is the Iowa Healthcare Collaborative, the organization founded by IHA and the Iowa Medical Society to advance health care quality in Iowa and beyond.  IHC has developed a comprehensive medical home model toolkit.

And Dr. Klitgaard?  He happens to be the co-chair of IHC’s medical home model workgroup.

A recent article in the New York Times illustrates the travails for one U.S. Senator as he finds himself between a health care reform rock and hard place.  The Senator is Florida’s Bill Nelson.  The rock is more than 1 million Florida senior citizens who enjoy spa-like services under Medicare Advantage.  The hard place is 50 million nonelderly uninsured individuals in the U.S., including more than 3.7 million in Florida. 

It’s a bit of a gut-check for Nelson, a Democrat, as he is forced to balance his loyalty to party and president against perhaps the most motivated voting bloc in the country.  And motivated they should be.  After all, Medicare spends an average of $8,794 a year on each Medicare enrollee (compared to $6,204 in Iowa) and an average monthly Medicare Advantage payment rate of $1,013 (compared to $752 in Iowa).  Clearly, Medicare Advantage has been a big hit in Florida, which is why it has a 28 percent market penetration, compared to barely 12 percent in Iowa. 

Just where Nelson is leaning is clear from the Times article, in which he declares, “It would be intolerable to ask senior citizens to give up substantial health benefits they are enjoying under Medicare…I am offering an amendment to shield seniors from those benefit cuts.” 

Iowans, of course, have subsidized Medicare health benefits in Florida and other high-flying states for years, as Congress and the Centers for Medicare & Medicaid Services have allowed geographic disparity within Medicare to go unchecked, despite reams of data that show (1) it’s unnecessary and (2) it doesn’t benefit patients and, in fact, appears to detract from their quality of life, if not their overall health.  Speaking of “intolerable” – it’s doubtful that the Sunshine State Senator is aware that Florida is in the top 10 for Medicare spending and the bottom 10 for quality of care provided to Medicare beneficiaries. 

The good Senator gauges the situation by the e-mails and letters he has received, including, apparently, those coerced by Humana, one of Florida’s big Medicare Advantage insurers.  (Humana has since been taken to the CMS woodshed for using its Medicare Advantage database to further its political advocacy.)  What he should be looking at is why his state, home to the most expensive Medicare region in the country (Miami, at more than $16,000 per enrollee per year) is such a Medicare outlier.  That kind of guzzling at the public trough is bound to get you some well-deserved attention. 

It boils down to a basic question of equity.  Floridians are simply being asked to shoulder a small portion of what Iowans have hauled around since the Medicare Prospective Payment System was put in place.  Whether or not they choose to see the bigger picture and support a reformed national health care system that prioritizes patients – not just services – will depend a great deal on the words and actions of leaders like Senator Nelson and those who can, if necessary, neutralize him.

Late last week, Iowa’s Democratic Representatives overcame steep political odds in the House and struck a deal with leadership to add language to the health reform bill seeking to address the Medicare geographic variation issue.  This deal, spearheaded by Iowa Congressman Bruce Braley, appears to have broken the indefinite stalemate in the Energy and Commerce Committee that until then had prevented the legislation from moving forward.  Iowa Congressman Dave Loebsack also joined the conversation with leadership and defended Braley’s proposal threatening to withhold his vote on the legislation unless this issue was addressed.  This comes at a critical juncture in the health care reform debate, and IHA supports and applauds the efforts of Iowa’s House Democrats in addressing the long-standing problem of Medicare geographic disparity.

Specifically the proposal instructs the Institute of Medicine (IOM) to conduct two studies.  For the first study, IOM will have one year to evaluate geographic adjustment factors in the Medicare payment formulas including the wage index and the geographic practice cost index to determine whether the data and assumptions for the adjustments are accurate or based on flawed data.  The Secretary of Health and Human Services (HHS) must then implement the findings from the study automatically without Congressional review.  The legislation would establish funding available for FYs 2012 and 2013 to increase payment rates in regions where rates are low and hold harmless areas where payments have been historically inflated.  The hold harmless protection expires after FY 2013 and any adjustments due to the IOM recommendations will become budget neutral.

 The legislation also instructs IOM to complete a study of geographic variation in health care spending and promoting high value health care, with specific instructions to consider adopting a value index.  IOM will have two years to make recommendations to HHS on how to promote the efficient delivery of high quality, evidence-based, patient-centered care.  HHS will then submit a report to Congress on implementing a plan to revise Medicare payment systems based on the finding from the above IOM study, which will be implemented unless Congress votes against it by February 28, 2012. 

IHA also continues to work on the issue of value-based purchasing with a Medicare cost-per-beneficiary component with the Senate Finance Committee where Senator Chuck Grassley has been a leading voice on the issue during the bi-partisan negotiations.  The Senate approach would be in accord with IHA’s long standing position in support of a value-based purchasing program that not only measures quality but also resource utilization and efficiency. 

 While health reform is far from final, Iowa’s congressional delegation continues to stand up for Iowa hospitals and health care providers in the debate and deserve recognition for their efforts when they return home for the upcoming August recess.

Recent momentum in the ongoing health care reform debate in Congress was brought to an abrupt halt last week as conservative “Blue Dog” Democrats on the House Energy and Commerce Committee (the last of the three committees needed to approve the legislation in the House), refused to sign off on the bill, thereby halting progress indefinitely. However, late last week reports indicated a compromise may have been reached with the committee chair, but the deal is not sitting well with the health care industry, including IHA.

The Blue Dogs, supported by budget figures from the Congressional Budget Office, shared concerns that that House bill doesn’t go far enough to rein in Medicare spending over time and runs the potential of increasing the national deficit by $250 billion over 10 years.  Their solution is to transfer the authority of setting Medicare payment rates from Congress to the executive branch through an “Independent Medicare Advisory Commission” that, along with the president, would have unprecedented power to set annual payment rates for doctors, hospitals and other health care providers.

Further, once the commission announces Medicare payment rate cuts (or increases), Congress would then have 30 days for both chambers to pass a “joint resolution of disapproval,” which would be subject to a presidential veto that would require a difficult-to-achieve two-thirds majority “override” vote to undo the commission’s recommendations.

This is an unacceptable proposal that is opposed by IHA.  Not only does this strip power from Congress, but it also removes hospitals and providers from the debate, as a presidentially appointed commission is less likely to listen to input from industry leaders.

IHA has been in contact with Congressman Bruce Braley, who serves on the House Energy and Commerce Committee, to express opposition to this measure.  At this time, Braley, who is not a Blue Dog, has not commented on his support or opposition to this compromise.

Meanwhile, the Senate has also ground its efforts to a near halt as Democratic leaders announced this week that they have abandoned plans for a vote on health care reform before Congress’ August recess.  This news comes one day after President Obama’s fourth prime-time news conference on the issue of health care reform.  Senate Majority Leader Harry Reid (D-NV), held a news conference echoing many legislators from both sides of the aisle, saying, “It’s better to have a product based on quality and thoughtfulness rather than try to jam something through.”

The Senate Finance Committee has yet to release its legislation and is still working to put together a comprehensive, bipartisan proposal.

IHA continues to work with Iowa’s Congressional Delegation on the many issues that remain outstanding in the health care reform debate, including the need to include an efficiency measure based on cost in the proposed value-based purchasing program in Medicare.

As the health care reform debate continues, it is critical that Iowa’s Congressional Delegation hear from hospital leaders on the issues, especially in light of the announced cuts to hospital payments.  Over the next few weeks, Iowa Senators Tom Harkin and Chuck Grassley and their staffs will be traveling across Iowa holding listening posts and town hall meetings on health care reform.  Hospital leaders are encouraged to attend these meetings and take the opportunity to address concerns about health care reform.

It is very important for hospital leaders to attend these forums to address concerns and share ideas.  IHA has produced talking points for hospital advocates to use while addressing Iowa’s congressional delegation in these meetings.  Our health care reform hospital talking points have been updated to include the recent announcements of major cuts to Medicare.

Events hosted by Senator Grassley

Grassley is the ranking member on the Senate Finance Committee that oversees the Medicare program and other health care finance related issues.  He is not holding specific hospital meetings, but will be holding the following events:

June 30 8:15-9:15 a.m. Allamakee County Town Meeting Farmers & Merchants Savings Bank Community Room 201 West Main Street, Waukon	July 3 7:30-8:30 a.m. Marion County Town Meeting Pella Community Services Building 712 Union Street, Pella
10:45-11:45 a.m. Clayton County Town Meeting Elkader City Hall Lower Level 207 North Main Street, Elkader	10:00-11:00 a.m. Poweshiek County Town Meeting Brooklyn Public Library 306 Jackson Street, Brooklyn
1:45-2:45 p.m. Dubuque County Town Meeting Dupaco Community Credit Union 5865 Saratoga Road, Asbury	12:00-1:00 p.m. Tama County Town Meeting Renig Toledo Civic Center 1007 South Prospect Drive, Toledo

Events hosted by Senator Harkin

Harkin chairs the Health, Education, Labor and Pensions Committee’s Prevention and Public Health Working Group charged with crafting the prevention and public health components of the health reform bill. Notice time change for Cedar Rapids.

June 29 9:00-10:00 a.m. Linn Community Health Center Medical Plaza Building- Lower Level 855 A Avenue NE, Cedar Rapids	June 30 9:30-10:30 a.m. Adair County Memorial Hospital 609 Se Kent St., Greenfield	July 1 9:00-10:00 a.m. Winneshiek Medical Center Conference Room B 901 Montgomery Street, Decorah
10:30- 11:30 a.m. (corrected) St. Luke’s Hospital 1026 A Avenue NE, Cedar Rapids	11 a.m.-noon Regional Health Services Of Howard County 235 8th Avenue West, Cresco	10:00-11:00 a.m. Denison Community Room 111 N. Main Street, Denison
12:30-1:30 p.m. (corrected) Mercy Medical Center 701 10th Street SE, Cedar Rapids	1:30- 2:30 p.m. Guthrie County Hospital Todd/ Neff Conference Room 710 N 12th Street, Guthrie Center	11:30-12:30 p.m. Crawford County Senior Center 201 S. Main Street, Denison
	2:45-3:45 p.m. Mercy Medical Center- New Hampton Health Education Center 308 N. Maple Avenue, New Hampton	11 a.m.-noon Veterans Memorial Hospital Lower Level Large Conference Room 9 40 First Street SE, Waukon
	4:00-5:00 p.m. Grape Community Hospital Cafeteria 2959 State Highway 275, Hamburg	2:00-3:00 p.m. Burgess Health Center Boardroom 1600 Diamond Street, Onawa

Attending an event? Send us your feedback

If you attend any of these events, feel free to send us your notes or feedback about what was discussed. We’d love to continue these conversations on our blog.

Content can be forwarded to Dan Royer.