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For decades, organizations like the American College of Obstetricians and Gynecologists and the March of Dimes have been promoting the importance of full-term pregnancies – those naturally reaching at least 39 weeks gestation – yet early elective deliveries in many states account for 10-15 percent of all deliveries.

Numerous studies show early elective deliveries are associated with increased maternal and neonatal complications for both mothers and newborns, compared to deliveries occurring beyond 39 weeks and women who go into labor on their own.

Babies born before 39 weeks are more likely to have feeding and breathing problems and infections that can result in admissions to neonatal intensive care units than those who are born later, studies show.  The elective deliveries can also cause developmental problems that show up years after birth.  Inducing labor early also carries risks for mothers because it increases the chances they will need cesarian sections.

Decreasing the rate of early elective deliveries means more mothers get safe, evidence-based care and infants improve their chances for good physical and developmental health.  Additionally, it means lower costs for public and private payers because they’re performing less caesarian sections for failed inductions, they have less neonatal intensive care unit admissions and less associated complications for the newborns.

In Iowa, hospitals and physicians working through the Iowa Healthcare Collaborative and the national Partnership for Patients initiative have made a concerted effort to reduce early elective deliveries.  In fact, “hard-stop” policies implemented by Iowa hospitals have all but eliminated such deliveries, as the video below discusses.

 

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(Eric Greitens will be a keynote speaker at the IHA Annual Meeting on October 9.  This column originally appeared on the TIME magazine website and is republished with permission.)

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Eric Greitens

The Department of Veterans Affairs is facing an emergency.  Deception in record keeping, manipulation of data, lies to families, secret lists, systemic corruption at health centers.  Yet this crisis of credibility is more than a short-term emergency at the department that pledges to fulfill Lincoln’s promise to “care for him who shall have borne the battle, and for his widow, and his orphan.”  There’s also a long-term challenge.  To meet it, the VA leadership will have to move boldly to address questions both strategic and cultural.

I’ve worked with thousands of veterans since returning from Iraq in 2007.  My team has honored nurses and doctors in the VA who saved lives, and there are many stories of the sweat and courage of VA employees that are too infrequently told.  Many veterans are satisfied with the care they receive, and the VA has model programs for some illnesses.  Yet almost every veteran has at least one story of VA dysfunction.  Too much VA heroism is about fighting the VA itself by going above, under or around its beastly bureaucracy.

After the Pentagon, the VA is the single largest department of the government, spending more than $160 billion dollars a year and employing 300,000 people.  Leading any organization of this size through a crisis would be difficult.  At the VA, new leadership will have to build a team, shape a culture and develop a strategy to face the twin challenges of restoring credibility while also leading transformation.

At the moment, the VA is facing a crisis of demand.  Veterans who need care can’t get it from VA hospitals.  Because of the wars in Iraq and Afghanistan, many people believe that the veteran population is growing.  It would be easy to think that the answer is simple: hire more and spend more.  But in fact, we’ve lost more than 6 million veterans over the last 30 years, and veterans now represent less than 7 percent of the population.  We face a future with millions fewer veterans in a country with millions more people.  Over the long term, the VA will have to adjust to a shrinking population with changing needs.  The right kind of planning will rely less on predicting the future and more on building a flexible system that responds quickly to shifting needs.

The current structure of VA health care makes that kind of planning difficult.  A patient-centered approach would incorporate lessons from other hospital systems to create structures for physicians and hospitals to deliver excellence while providing flexibility for patients to go wherever they can to get the best care.  This is easy to write and hard to do.  But it’s the kind of thinking and planning that the VA must do if they are going to preserve centers of excellence and avoid the waste of half-filled hospitals and ghost town clinics.  Solving this challenge will require close work with Congress on a sensible plan for consolidation in some areas, while expanding excellent care options for all veterans, especially those living in rural and remote areas.

Unlike the military, almost every function performed by the VA (health care, home loans, scholarships, cemeteries) has a clear private sector counterpart.  Innovative leaders have to look to public/private partnerships and market competition and ask, “What works best?”  We should rethink what services we want the VA only to pay for and which ones we want it to provide.

In addition, through increased collaboration the VA can take far greater advantage of the work of high-performing non-profit organizations that are providing quality services to veterans.  Perhaps more than at any time in American history, the average citizen is ready and willing to help veterans.  But for reasons of privacy, health, and quality, the VA has built a high wall around its patients.  (Some of these walls are necessary; there are many people with good intentions who create no results, and the field of those who say they want to help veterans includes people who are fraudulent and manipulative.) The VA should create a certification system for quality, proven organizations to make a difference in the lives of veterans who would benefit from the healing presence and helpful service of their fellow Americans.

In a similar vein, civil service reform may not seem exciting, but it’s essential.  With 300,000 employees and a crisis of accountability, the VA must find ways to remove poor performers, promote and reward excellence and attract and retain top talent.  Insisting on excellence is the best way to preserve, promote and celebrate the public service ethic shared by many VA physicians who forego higher salaries to serve veterans.  Done right, reform at the VA could point the way toward a more dynamic and effective civil service.
Finally, any discussion of the structural and strategic challenges facing the VA has to include technology.  Both the inability of the Pentagon and the VA to smoothly transition a service members’ health records and the VA backlog of disability claims have been well documented and much discussed.  But without a fix, serious problems will persist.

In addition to these structural issues, there are cultural issues that must be tackled as well.  Thus far, the VA has failed to fully integrate this generation of veterans into its systems or culture.  Combat-injured veterans from Iraq and Afghanistan with pressing needs too often continue to wait in horrific lines.  Their signature injuries—traumatic brain injury and PTSD–have still not been effectively addressed.  And despite some women’s health centers, the VA too often thinks of veterans only as men, when female service members now make up 14 percent of the force.

The “pop a pill” approach to pain in general and to PTSD in particular is also hurting.  There’s a place for prescription medication for some patients, but the side effects of overmedication too often include addiction and suicide.  Exercise, service in the community, work with dignity and meaningful relationships all seem to have a lasting effect on relieving PTSD.  These are not things that a government can provide for its citizens; all people, veterans included, must be partners in the protection and promotion of their own health.  The VA needs to encourage therapeutic plans that reinforce a culture of responsibility.

The disability system itself has also devolved into a cumbersome check-writing scheme unattached from commonsense understanding of disability.  (Because of that, I and many others make a point of donating “disability” checks to charity.)  Veterans who were disabled by war and need financial assistance to lead a dignified life should get it.  Veterans who do not need disability payments should be able to easily opt out of receiving them, while not forfeiting their future eligibility should they suffer a setback.  Lost eyesight rarely returns and limbs don’t grow back, but where a disability can be overcome, veterans should be aided by a system that incentivizes progress toward health rather than simply paying for disability.  The money we save could be redirected toward programs that help reintroduce veterans as contributing citizens to society.

Many people who work with veterans are frustrated by media stories that focus on “troubled” veterans: stories of suicide, sexual assault, homelessness and crime.  But the journalists who cover these issues are often veterans themselves, and many spent time embedded in military units.  When they draw attention to flaws at the VA, they should be thanked rather than shut out.

Criticism of the media counts for little if veterans don’t join the conversation.  Perhaps more than anything, new leadership at the VA must help the public to know the men and women I know: men and women who served with courage overseas and who’ve come back home to help us build stronger communities.  The leader of the VA serves as the most visible and powerful spokesperson for veterans in the country.  As such, he or she must help the country understand not only what veterans deserve, but also what they offer.

Many of these problems have roots that go back more than 50 years.  They won’t be solved in five months.  Still, discussions about veterans have been buoyed for too long by the rhetoric of intentions.  We know that everyone wants to do well by veterans, but there is a vast difference between wanting a result and creating one.

The veterans that came home from World War II shaped a nation.  The generation that came home from Vietnam shaped a culture.  What will be the legacy of this generation?  The men and women I served with were never afraid to do hard things.  This too will be hard.  But it’s what we all want: veterans, honorable employees inside the VA and every American who believes it’s time we got this right.

Eric Greitens, a Navy SEAL and founder and founder of The Mission Continues, was a TIME 100 honoree in 2013.  He was recently named by Fortune Magazine as one of the 50 Best Leaders in the World.

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(From time to time, the blog features recipients of the IHA Iowa Hospital Heroes Award.  These outstanding hospital employees come from across the state and work at hospitals of every size.  They exemplify the courage, caring and community focus that are at the center of the hospital mission in Iowa.)

profile-photo-smallHospitals are the place to go when you break a bone, need surgery or have a baby; hospitals are not as well designed to heal the emotional and mental needs that many of our patients also bring with them.   Social Worker Maggie Martinez is the person that Buena Vista Regional Medical Center in Storm Lake turns to when patients need more assistance than medical training can provide.

Maggie is known to come in at any hour, vacation days and holidays to assist with those patients with mental or social needs.  She spends countless hours on the phone seeking out various resources that patients need after they are discharged from the hospital.  Physicians often make comments that she “ensures our patients are not lost once they leave the hospital.”

About a year ago a mentally disabled man with a chronic illness was admitted to the hospital.  He lived in an unsafe environment and had no family to help.  Maggie helped to secure a nursing home bed.  To accomplish this, she traveled to the man’s home and spent many hours on the phone with a judge, physicians and nursing homes.  She even accompanied him to the nursing home the day he was discharged because he was so frightened.  He remains living there today in a safe, clean environment he calls home.

Hero_MaggieM_8-2013-008smallRecently she dealt with a troubled teen whose parents could no longer handle and multiple programs and agencies would not accept. Maggie spent countless hours and days with this patient.  With persistence, she found a program that would accept the teen.

Maggie’s presence helps not only the patients but all the staff dealing with difficult situations. Our hospital employees are often involved with difficult cases that impact them emotionally.  The staff does what they need to do in each situation to provide the best outcome and experience for the patient and their family.  Maggie is crucial to making sure our staff learns how to deal with their own emotions regarding the event, enabling staff to provide the best care to patients.

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The additive manufacturing movement will provide form along with function.

The additive manufacturing movement will provide form along with function.

Johannes Gutenberg would be astounded at what is now possible as the world has progressed far beyond anything he might have imagined when he first printed the Bible on his movable type press.  That’s because the practice of putting ink to paper was mastered and made obsolete in the last several decades and humanity is now moving forward with the next step in the evolution – printing three-dimensional objects.

Lifelong fans of Star Trek would interject at this moment and say that this movement is more akin to replication than printing.  That’s because these sci-fi aficionados began dreaming of this day ever since they saw Captain Picard utter, “Tea…Earl Grey…Hot,” to a wall-mounted machine and suddenly a piping beverage would appear before him out of thin air.

3-D printing, or “additive manufacturing,” as it’s more commonly referred to, still primarily uses molten plastic, so it’s a long way from such the Star Trek scenario.  However, the possibilities it’s yielding are still remarkable, to say the least.  Some say this is the beginning of a new industrial revolution where consumers will eventually cease purchasing objects but rather buy the digital blueprints to create those objects (or their components) at home using 3-D printing machines.  Alas, while this probably won’t make your Ikea furniture any less confusing to assemble, this scenario is already in the early stages of realization, even within the realm of health care.

Take for example a young child who, by way of a tragic affliction or accident, has lost a leg. In the current prosthetic environment, these implements are not made to fit the patient, rather it’s quite the opposite and still remains an expensive ordeal despite years of discomfort and chronic joint and back issues that can be caused as a result.

Through additive manufacturing, that child is now able to have custom prosthetics crafted to fit his or her body and then have new versions of the implement scaled as the child grows.  In the case of a hand prosthetic, different hand positions can be crafted to enable the patient to do things that were previously accomplished using more arcane-looking attachments like hooks and claws.

But even further down the rabbit hole lies a couple of advancements that may seem even more like science fiction but are already nearing a state of practical use. The first is 3D-printed organs and organ tissue which companies like Organovo are already manufacturing. While still somewhat in the development phase, 3D-printed organ tissue has potential to revolutionize transplants by offering “off-the-shelf” organs and eventually eliminating the often heartbreaking wait and disappointment of donor organs and donor lists. One other anticipated practical use of 3D-printed organs is in pharmaceutical drug testing using actual human tissue, thus yielding more accurate results than previously possible with 2-D cell cultures or animal testing.

And it’s not only organs that are coming off the press, but food as well. This has obvious humanitarian implications as 842 million people in the world are suffering from hunger. Organizations such as Meals from the Heartland, which benefit largely from volunteers (one of IHA’s favorite volunteer activities every year) and donations, could soon be directly benefitted from such an advancement.

And here at home, the U.S. Army is currently considering 3D-printed food as an alternative to the current “meals ready to eat” for feeding its troops. For now, the menu hasn’t ventured beyond the “paste and gruel” varieties, so odds are we won’t see Gordon Ramsay popping a blood vessel over poorly rendered gourmet 3D food any time soon, but we all had to learn to cook ramen once before we could move up to tiramisu.

All of these facets of additive manufacturing as well as some you might not expect will be discussed by Kendall Joudrie, founder and CEO of Thinking Robot Studios, as part of a track of sessions examining innovation at this year’s IHA Annual Meeting, October 7-9 at Veterans Memorial Community Choice Credit Union Convention Center in Des Moines.

Don’t feel ashamed if all of this techy goodness finds you in a geeky mood and asking iPhone’s SIRI for “Tea…Earl Grey…Hot.” The outcome won’t readily quench your thirst, but she’ll still come back with a number of great places around downtown Des Moines where you can hoof it to.

 (photo credit: Melissa Ng, www.lumecluster.com)

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It’s becoming more and more apparent that the struggle to expand insurance coverage in Iowa through Medicaid was well worth the effort.  As these pages have recently noted, coverage is up and uncompensated care is down in both Iowa and other states that expanded Medicaid.  That trend has impacted more than medical care and finances; it has helped smooth Iowa’s mental health system reform and contributed to Iowa ranking as best in the nation for children’s health.

In other parts of the nation, the positive impacts are also being documented, including actual lives saved.  In Massachusetts, which adopted insurance expansion in 2006, a study published last spring determined that mortality declined almost 3 percent relative to control counties in the four years after the state’s health expansion was rolled out.  Mortality related to health care-amenable conditions fell by 4.5 percent.

As IHA’s successful campaign stated and restated in 2013: coverage matters.

medicaid-mapUnfortunately, it also matters for the 24 states that have so far turned their backs to Medicaid expansion (though a few are on the fence).  An Urban Institute survey found that the uninsured rate among adults under 65 had declined by 6.1 percentage points in states that expanded, compared with only 1.7 percentage points in those that didn’t.

The situation in these states has put hospitals in peril.  Carolinas HealthCare System, which has some 900 care locations including 7,640 licensed beds in North and South Carolina, reported an astounding 53 percent drop in earnings.  Had North Carolina expanded Medicaid, it would have covered 500,000 additional people and brought an additional $413 million to the state.  Meanwhile, Fitch Ratings had this blunt assessment: “We expect providers in states that have chosen not to participate in expanded Medicaid eligibility to face increasing financial challenges in 2014 and beyond.”

What’s more, many of these states, by many measures, were among the least healthy in the nation long before the Affordable Care Act (ACA) became law.  Look at the Kids Count Survey which Iowa led and you will see Louisiana, Alabama, Mississippi and other far-southern states struggling with every sort of children’s health issue, from low-birth weight babies and infant mortality to childhood immunization rates and the number of children struggling with mental health issues.  Amazingly, seven of the 10 states with the highest uninsured rate (for total population) are not moving forward with Medicaid expansion.

On top of all this, the United States Court of Appeals for the District of Columbia Circuit ruled last week that ACA does not allow the federal government to offer financial assistance to people buying insurance in states not running their own insurance marketplaces.  If that ruling stands (keep in mind another federal court ruled the subsidies are fine), it could mean that millions of residents in 36 states, including Iowa, would lose access to insurance through ACA.

Having expanded Medicaid, Iowa remains well-positioned for the future.  However, many states (including four of the six bordering Iowa) have declined the offer, leaving millions of Americans even more on the fringes of the health care system.  In that way, ACA has fallen short as a national solution for providing health care access to uninsured Americans.

The need remains – in fact, it has only become greater.  The question is, given the unexpected curves and bumps thrown in front of ACA’s otherwise admirable progress, what can or should be done to get states that have been left behind back on track?  Furthermore, how will their lack of progress impact states like Iowa that have done the right thing and continue to make great strides in providing high-quality, high-value health care?

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