IHA and Iowa Business Council have partnered to produce a new report designed to help businesses, health care providers and employees work better together to improve health and control health care costs.
Using case studies from 19 large Iowa employers, “Partners for Health: How Iowa Businesses, Health Care Providers and Employees are Collaborating to Create Value” offers specific real-world examples of successful programs Iowa businesses have implemented to engage employees in their health and improve individual and organizational wellness. Sectors represented in the report include manufacturing, retail, health care, education and energy.
“Iowa businesses are deeply invested in the health of their employees,” said Michael Wells, chair of the IBC board and president and CEO of Wells Enterprises Inc. in Le Mars. “But we realize we must do more than provide health care coverage. We must engage employees in their health, incent and support good habits and work with health care providers. These case studies show collaboration is crucial.”
We applaud Iowa businesses that have joined with their employees and health care providers to ensure good health,” said Marie Knedler, chair of the IHA board and president of CHI Health Mercy Council Bluffs. “We know in the health system that coordination of care is necessary for successful outcomes. We also realize that coordination not only involves providers, but our patients and their employers working together toward prevention and wellness. That is how value is cultivated in health care.”
(The following was written in response to this column.)
Dr. Steven Goldberg, the chief medical officer from WellCare, one of the managed care organizations (MCOs) contracted to take over Iowa’s Medicaid program, paints quite a rosy picture of managed care under companies like his. On behalf of Iowa’s hospitals and the vulnerable Iowans who depend on Medicaid, the Iowa Hospital Association would like to explore these claims a bit further:
- Regarding the studies from the Menges Group and Lewin Group that purport to show savings from managed care: The $2.4 billion in “savings” claimed in the Menges report sounds impressive, until you divide it among the 40 managed care states, which includes nearly all the largest states in the union. California alone has 9 million managed care enrollees – 16 times the potential number in Iowa – so how much of this claimed savings could possibly find its way to Iowa?
- However, that might be a moot question, because the numbers from the Menges report are not actual savings but projections based on assumptions of reducing inpatient admissions (30 percent) and outpatient services (25 percent) due to care coordination, something Iowa providers are already doing.
- The 2009 Lewin Group study also depends on data from as far back as 1995. The relevance of this information is questionable in a post-Affordable Care Act health care world.
- That same study raises serious doubts about Medicaid managed care’s viability in a state like Iowa: “Rural settings pose daunting challenges to the managed care model in Medicaid (as well as for other payers). The limited number of providers can make development of a network problematic, and the market may be unable to provide the economies of scale that are achievable in more metropolitan areas.”
- While Dr. Goldberg is quick to point to savings “up to 20 percent” reported in the Lewin paper, that’s the highest end of the spectrum. Most states reported significantly less savings – as little as one-half of one percent.
- A much more rigorous and recent Medicaid managed care study by the Robert Wood Johnson Foundation (RWJF) found that “any potential savings will not be significant” and that those savings “generally are due to reductions in provider reimbursement rates rather than managed care techniques.”
- It’s also worth noting that both of the studies cited by Dr. Goldberg were not peer-reviewed and were paid for by the health plan industry (companies like WellCare), while the RWJF report was done independently and only included peer-reviewed studies.
- With regard to the health care outcomes results WellCare credits to managed care in Kentucky and Missouri: The managed care industry doesn’t own a patent on coordinated, preventive care. Through existing Accountable Care Organizations, Integrated Health Homes, the State Innovation Model and the Iowa Health and Wellness Plan, these same efforts are underway and creating positive results in Iowa – without the additional cost to taxpayers to cover an out-of-state company’s profit margin.
- In fact, the University of Iowa Public Policy Center released a report just this past March indicating that existing care coordination through Iowa’s Primary Care Health Home Program has generated 20 percent in savings ($11 million) in its first 18 months. With results like this already occurring, why is the state looking to eliminate this and other successful programs for an untested MCO model?
As the media have reported –and in addition to assorted legal and regulatory misdeeds – the four Iowa contractors have a history of making unverifiable claims. But once the MCOs have taken control from a state, these claims take on a life of their own because only the companies have access to the complete information. Meanwhile, the RWJF study, the most current and objective available, found virtually no upside to Medicaid managed care with regard to savings, access to care or quality improvement.
This massive, fast-moving change offers nothing to Iowa. What these health plans claim they can bring is already happening here – led by Iowans, for Iowans.
It’s time to show the MCOs the door.
Let’s just clear one thing up from the get-go: Iowa hospital leaders do not fear change. Anyone who does fear change really has no business in health care administration – or health care, for that matter.
Health care is change. Much of it is necessary and welcome, innovative, even revolutionary. Some of it is unnecessary, a hindrance, even dangerous. The bulk of it is somewhere in between – basically good ideas in need of refinement, testing, tweaking, discussion, compromise. In health care, real, disciplined change takes leadership, cooperation and time.
But that’s not how it’s working with Medicaid managed care, with the state single-handedly rocketing toward its January 1, 2016 implementation. It is, at this point, a dictatorial do-something that lacks credibility and buy-in. And now accusations have been laid down that those questioning that plan and timeline – including health care providers – are merely defending the “status-quo” and have no real arguments, but only fear the change.
So let’s talk about what really comprises the status quo in managing Medicaid. In support of its version of Medicaid managed care, the current administration points out that dozens of states have privatized their programs. Not only that, many of those states have contracted with the very same companies that won Iowa’s bid. This is put forth as proof that the administration’s plan is a good plan.
One would hope for something more substantial, but “everybody’s doing it” seems to be the beginning and end of the administration’s central point. It’s not for lack of trying to create a substantial argument, one can assume, but for lack of substantive proof (see “$51 million in Medicaid savings”). Despite years of experience in dozens of states, there is simply no evidence that privatized Medicaid managed care improves health, increases access or saves money.
Talk about status quo, how can anyone reasonably expect something new, different and better when the same plan is being put into place with the same out-of-state, profit-driven business partners? And putting it into place at breakneck speed certainly doesn’t bolster the state’s case. In fact, the rush to implementation not only undermines credibility, but wrecks any real chance of collaboration and innovation. Who has the time (or motivation) to do anything new and thoughtful for Iowa?
The real rub to all this is that not only can Iowa do Medicaid better, Iowa is doing Medicaid better. Through the State Innovation Model, Accountable Care Organizations and Integrated Health Homes, there is progress on accessibility, quality and cost. Those changes and that progress are being made because there has been teamwork between the state and providers, because good ideas have been refined, tested, tweaked and, when needed, compromised on. How can slicing up Iowa’s Medicaid population and the people who care for it between four huge, out-of-state companies possibly create an environment conducive to care coordination?
Iowa hospitals lead change, with Medicaid and on countless other fronts. When it is collaborative, positive and patient-centered, Iowa hospital leaders embrace change. But the state’s plan for Medicaid has none of those qualities. The state’s approach is change without discipline and it needs to be rescheduled and rethought.
It isn’t out of trepidation that Iowa hospitals have reached that conclusion; it is out of well-considered, ongoing analysis based foremost on putting the health of people and communities first.
Month after month, Natalia Pedroza showed up at the doctor’s office with uncontrolled diabetes and high blood pressure. Her medications never seemed to work, and she kept returning to the emergency room in crisis.
Walfred Lopez, a Los Angeles County community health worker, was determined to figure out why.
Lopez spoke to her in her native Spanish and, little by little, gained her trust. Pedroza, a street vendor living in downtown Los Angeles, shared with him that she was depressed. She didn’t have immigration papers, she told him, and her children still lived in Mexico.
Then she mentioned something she hadn’t told her doctors: She was nearly blind.
Pedroza’s doctor, Janina Morrison, was stunned. For years, Morrison said, “people have been changing her medications and changing her insulin doses, not really realizing that she can’t read the bottles.”
Health officials across the country face a vexing quandary – how do you help the sickest and neediest patients get healthier and prevent their costly visits to emergency rooms? Los Angeles County is testing whether community health workers like Walfred Lopez may be one part of the answer.
Lopez is among 25 workers employed by the county to do everything possible to remove obstacles standing in the way of patients’ health. That may mean coaching them about their diseases, ensuring they take their medications or scheduling medical appointments. Their help can extend beyond the clinic walls, too, to such things as finding housing or getting food stamps.
The workers don’t necessarily have a medical background. They get several months of county-sponsored training, which includes instruction on different diseases and medications, as well as tips on how to help patients change behavior. They are chosen for their ability to relate to both patients and providers. Many have been doing this job for friends and family for years – just without pay.
“By being from the community, by speaking their language, by having these shared life experiences, they are able to break through and engage patients in ways that we as providers often can’t,” said Dr. Clemens Hong, who is heading the program for the county. “That helps break down barriers.”
For now, they work with about 150 patients, many of whom have mental health issues, substance abuse problems and multiple chronic diseases. The patients haven’t always had the best experience with the county’s massive health care system.
“They tell us, ‘I am just a number on this list,’” Lopez said. “When you call them by name and when you know them one-on-one … they receive that message that I care for you. You are not a number.”
By spring, Hong said he hopes to have hundreds more patients in the program.
Community health workers have been used for decades in the U.S. and even longer in other countries. But now officials in various counties and states — including Massachusetts, Pennsylvania and Oregon — are relying on them more as pressure grows to improve health outcomes and reduce Medicaid and other public costs, experts said.
“They are finding a resurgence because of the Affordable Care Act and because health care providers are being held financially accountable for factors that occur outside the clinical walls,” said Dr. Shreya Kangovi, assistant professor of medicine at the University of Pennsylvania and director of the Penn Center for Community Health Workers.
Kangovi said community health worker programs, however, are likely to fail if they don’t hire the right people, focus too narrowly on certain diseases or operate outside of the medical system. They also need to be guided by the best scientific evidence on what works.
“A lot of people think… they can sort of make it up as they go along, but the reality is that it is really hard,” she said.
Hong, who designed the program based on lessons learned from other models, said Los Angeles County is taking a rigorous approach. It is conducting a study comparing the costs and outcomes of patients in the program against similar patients without assigned workers.
The patients are chosen based on their illnesses, how often they end up in the hospital and whether doctors believe they would benefit.
To Lopez, 43, the work is personal. A former accountant from Guatemala, Lopez has a genetic condition that led to a kidney transplant. Like some of his patients, including Pedroza, he is now on dialysis.
He tries to use his experience and education to get what patients need. But even he runs into snags, he said. One time, he had to argue with a clerk who turned away his patient at an appointment because she didn’t have identification.
“The hardest part is the system,” Lopez said. “Trying to navigate it is sometimes even hard for us.”
Lopez and his fellow community health worker, Jessie Cho, sit in small cubicles in the clinic at Los Angeles County-USC Medical Center, the county’s biggest and busiest public hospital. Throughout the day, they accompany patients to visits and meet with them before and after the doctor does. They also visit patients at home and in the hospital, and give out their cell phone numbers so patients can reach them quickly.
Cho said the patients often can’t believe that somebody is willing to listen to them. “Nobody else on the medical team has it as their job to provide empathy and compassion,” she said.
Morrison, the clinic physician, said both workers have become an essential part of the health team.
“There is just a limited amount I can accomplish in 15 or 20 minutes,” Morrison said. “There are all these mysteries of my patients’ lives that I know are getting in the way of taking care of their chronic medical problems. I either don’t have time to get to the bottom of it or they are never going to really feel that comfortable talking to me about it.”
Natalia Pedroza, who wears a colorful scarf around her head and speaks only Spanish, is a perfect example. Morrison said before Lopez came on board, “I wasn’t getting anywhere with her.”
Initially, Lopez had a hard time helping her understand her health conditions and overcoming her distrust of the system. When they first met, Pedroza believed the dialysis that kept her kidneys functioning was the cause of her health problems. And she didn’t get why Lopez was always around.
But he helped her — by getting her appointments, for instance, and helping arrange for Pedroza to get pre-packaged medications so she wouldn’t have to read the directions. Now Pedroza thinks Lopez is helping her to get better.
On a recent afternoon, Lopez sat down with Pedroza before her medical appointment.
“How are you feeling?” he asked in Spanish.
Pedroza responded that her hair was still falling out and that she still felt sick. She also said she hadn’t been checking her blood sugar because she didn’t know how to use the machine. Lopez calmly demonstrated how the machine worked, and then the two spent several minutes chatting about her job and her neighborhood.
Lopez said he believes he has a made a difference for other patients as well. On a recent Sunday, a 43-year-old patient with chronic pain who initially refused his help texted that he planned to go to the emergency room because of a headache. Lopez reached Morrison, who agreed to squeeze him into the schedule a few days later. And the patient didn’t go to the ER.
Lopez persuaded another patient, a 56-year-old woman, to take her blood pressure medication before her appointments so that when she arrived, the doctors wouldn’t get worried about her numbers and send her to the hospital.
In one case, his ability to bond with a patient almost undermined his goal of getting the man the help he needed. The patient, who was depressed, said he didn’t want to go see a mental health counselor because he was more comfortable talking to Lopez.
“It was touching,” Lopez said. “I was about to cry.”Comm
The Iowa Hospital Association (IHA) opposes the state’s plan because it seeks to reduce Medicaid costs by restricting access to health care services and reducing reimbursement to providers through claims denials and requirements for prior authorization. Merely copying what 40 other states have pursued unsuccessfully is not new or innovative. It simply hands the reins of Iowa’s second largest insurance program to four out-of-state companies, along with a half a billion dollars of Iowa taxpayer funding.
Research of publicly funded managed care in both Medicaid and Medicare clearly demonstrates that minimal to no savings occur through the private management of these programs. In fact, spending for private management actually increases the cost of these programs in markets that are efficient utilizers of public resources. Iowa is such a market, as shown by the state’s low average cost per Medicaid enrollee and its low Medicaid administrative costs (among the lowest in the nation, in fact).
The current administration and Iowa hospitals agree that Iowa has been an innovator in its management of Medicaid. Just this year, the federal Centers for Medicare & Medicaid Services (CMS) approved a $40 million implementation grant for Iowa to continue work on the State Innovation Model (SIM) initiative, a multi-payer Accountable Care Organization (ACO) model that resulted from an 18-month collaborative plan design phase. The plan was approved by CMS and envisioned a long-term goal of advancing the significant progress made after the state expanded Medicaid to create the Iowa Health and Wellness Plan, which provided health insurance to more than 150,000 newly eligible Iowans.
The first five years of ACOs have yielded cost savings in both the private insurance market and the public sector (with Medicare) that have already eclipsed decades of experience with privatized Medicaid managed care. Moving to privatized Medicaid is a divergence that will inhibit, not improve, further opportunities for innovation.
One way Medicaid innovation is at work today is through Integrated Health Homes (IHH), which coordinate care for Iowa adults and children with serious mental health issues. Along with mental illness, these patients typically have three or more chronic health conditions, often leading to trips to the emergency room (ER) and hospitalizations, making their health care very expensive.
Managing care for such complex patients, who interact with many parts of the health care system, is always difficult and often fragmented. However, the health homes’ team-based approach addresses those issues by training providers, tracking patients and sharing information among providers, resulting in fewer ER visits and hospitalizations, reduced cost to Medicaid and a better quality of life for these Iowans.
So what is the future for these forward-looking programs under the state’s Medicaid managed care plan? The truth is, no one seems to know. The state is moving so fast and awarding contracts so quickly, those kinds of questions have been left unanswered. This is why there is grave concern among Iowa hospitals and other health care providers that these innovative and effective programs will simply be run over in the rush to implement privatized managed care.
The vast majority of Iowans are not on Medicaid, but the 560,000 who are in the program are among the state’s most vulnerable and least represented. We should all be concerned about their health care, not to mention what happens to the taxes that pay for it. There is no solid evidence from other states that privatized management will improve the health of Medicaid recipients, provide better access to care or save money.
Those in charge of the state’s fast-track plan for Medicaid privatization seem to rely on no one noticing the perils ahead. Iowans who care about their neighbors and holding our government accountable should prove them wrong.