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Health Care ReformThe Affordable Care Act has now been in place and functioning for a year and many are wondering, is the law fulfilling its core goals?  The New York Times recently provided an expanded analysis of the law and generally concluded the law is succeeding, though more time is needed to know for certain.  Here is a summary of the Times’ findings:

Fewer Uninsured

The main goal of the Affordable Care Act was to reduce the number of Americans without health insurance.  Since the law was enacted, the percentage of uninsured Americans has decreased by about 25 percent within one year, or approximately eight to 11 million people.  Much of this is because of state Medicaid expansion, with at least as many people enrolled in Medicaid as have signed up for private insurances.  Although the Affordable Care Act will never bring universal health insurance coverage, it hopes to continue closing the gap and over the next four years it is projected to expand coverage to millions more Americans.

Affordable Coverage

For millions of Americans, the Affordable Care Act has provided access to comprehensive coverage at an affordable price.  Of the 7.3 million people who signed up for private insurance through online exchanges, 85 percent qualified for government subsidies to reduce the cost of premiums.  Although the law has made insurance affordable for some, it has also created high deductibles and out-of-pocket expenses for others, and has caused premiums to raise for some who already had insurance or were not eligible for subsidies.  Additionally, while trying to keep costs down, insurers may be too restrictive about allowing consumers to use doctors outside of the company’s network.  With wide variations in pricing between states, it is difficult to know who will find plans unaffordable, but evidence suggests middle-income people who don’t qualify for subsidies will struggle the most with health insurance costs.  A 4 percent median premium increase is expected for 2015, so consumers will need to shop around for the lowest prices.

Improved Health

Currently, there is not enough data on the entire population to determine whether the law is improving the nation’s overall health.  Some early data does suggest that the law is having a positive impact on young people.  Because the law permits young Americans to remain on their parent’s insurance plans until reaching the age of 26, the share of 19-to-25-year-olds without health insurance declined to 21 percent in the first quarter of the year, a reduction of about four million people.  Outside the young adult group, there were very little changes in a variety of health measures, such as the number of flu shots received or whether people had a regular place to go for medical care.  However, preventative screenings, especially for colon cancer, have increased 8 percent since 2010.  More time is needed to determine if the law will positively impact the nation’s health in the long run.

Financial Stability for Providers and Insurers

Both Wall Street analysts and health care experts say the Affordable Care Act has helped the health care industry financially.  The insurance industry has seen the greatest benefits thus far, because of new customers and growth in demand for private insurance. The number of insurers participating in the online health exchanges is also expected to increase in 2015, an indicator of the profitability of the marketplace and the business the law has created.  The law also brought new paying patients to hospitals and new prescription users to the pharmaceutical industry.  Although hospitals are being hurt by a provision of the law that cuts their Medicare payments by $260 billion over 10 years, they are estimated to save $5-7 billion in uncompensated care costs this year because more people have insurance, according to the Department of Health and Human Services.  Iowa hospitals have seen a significant decrease in charity care over the last year.

Expanded Medicaid

The expansion of Medicaid, the government health care program for low-income citizens, is a crucial part of the Affordable Care Act. Medicaid expansion is optional for all states and 27 states and the District of Columbia (as well as Iowa) have expanded.  These states, including Iowa, have seen a significant reduction in uninsured people, while states without expanded Medicaid are seeing a coverage gap in health insurance for people who earn too much to receive Medicaid, but too little to receive federal subsidies to reduce premiums.  Pressure from hospitals that can get federal funds from Medicaid expansion has caused some states to consider expansion.  Federal officials say 8.7 million people have been added to Medicaid rolls since last October; however, with so many new people in the expanded program, there are growing concerns with the shortage of doctors.

Controlling Health Care Spending

While the Affordable Care Act was intended to slow down health care spending, the amount of money being spent on health care had begun slowing even before the law was put in place.  There has been a significant slowdown in the growth of health spending, due to the recession, higher-deductible policies that discourage people from seeking health care, a decline in the development of new and costly prescription drugs and the reduction of unneeded care.  In the short term, the law could actually increase health care spending because of the expansion of health insurance to millions of Americans.  The real test of the Affordable Care Act will be whether or not the declined spending continues, even with the amount of new insured people in the system.

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symptomsThe emergence of the Ebola virus in the U.S. has heightened awareness of all hospitals and health care workers about the importance of following strict infection control procedures. Throughout both Iowa and the nation, now is the time to share collective wisdom to stop Ebola from spreading further.

The health and safety of every patient and visitor to Iowa’s hospitals are of utmost importance. Indeed, the very reason hospitals exist is to heal patients and make sure they stay healthy. Iowa hospitals are deeply committed to maintaining the highest standards and most current protocols and training, to minimize the risk of anyone contracting an infectious disease like Ebola.

All of Iowa’s hospitals are convening regularly so that hospital infection specialists and emergency services leaders receive the latest updates on Ebola management and treatment and can learn from one another. Hospital leaders are continuously examining and refining best practices and protocols from an amalgamation of resources including academic research, day-to-day learning and media coverage, in addition to shared information from state, federal and international health agencies.

Hospital professionals are trained to provide treatment to patients with infectious diseases and each hospital has infection control procedures in place. Hospital officials are in contact with experts from the Iowa Department of Public Health and Centers for Disease Control and Prevention to stay abreast of the latest developments on procedures related to the treatment of an Ebola patient. Education is also being provided to hospital personnel in the event that a known or suspected Ebola patient would seek treatment locally.

Collaboration and communication within Iowa’s health care community are key to the state’s readiness efforts. From Fort Madison to Rock Valley, Iowa hospitals are working closely with local, state and federal health agencies to ensure each hospital and every employee are well-prepared should they have to care for an Ebola patient.

This is a rapidly changing situation and Iowa hospitals are doing everything they can with guidance from national, state and local partners. Across the state, hospitals are committed to the safety of their health care workforce and to working together to ensure they are ready and capable of providing care should a case of Ebola develop in our state.

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(An expert on population health, Dr. Jeffrey Brenner recently spoke to Iowa hospital executives and trustees at the IHA Summer Leadership Forum.  In this interview with Kaiser Health News reporter Lisa Gillespie, he discusses how providers can better coordinate the care of chronically ill patients.)

Jeffrey Brenner doesn’t believe in blaming a person for showing up at an emergency room for a cold or an ear infection, even if the illness could have been treated in a doctor’s office at much lower cost. Instead, he faults the health care system, and he wants to prove that if providers, employers and insurers work together more effectively, that person will stop going to the ER.

Jeffrey Brenner. (Photo by MacArthur Foundation)

Brenner, a 2013 MacArthur Fellow and executive director of the Camden Coalition of Healthcare Providers, is testing this theory with a randomized controlled trial. Findings are due out in 2016.

The trial extends what the Coalition has been doing for years in hospitals and primary care offices that serve the low-income neighborhoods of Camden, N.J. For the past decade, the nonprofit has worked to bring together hospitals, physician offices and other providers to create programs to better coordinate care for the high proportion of Medicare and Medicaid patients in the region. Brenner’s team flags patients with multiple hospital visits — the so-called “super utilizers” — and sends a care coordinator to their bedside. The goal is to find out why they went to the hospital instead of a doctor’s office. Then, a nurse, a health coach and a social worker meet regularly with patients, and determine how to address their continuing needs.

Employer health plans also have super-utilizers who rack up medical bills, prompting some employers to experiment with ways to control these costs.

Q: Can you explain the randomized trial? What are you trying to show? 

A: We identify the patients … who have had two or more hospital admissions, and then they get randomized into the control [group] — care as usual — or they have 90 to 120 days of intensive wrap-around coaching. [We] will track them for a year and possibly longer. The end point [measures] are [whether we achieve] a reduction in ER and hospitalization utilization. We also look at [the] patients’ overall wellbeing.

We’re trying to prove that we’re using the wrong methods to approach these patients. You don’t need new money [to care for patients], you just need new service delivery systems. We have to stop giving up on poor people. There is a feeling that it’s the patients’ fault that their care process isn’t going well, and that the health care system has done everything it can do and the rest is up to the patient.

We spend money in the wrong places delivering the wrong services at the wrong time, and this is about rethinking how we deliver care. As I meet with congressmen, hospital CEOs, the numbers of stories told behind closed doors of family members getting lost in the health care system is tragic. As baby boomers age, more and more families are experiencing what it feels like to get lost and have too much unnecessary stuff done to a family member.

Q: So the trial is looking at a high proportion of Medicaid and Medicare patients, but do you think the findings could also prove helpful to employers regarding the health costs of workers’ and retirees’ coverage?

A: A lot of the failures happening for poor people are happening for the middle class. [We] are all trying to solve a similar problem: how do you engage very sick people and help them work their way through problems? In every population that you look at, a small percentage of patients is responsible for most of the costs.  So for employees and their dependents, you’ll find the same pattern — that 1 percent of patients account for 25 percent of costs. Whether you’re middle class or poor, the health care system falls apart when you’re a complex patient. We need to coordinate care and have engagement models for the sickest patients.

Take for instance a middle class woman with a master’s degree getting care at a five-hospital integrated system, connected electronically. She was going to the ER repeatedly and, in a three-and-a-half-year period, she had 79 CT scans to the head. A group of family medicine residents got to know her and found out she had severe anxiety, so they got her working with a psychologist and she stopped going to the ER.

These hospitals were electronically connected. They could have seen the other CAT scans, but they did not. So I don’t think the phenomena we’re talking about is exclusively for poor patients. If you have good insurance, you can also have an enormous amount of unnecessary care.

Q:  Are public and private insurance plans already doing some of this coordinated care you’re talking about?

A:  There are lots of examples: Boeing has a patient-centered medical home for employees, and Bravo Health has a Medicare Advantage plan in Philly.

There’s been a big shift amongst health care plans because telephonic health case management isn’t effective. It takes boots on the ground to shift the trajectory. So you’re seeing more and more insurers get into the work of delivering care. Bravo Health has built two physical offices to deliver care, with shuttles and vans picking people up and [with] phenomenal hospitalists. They’ve put these in two of the poorest neighborhoods in Philly. They’ve made incredible profit, and Cigna bought them and now they’re trying to scale the model. That’s evidence that there’s money to be made on delivering coordinated care.

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walmart clinicAnd then there was Walmart, primary care provider.

In recent months, the retail giant has opened a half dozen primary care clinics in an aggressive move to become a one-stop shopping destination for medical care.  The push is making news because it’s a step beyond the dozens of bare-bones, acute care clinics Walmart has opened – and, in many cases, closed.  In other words, Walmart is looking to jump well ahead of its traditional competition like CVS and Walgreens and possibly go toe-to-toe with hospitals.

The scenario becomes more interesting for Iowa because these first few expanded clinics are showing up in small, rural markets.  But a closer look shows Walmart’s strategy may be more sophisticated.

The new clinics are in South Carolina and Texas, two of the poorest, least healthy and under-insured states in the nation.  That might seem like a blunder by Walmart as it appears to overlook the billions of dollars being pumped into states like Iowa that have expanded Medicaid (South Carolina and Texas have not and, in all likelihood, never will).

But it’s no mistake, because with low-cost care (appointments start at $40), Walmart can position itself as the option to Medicaid in states and communities that desperately need that option.  As the mayor in one of the South Carolina communities put it, “I think this is good news and bad news…The bad news is, I guess, the two (clinics) are being opened in Florence and Sumter because we have lots of people who need service.  The good news is that it is affordable…We have to have every access point possible in the system.”

According to its website, Walmart’s “expanded scope of coverage enables us to be your primary medical provider.”  What’s not clear is how the retailer defines “primary care.”  However, in addition to the uninsured, Walmart appears to be targeting chronically ill patients.  Not a bad move, given the enormous sums spent caring for that relatively small population.  The question is, can a retail-based clinic effectively manage disease?

The answer from hospitals and other traditional providers has been quick and clear. “There’s not a role for retail clinics to take care of chronic, ongoing problems like that,” Dr. Robert L. Wergin, president-elect of the American Academy of Family Physicians, told the New York Times. “It can provide a service, maybe an entryway into a system.”

Whether or not the place where you can pick up pork rinds and Pall Malls can (or should) serve as a medical home is certainly up for debate, but right now it’s a little beside the point.  What is clear is that Walmart has a sound, consumer-friendly strategy of low price and easy access that traditional providers must be prepared to counter.

In the post-Affordable Care Act world, where high-powered innovators like Walmart are anxious to find a lucrative niche, patient needs and preferences are changing.  In response, providers need to understand what patients value and the relative importance they place on different components of value.  What really matters to the patient: how close the clinic is, how quickly the patient is seen or who the patient sees?  You might be surprised (and you can certainly learn a thing or two about it at this year’s IHA Annual Meeting).

In any case, there’s no ignoring Walmart, which has more than 60 Iowa locations, nearly all of which are a very short distance from a hospital.  Everyone knows the old saying about 800-pound gorillas.  Well, Walmart is more like an 800-ton behemoth that combines both power and agility and that, more than ever, is looking hard at hospitals’ side of the jungle.

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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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