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(This article, by Barbara Feder Ostrov, was provided by Kaiser Health News.)

doctor patientA health care startup made a wild pitch to Cara Waller, CEO of the Newport Orthopedic Institute in Newport Beach, California. The company said it could get patients more engaged by “automating” physician empathy.

It “almost made me nauseous,” she said. How can you automate something as deeply personal as empathy?

But Waller needed help. Her physicians, who perform as many as 500 surgeries a year, manage large numbers of patients at various stages of treatment and recovery. They needed a better way to communicate with patients and track their progress.

The California startup, HealthLoop, told Waller its messaging technology would improve their satisfaction and help keep them out of the hospital. High satisfaction scores and low readmission rates mean higher reimbursements from Medicare, so Waller was intrigued.

So far, she’s been surprised at patients’ enthusiasm for the personalized — but automated — daily emails they receive from their doctor.

“There’s a limited number of resources in health care. If you do 500 joint replacements in a year, how do you follow up all of those patients every day?” Waller said. The technology “allows you to direct your energy to people who need the handholding.”

“Automating empathy” is a new healthcare buzzword for helping doctors stay in touch with patients before and after medical procedures — cheaply and with minimal effort from already overextended physicians.

It may sound like an oxymoron, but it’s a powerful draw for hospitals and other health care providers scrambling to adjust to sweeping changes in how they’re paid for the care they provide. Whether the emails actually trigger an empathetic connection or not, the idea of tailoring regular electronic communications to patients counts as an innovation in health care with potential to save money and improve quality.

Startups like HealthLoop are promising that their technologies will help patients stick to their treatment and recovery regimens, avoid a repeat hospital stay, and be more satisfied with their care. Similar companies in the “patient engagement” industry include Wellframe, Curaspan, and Infield Health.

HealthLoop’s technology is being tested at reputable medical centers including the Cleveland Clinic, Kaiser Permanente-Southern California, the University of California, San Francisco, and the Newport Orthopedic Institute in Orange County, company officials said.

Doctors can send daily emails with information timed to milestones in surgery prep and recovery and ask patients or caregivers for feedback on specific issues patients may face during recovery.

The doctors may write their own email scripts, as Newport Orthopedics’ physicians did, or use the company’s suggested content. An online dashboard helps doctors and administrators keep track of which patients are doing well and who might need more follow-up care. Patients can also communicate with office staff about medications and office visits. Their responses to daily emails can trigger a call from the doctor’s office.

A patient might see this message: “How are you? Let me know so I can make sure you’re okay. I have four questions for you today.”

Such a call may have been a lifesaver for David Larson, a Huntington Beach retiree. After Larson responded “yes” to an email that asked if he had calf pain after knee surgery, he got a call from his doctor’s office telling him to come in immediately. An ultrasound confirmed he had a blood clot that could have landed him back in the hospital — or threatened his life. With treatment, the blood clot dissolved and he resumed recovery.

“There were times when it was like, ‘Oh brother, they’re contacting me again,’ but none of this would have been caught if it wasn’t for the email,” said Larson, 66. “So it was more than worth it to me. Now I’m back to walking the dog, surfing, riding a bike.”

How to keep patients like Larson from hospital readmission because of avoidable complications after a hospital stay has long been one of health care’s most vexing and expensive challenges.

Almost one of every five Medicare patients discharged from a hospital — approximately 2.6 million seniors — must be readmitted within 30 days, at an annual cost of more than $26 billion, according to the Centers for Medicare and Medicaid Services.

For decades, hospitals had no financial incentive to keep patients out of the hospital after they were discharged. But under the Affordable Care Act, financial penalties were established for hospitals with readmission rates higher than the national average for certain conditions.

Also under the ACA, hospitals are financially rewarded for high scores on patient satisfaction scores and good performance on other quality measures set by CMS.

Doctors’ groups increasingly are affected financially by this sea change, either because they are part-owners in a hospital, as Newport Orthopedics is with Hoag Hospital in Newport Beach, or because they participate in other risk-sharing financial partnerships with hospitals.

With that kind of money at stake, hospitals and other health care providers may be willing to pay for programs like HealthLoop, if the tryouts prove successful. And you could see your own relationship with your physician change as a result, whether you’re on Medicare or not: HealthLoop is aimed at all patients, whatever the payment source.

Some experts worry that health care providers will come to rely too heavily on electronic communication as a cheap substitute for the hard work of improving the doctor-patient relationship and the quality of care that patients get.

“Automating personalized messages isn’t a terrible thing; we all get some of that in our everyday lives,” said Michael Millenson, a health industry consultant. “The real question is whether this kind of automated messaging is in conjunction with a cultural change in how doctors think about their patients or not.”

Health care providers have long experimented with ways to prevent complications that can land a patient back in the hospital, with varying success, said Kristin Carman, vice president of health policy research at the American Institutes for Research. Robo-calls reminding you to take your medicine, for example, don’t seem to be very effective. And the new technologies don’t always address demographic, cultural and language barriers that can prevent patients from communicating with their doctors. For now, HealthLoop is only available in English.

Dr. Jordan Shlain, a San Francisco internist, said he founded HealthLoop because he wanted a simple way to keep track of his patients’ progress after a hospital visit or procedure.

“Every human has the same kind of trajectory of concerns and anxieties with regard to medical situations,” Shlain said.

HealthLoop, based in Mountain View, offers “a digital extension of the doctor,” he said. “You know your doctor can’t email you every day; you know your doctor usually will not call you. Now you’re in a world where your doctor says I’d like to use this system to stay in touch with you and guide you through your recovery.”

Dr. Thomas Vail, professor and chairman of the department of orthopedic surgery at the University of California-San Francisco would agree — up to a point.

With his UCSF colleagues, Vail is testing HealthLoop’s system with his patients, and the university will be evaluating whether patients who use it have fewer adverse events than their peers.

UCSF helped create some of the language for the automated emails and has a financial relationship with the company, said Dr. Aenor Sawyer, who directs UCSF’s Skeletal Health Service and is a leader at the university’s Center for Digital Health Innovation.

While Vail thinks HealthLoop is potentially promising, he’s cautious about its role in his practice.

“I don’t think it substitutes for face-to-face communication,” Vail said, “but it does help us collectively to not overlook something that might be important.”

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fact-myth_memeAs Iowa’s 118 community hospitals and 71,000 hospital employees work daily to bring healing and wellness to all Iowans, the state’s reckless rush toward privatization of the Medicaid program has been a source of extreme concern. Most concerning are the myths about privatization perpetuated by our own governor as he tries to promote what is simply a bad idea for Iowa and, especially, for 560,000 vulnerable Iowans who depend on Medicaid.

On behalf of those Iowans and the health care professionals who care for them, it’s time that all of Iowa sees these myths for what they are: misleading half-truths that cannot hide the failures of this ill-conceived plan.

Myth: The federal government held Iowa to a higher standard when it forced the state to delay its plan.

Fact: The governor and his staff knew exactly what was needed to satisfy federal officials and, with any exercise of due diligence, they should have also realized it would be impossible to make this wholesale transition in only a year. No other state has ever privatized even part of its Medicaid program in such a tight timeframe, let alone the entire program, as the governor is seeking to do.

It was obvious to everyone, particularly among frustrated Medicaid beneficiaries, that the state was not ready, but Governor Branstad chose to ignore them, the people who provide their health care and other state leaders. Federal officials did what they were supposed to do: protect beneficiaries and ensure program integrity.

Myth: Medicaid privatization is the only option for coordinated, accountable care.

Fact: With the full knowledge and endorsement of Governor Branstad, the state already supports alternatives through the Medicaid State Innovation Model, Integrated Health Homes and Accountable Care Organizations – and as far as reducing cost and improving efficiency, they are working. The state and hospitals have put cooperative effort into these programs and they have shown more savings in the past five years than private managed care for Medicaid has demonstrated in 30 years of so-called “innovation”. Then again, there is nothing innovative about denying and delaying care.

The bottom line is Iowa already has one of the most efficient Medicaid systems in the nation and the state and health care providers have been working, hand-in-hand, to make it even better. Privatization will simply interject a very expensive middleman who will extract millions of dollars to meet corporate goals while adding no value to the system.

Myth: Iowans will support clean water, strong public education or a community-based, efficient and patient-oriented Medicaid program, but not all three.

Fact: Iowans can and do support all three and the path hospitals and other health providers desire to take will further sustain Medicaid and other widely-held priorities. The people of this state would rightfully reject wholesale privatization of the public school system or water resources, so it’s no surprise that nearly eight out of 10 Iowans oppose privatizing health care coverage for a half million highly vulnerable citizens. Knowing that, Governor Branstad’s administration fired its plan through the Capitol with no legislative debate and then, with the throttle firmly planted to the floor, pretended to take input from a predictably skeptical public.

As of today, nothing has been done to assuage that skepticism, which is why IHA, along with thousands of health care professionals and even more every-day Iowans, continues to oppose this untenable, unnecessary plan that puts the health of impoverished, disabled and elderly Iowans at risk.

Health care providers across the state know we can do better. In fact, we already are.

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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 the hallmarks of the hospital mission in Iowa.)

Kevin BradleyA man of distinguished courage and ability, admired for his brave deeds and noble qualities: At Mercy Medical Center-Centerville, Hospital Hero Kevin Bradley is recognized for all this and much more. Distinguished ability: Kevin has worked at Mercy-Centerville for 29 years as the radiology manager. He holds registry in six different areas including diagnostic medical sonography, CT, diagnostic cardiac sonography, radiography, nuclear medicine and vascular medicine.

Kevin’s deeds and noble qualities heavily outweigh even his impressive resume. He puts the patient’s needs before his own, sacrificing so much of his personal time to ensure the people of Centerville have the best care possible. Throughout his tenure, Kevin has made himself available to be called in to do ultrasounds or CT scans – day, night, weekends and holidays. This is beyond his regular hours or any scheduled call hours. He considers it his community service to come in and perform a test for the convenience of patients, sparing them from making a trip elsewhere.

ct patientHe is highly respected and trusted by the medical staff who are not only confident in his skills and expertise but appreciate his compassionate and accommodating personality. Outside emergency room physicians recently praised Kevin saying, “There is no one like Kevin in the state.”

More importantly, patients recognize Kevin as a beacon for the Mercy-Centerville imaging services. “His personal touch combined with my trust in the care I am receiving allows me to have a positive experience every time I need services,” explained one patient. Kevin has made Mercy-Centerville a destination for medical care rather than a stop along the way by making sure that no patient ever has to wait for the care they need. His staff said this of him: He is a model of what gracious care truly is. His passion for health care is not simply part of the job to him, it is part of his soul and a staple in his character. It is simply not enough to say that Kevin leads all of us by example. Rather it is his example that shapes all of us to be a Hospital Hero every day for our patients.

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The Edberg family (left to right): Liam, 11, Carol, Jeff, Fiona, 20, and Colin, 11

The Edberg family (left to right): Liam, 11, Carol, Jeff, Fiona, 20, and Colin, 11

I adopted Colin and brought him home when he was one-day old. My wife and I were filled with joy as only new parents can be. It soon became clear that our perfect baby had severe difficulties. He had microcephaly, cerebral palsy, hypertonia and was almost blind. We were committed to him and started to find help, as his condition was way over our heads! We found Medicaid provided services in order to give him the help we were unable to give, and that would help him have a happy, productive life.

I also adopted my second son and found that he also had a medical condition that we had not known about. No one did. These boys are darling boys with their own talents and difficulties. Colin’s smile will light up any room, and he never, never feels sorry for himself. He was the boy that was to never, see, walk nor talk. He does all three.

My two special needs children now face a new challenge: the privatization of Medicaid services.

The changeover in Iowa from the reliable and efficient Medicaid system that dispenses $4,200,000,000 (that’s billion) dollars of needed medication and services to the elderly, sick and disabled community of 560,000 people in Iowa has gone from really bad to unworkable. I’m not a political person, and I’m certainly not taking an academic view of this situation. This issue is very personal to me as two of my three children are recipients of medical services they clearly need and that I cannot otherwise provide them. The State of Iowa is treating this like a game, or a political contest to be won or lost. I have two beautiful boys, 11 and 13 who are affected by the outcome of this issue and the results may continue to give them a good life, or become life-changing, if not threatening for them.


Here’s what I see. Our society has decided to take care of the less fortunate than us, the sick and the disabled. This is not because of who they are, but because of who we are and how we want to see ourselves. Medicaid in Iowa has been funded by 45 percent State funds and 55 percent Federal funds to accomplish this task. In the 13 years I have been personally involved in this system, I have found Medicaid and the Iowa Department of Human Services workers who administer its funds and services to be dedicated, caring, competent and, yes, overworked. The overhead that administration has cost is 4 percent of the fund. Now, 4 percent of the $4.2 billion is a lot of money, but just wait. It gets a lot better.

The new system will be administered by four (now three) for-profit managed care organizations that will be allowed 15 percent for overhead and profit. My radar goes up when this much money is involved, when it is being rushed to completion, when one of the four MCOs is removed by an Iowa judge after being involved in fraud and misrepresentation, and when providers and recipients cannot get answers to basic questions like how much they will be paid and how the system will work. Why is the Iowa administration (governor’s office) claiming that $51 million will be saved when this system will cost $462 million more in direct fees to the MCOs than what currently goes to administrative costs? I’m a real estate broker, not a math teacher, but if we don’t get more state or federal money, and the system costs $462 million more than the one we have that works, the only way to do that is to cut services. That means that my sons will pay the bill in reduced services so we can privatize a system that already works very well. Why are we doing this? Certainly not to save $51 million. As the numbers indicate, it will cost money, not save money, if needed services are not cut.

The governor was fighting tooth and nail to implement this system by January first, and even the federal Heath and Human Services Administration acknowledged it was unworkable and mandated a 60-day delay to sort out the details, including the fact that not enough people or providers have signed up for it. So now we are caught in the middle of a changeover that may or may not happen, and the health and well-being of our children are caught in the middle of this political battle.


I have called Iowa Medicaid Enterprises twice and was promised both times that they would not throw my 13-year-old son out of the facility he lives in when the changeover time is up. My response was relief. All I asked was that they simply write that down, because all the reams of literature I have been provided with and have reviewed have never said that. I asked that they write me an email or letter simply stating that my son’s services would not be cut or eliminated, because he would not survive without constant care. They both said they could not write it down. I would have to trust them, and they would have a supervisor call who had the authority to write this letter. Neither the letter, or the call from the supervisor ever came.

So, I found out who the main providers are for my children, whom they have selected as MCOs, and I picked those MCOs for my children all before the deadline of Dec. 17. Here is where the system really starts to break down from the perspective of the recipients of Medicaid services. I found that one of the providers would approve a medication used by my youngest son. His prescribing doctor and his entire history of medical care has been associated with the University of Iowa Hospital in Iowa City. UIHC has not selected the MCO that will provide this medication. So, I cannot continue my son’s medical care there because of procedure — not because of any medical consideration. (Editor’s note: Since this article was originally published in December, UIHC has signed contracts with all of the participating MCOs).

The medical situation is even more difficult for my other son. He is medically fragile and lives in a wonderful home called an Intermediate Care Facility for Intellectual Disability, or ICF/ID. His ICF/ID has signed contracts with all four (now three) MCOs. None of these MCOs have given my care provider any indication regarding how they will be reimbursing my son’s care, so I don’t have any idea which one to select. Keep in mind that these funds are a benefit due to my son’s medical condition, not a contract between two business people trying to make a profit. This is his money they are dealing with and so far, no MCO has indicated what they will be giving this boy so he can live in a caring, medical environment.

I’m fully engaged in this process because my son’s well-being is involved and is at risk, but I keep wondering why we’re doing this in the first place. The former system was working very well and was very efficient. It was reliable and with one payer, it was not confusing. The doctors were caregivers and the disabled, elderly and needy were the patients. The governor says the shift will yield some mysterious $51 million in savings, but no one has been able to identify the origin of these savings for me.

I don’t know what the future will be regarding this system, but I do know that some very motivated people will be making $462 million each and every year, and my two sons’ medical futures are at best unsure, and very much at risk. Any “savings” will be paid for by Iowa’s Medicaid recipients because they are a population who often cannot even speak for themselves and are an easy target. I do know that with every passing day, this system is becoming more confusing. It seems to be falling apart from the inside. It will provide less care to those Iowans who need it most, and there continue to be fewer and fewer answers regarding coverage, care and procedure. Also, I cannot think of one reason that we are attempting to change a system that already works, aside from the $462 million reasons that the MCOs have to bring this managed care to Iowa.

Wouldn’t it be easier and better for Iowans if we quit while we are ahead, and keep the system that we have? I know it would be better for me and my family.

Jeff Edberg is a native of Iowa City, where he works as a real estate broker. He and his wife Carol are adoptive parents committed to their kids’ happiness and well-being.

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(The following was submitted to the Sioux City Journal in response to this editorial that appeared on December 20.)

wrong-wayThe Iowa Hospital Association has been analyzing and evaluating the state’s plan for privatizing management of the Medicaid program since it was announced nearly a year ago. But long before that, IHA and Iowa’s hospitals accumulated years of experience with this arrangement through Magellan’s contract to manage Medicaid behavioral health services.

It is that analysis and experience that has led IHA to oppose the state’s privatization plan.

With Iowa’s low cost per beneficiary and minimal administrative overhead, the managed care companies will struggle to return any savings to the state. But make no mistake; these huge, for-profit, out-of-state companies that have fought tooth and nail to win a contract from the state will do everything they can to make money from this deal. To accomplish that preeminent goal, they will restrict access to care and they will reduce payments to providers.

This is not a guess or a threat; it is what managed care companies have consistently done across the nation to meet their business goals. In other states, these companies are known not as care managers, but money managers. They control costs by limiting access to care and reimbursement for care to meet their obligations to shareholders. With these restrictions in place, they may even save the state some money, but rest assured that savings will come at a price for Medicaid beneficiaries and the people who care for them.

And be aware that these companies are far more dedicated to shareholders than taxpayers, as evidenced by the research. A rigorous and recent Medicaid managed care study by the Robert Wood Johnson Foundation 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.”

Meanwhile, Iowa hospitals and the state have already been working together to coordinate care and reduce costs. Through existing Accountable Care Organizations, Integrated Health Homes, the State Innovation Model and the Iowa Health and Wellness Plan, 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 these already occurring, why is the state looking to eliminate successful programs for an unsuccessful, unnecessary privatized model? And why is the Journal’s editorial board endorsing this plan, especially given the well-reported legal and ethical misdeeds of these companies as well as their botched rollout of the Iowa plan, which has been so poorly managed that the federal government was forced to step in and delay it?

There is no reliable evidence that Medicaid privatization reduces costs, improves quality or increases access to care. This is why Iowa’s hospitals encourage the Journal to reconsider its position and look beyond the claims and promises of companies that have no stake in Iowa, but simply seek to make money off of vulnerable Iowans.

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