(This column was written by Pam Matthews, a diabetic who lives in Humboldt. Matthews shared her story last month when UnityPoint Health-Fort Dodge hosted United States Secretary of Health and Human Services Sylvia Burwell at Trinity Regional Medical Center. The visit included a round-table discussion focused on the successes of the Pioneer Accountable Care Organization and how it has helped improve care coordination in the Fort Dodge region.)
I’m a widow and I don’t have children, but I’m an aunt, a great aunt and a great-great aunt. About two years ago, I tried to fully retire, but I just grew fatter and grouchier, so I started working part-time, taking care of people with intellectual disabilities. I love that work.
In 1997, I wasn’t feeling well. I was thirsty all the time. I knew something was wrong, but I really wasn’t committed to taking care of my health. I shopped around for doctors and each one told me that I had diabetes. But I did not want to hear what they were saying. I was clearly in denial.
I finally had a good moment of clarity with myself in 2011. One day, I had heart failure and an ambulance took me to the hospital. I realized that if I wanted to live and enjoy all my nephews and nieces, I had to take care of my health.
My sister had been seeing Dr. Dustin Smith at the UnityPoint Eagle Grove family health clinic for two years and was happy with him, so I made an appointment.
He told me that I definitely was diabetic and he said a lot more, but he wasn’t just talking at me. When I talked, I realized that he was listening to me. My health care would be a “we decision.”
His manner was very comforting and reassuring. I was obese, but he didn’t harp on my weight. He said he wanted to see me every three months, and he suggested a diabetes education program that would arm me with the knowledge of how to manage my condition. I was paired with a nurse and a care manager out of UnityPoint in Des Moines, who would call and check up on me from time to time. Working with my team, I set realistic goals.
I go to the clinic in Eagle Grove regularly for my blood work and I get the results from the nurse usually within two days. The goal of the clinic was to get patients’ A1C level, which measures blood sugar, down below 7. My number is now 5.8!
It’s so important to keep an open dialogue with your doctor. Dr. Smith respects my opinion. When I told him that I was feeling more than simply tired, he did some tests and found that I was anemic.
When I felt really sick this winter, he determined that a change in my medications had led to a fluid buildup around my heart. He put me back on diuretics and I’m feeling good now. And he made sure that I met with a cardiologist.
The clinic in Eagle Grove, a rural family medicine practice, is part of the UnityPoint Health Accountable Care Organization. I’m told it’s designed to improve communications between health care providers and their patients and provide more coordinated care to people enrolled in Medicare. It’s one of the ways the Affordable Care Act is promoting smarter care and lower costs all while putting patients first.
Health and Human Services Secretary Sylvia M. Burwell came to Fort Dodge recently to hear about the UnityPoint ACO experience and I was able to tell her about my story. I don’t know a whole lot about how ACOs work. But I like how I’m part of my health care team. I have a voice.
The Commonwealth Fund recently released its 2016 Scorecard on Local Health System Performance and Iowa communities were consistently ranked among the top in the nation on all measures of performance.
The latest in the series and the second to examine care at the local level, this scorecard compares health care access, quality, avoidable hospital use, costs of care and health outcomes for local areas around the country from 2011 through 2014. Using the most recent data available, the scorecard ranks 306 regional health care markets known as “hospital referral regions” on four main dimensions of performance: access to care, prevention and treatment, avoidable hospital use and cost and health lives.
The Upper Midwest has consistently fared well on these reports, but several Iowa cities stand out in this scorecard, demonstrating how Iowa hospitals continue improving health care in their communities. On overall performance, Dubuque was ranked number 10 with Cedar Rapids following at number 11, while Mason City, Iowa City and Des Moines were ranked 24th, 27th and 32nd respectively.
Drilling down the dimensions used in the scorecard, access to health care is an area where Iowa especially excels. In this dimension, Waterloo was ranked number 6 with Mason City close behind at number 7. Meanwhile, Dubuque, Cedar Rapids, Iowa City and Des Moines were all in the top 25. Similar Iowa results can be found across all four dimensions used in the scorecard.
Overall, the report found that in Iowa, health care has improved significantly since 2011. With several cities ranked in the top 50 of the 306 regional health care markets and nearly the entire state in the top quartile for overall performance, it is clear that Iowa is doing something right with when it comes to health care.
At least some of Iowa’s success can be attributed to the Affordable Care Act (ACA) and Medicaid expansion which, since implemented in 2013, has given more than 150,000 Iowans access to health insurance. According to the report, the ACA’s major coverage expansions seem to have led to some of the most visible gains in performance.
“This scorecard provides an in-depth look at how the health care system is working overtime in local communities and how that impacts peoples’ health,” said David Radley, researcher for the Commonwealth Fund’s Tracking Health System Performance program and lead author of the report.
“There is still a lot of variation and every community has room to improve. But it is striking to see the early effects of the Affordable Care Act at the local level as people increasingly get coverage and care and quality improves.”
At a recent meeting of the Iowa Senate Human Resources Committee, Medicaid beneficiaries and providers were asked to testify regarding the transition to Medicaid managed care. Their universal response? Not so great. Virtually everyone who testified complained of slow and inaccurate payments, significant increases in denial rates and consumer difficulty navigating incredibly complex regulatory waters.
More specifically for hospitals, members of the IHA finance group evaluating managed care concerns indicated in its separate meeting that many providers are not yet loaded into the managed care organizations’ (MCOs) systems, despite contracts being signed last spring; in many cases, remittances are being sent to the wrong hospitals; claims for Medicare/Medicaid deductibles and ambulance services are routinely being denied and there’s widespread inability to connect with MCO provider representatives to resolve questions.
In response to the Senate committee meeting, Governor Branstad was quoted in the Quad-City Times as saying that complaints are coming from providers who are upset “because we’re checking on them now.” He then added, “The Democrats don’t like it and the Des Moines Register hates it. These great so-called progressives are the ones that are the most against progress. They want to keep doing it the expensive, old-fashioned way that doesn’t work as effectively and efficiently as what we’re doing today and we’re not going to be deterred.”
So it’s all in the spin. Evidence from other states suggests that Medicaid privatization is not less expensive than traditional state-run Medicaid programs. Over time, these private insurance companies will most certainly come back to the Iowa General Assembly to ask for more money to manage our Medicaid program. And “efficient” was not a word uttered by one person at the Senate committee meeting. Even the CEOs of the managed care companies who testified at the meeting indicated the “transition period” to get things working smoothly could take as long as 12-18 months.
What is clear is that as data emerges in the coming weeks and months, we’ll all have more and more comparative information upon which to base our opinions. For example, the Iowa Department of Human Services (DHS) released its initial dashboard the evening before the Senate hearing. And while administration representatives touted the fact that the MCOs have processed and paid 3.47 million claims since the April 1 enactment of Medicaid privatization, they didn’t spend a lot of time highlighting the 1.5 million claims that have been denied, suspended or rejected in that same time period (and those are DHS figures). That’s a 30 percent rejection rate, unheard of under traditional Medicaid.
Senator Liz Mathis (D-Cedar Rapids), who chairs the Senate committee, said “I think the transition has been rugged, it’s been sloppy and there’s a disconnect between what we’re hearing from state officials and what the providers are telling us.” That’s putting it mildly.
One would think that even the supporters of Medicaid privatization would acknowledge that the MCOs have to get to a point of paying claims responsibly and correctly before their vision of a transformative Medicaid program is actually operating. Until then, that vision only exists for those who are closing their eyes and wishing it were so.
It’s been said that people are at their best when things are at their worst. Think about that and it explains a lot of things: Why crime went down immediately after 9/11. Why drivers let others merge during the worst of traffic jams. Why first responders talk about the “rush” of working a scene. Why volunteers helping clean up a disaster site can smile and even laugh.
In a place where teamwork has always been important, hospital staff can certainly understand. It’s belonging to something bigger, a united sense of place and purpose and making a difference in the lives of people in need. Making that happen is life-affirming and energizing. It’s a reason – maybe the reason – for getting up in the morning.
But what about being out in the world doing the day-to-day things? The commute, the shopping, the bill-paying. Most people don’t find these things to be life-affirming or energizing. On the contrary, they call it the “daily grind.” Is it because we are so disconnected and alone as we do these things that we find them so taxing?
That’s the theory posited by author and war correspondent Sebastian Junger, best known for his book “The Perfect Storm” and the combat documentaries “Restrepo” and “Korengal.” In Junger’s new book, “Tribe: On Homecoming and Belonging,” he suggests that veterans, even those who don’t see combat, find American society hard to re-enter because it’s an alienating, anti-social environment.
“Western society has this narrative that we’re moving steadily toward a kind of societal perfection,” he recently explained to an interviewer. “But there’s this massive unseen cost which is our sense of connectedness to the group.”
Two million years of connectedness have allowed humans to survive and thrive in spite of constant stress and trauma. But now that we are safe from much of the danger that pushed our ancestors to form communities, Junger finds lack of community is at least contributing to growth in post-traumatic stress disorder and suicide among veterans and Americans in general.
“If trauma left half of us incapacitated, as one could conclude from the military statistics, we wouldn’t be here today as a species,” he said. “So what is going on? The answer I came up with is that the level of long-term trauma isn’t a function of the trauma, it’s a function of the society you come home to. In other words, the vets aren’t messed up. We are. We as a society.”
It’s an interesting theory that has massive ramifications not only for behavioral health but for health care providers and the communities they serve. In the quest for efficiency and independence, at what point does empowering the individual and the demise of the team or community become detrimental? When does the societal cost Junger describes become too high – or has it already?
This week, the Journal of the American Medical Association (JAMA) published an article authored by President Barack Obama on his assessment of the Affordable Care Act (ACA). The article reviews the factors influencing the president’s decision to pursue health care reform, summarizes evidence on the effects of the law to date, recommends actions that could build on the progress made under the law to improve our health care system and identifies general lessons for current and future policymakers.
This article is the culmination of a review of the ACA’s performance that started more than six months ago at the president’s request, examining areas in which the law has been successful and in which it could be further strengthened to ensure all Americans have access to quality, affordable health care.
The president presents evidence in JAMA demonstrating the ways the law is working. This includes: sharply increasing insurance coverage and greatly improving coverage for those who already had it, which is improving Americans’ access to care, financial security, health and well-being; and shifting our health care system toward one that rewards doctors and hospitals for delivering efficient, high-quality care to patients, which has helped reduce hospital readmissions and deaths from hospital-acquired conditions and helped lower Medicare and private-sector health care spending.
Despite this significant progress, the president recognizes that more work is necessary to ensure every American can afford health care and navigate a complex health system. That’s why he offered five suggestions on how to do so:
Stay the course: Policymakers should build on the ACA’s successful framework by encouraging the remaining 19 states to expand Medicaid and continuing ongoing efforts to reform the health care delivery system, while maintaining bipartisan support for Precision Medicine, the BRAIN Initiative and the Cancer Moonshot.
Increase financial assistance to purchase health insurance: Because some individuals still report being unable to afford coverage, Congress should provide increased financial assistance to purchase coverage. The ACA’s coverage provisions are projected to cost 28 percent less than original Congressional Budget Office projections, providing an opportunity to reinvest these savings to make coverage even more affordable while keeping costs below initial projections.
Add a public plan option in areas of the country lacking competition: While the vast majority of Americans live in areas where there’s competition in the Health Insurance Marketplace, some parts of the country have long struggled with limited insurance market competition and continue to do so. That’s why the president urges Congress to revisit legislation to allow a public plan to compete alongside private insurers in areas of the country where competition is limited.
Address prescription drug costs: The increasing costs of prescription drugs are a major concern for Americans, employers, and taxpayers alike. Congress should act on proposals to lower the cost of prescription drugs, like the ones included in the president’s budget.
Avoid moving backward: The time spent by Republicans on more than 60 attempts to repeal parts of all of the ACA could have been better spent working to improve our health care system and economy.
Finally, the president offers some lessons to current and future policymakers that he learned from his experience: that any change is difficult, especially when facing hyperpartisanship; that special interests pose a continued obstacle and we must continue to tackle them, and that pragmatism is of the utmost importance in both legislation and implementation. But most importantly, that the president’s experience with the ACA makes him optimistic about America’s capacity to make meaningful progress on even the biggest public policy challenges. As progress on health care reform demonstrates, faith in responsibility, belief in opportunity and ability to unite around common values are what make this nation great.