by Scott McIntyre on Friday, May 11, 2012
3New data from the federal government has reaffirmed that Iowa’s hospitals are among the most cost efficient in the nation. The new Medicare figures show wide variance among hospitals around the country, even within the same city. In Los Angeles, for example, the average patient admitted to Temple Community Hospital cost Medicare $24,104 during the stay and in the month afterward, 34 percent above the national median. Meanwhile, about a mile and a half away at Saint Vincent Medical Center, the cost was $17,628, or 5 percent below the median.
Every Iowa hospital included in the data came in below the national median and the level of variance was not nearly as wide in Iowa, where the average Medicare cost ranged from 16 percent to 2 percent below the national median. Iowa hospitals, on average, cost Medicare $16,427, or about 9 percent below median. This ranked Iowa as the 9th most efficient state in the nation.
The efficiency of hospitals has become more important in recent years, particularly with regard to Medicare, which is looking for ways to rein in costs. Some researchers believe as much as one-third of Medicare’s $551 billion in health care spending – and the nation’s $2.6 trillion – is wasted on excessive care. In Medicare, that waste occurs, for example, when patients use multiple physicians, including many specialists, and at the end of life when they spend days and even weeks in hospital and intensive care units instead of hospice care.
More and more, Medicare is implementing a payment model that recognizes and rewards value, like that seen in Iowa. IHA supports value-based payment, as it ensures patients receive appropriate care in the appropriate settings while also reducing overall cost. If high-cost hospitals were able to reduce their spending to Iowa’s level, or even just the current national median, billions of dollars could be saved.
The new Medicare data is adjusted for certain factors that some believed were a problem in earlier analyses, such as the fact that certain hospitals receive greater Medicare reimbursements to offset higher wages, the large numbers of low-income patients they treat and the number of medical residents they train.
Medicare also took into account the differing mixes of patients hospitals treat, allowing for academic medical centers that handle more complex cases to be compared to small rural community hospitals. This was done to quell complaints from large urban hospitals, particularly in New York City, which claimed that the unadjusted figures unfairly punished them for treating sicker and poorer patients. Despite the adjustments, an analysis by Kaiser Health News showed Medicare paid 5 percent or more above the national median to care for patients from 657 hospitals, about one in every five. The cost for caring for Medicare patients at 1,150 other hospitals — or one out of every three — was at least 5 percent below the national median, according to the analysis.
But the changes worked out well for the New York hospitals. In the Manhattan region, which other studies showed to be among the most expensive, the average cost was $17,039, about 5 percent less than the national median. California and Texas are a different story; more than half of the 50 most expensive hospitals are in those two states. Those 28 hospitals spent an average of $23,143 per patient, or about 29 percent above the national median.
by Kirk Norris on Tuesday, May 1, 2012
In the discourse of representative government, good politics often takes precedence over the prerogative of good public policy. Good public policy works in the interests of all involved, is vetted, discussed openly and supported by majorities of elected representatives and ultimately stands the test of time. Good politics is often the lubricant that’s applied in hurried, end-stage negotiations to resolve larger and more routine business like passing a state’s annual budget. That’s the context for the politics articulated in the Des Moines Register’s April 28 front-page story and subsequent editorial on Cedar Rapids ophthalmologist Dr. Lee Birchansky.
The public policy questions at hand is two-fold, whether one believes: 1) that Certificate of Need (CON) improves health care in Iowa and 2) it is good public policy to grant political exemptions to an administrative process created by the Legislature (and in this specific decision affecting one individual, a decision upheld by Iowa’s Supreme Court).
IHA’s position is that the CON process is good public policy and the Legislature should not grant political exemptions to this process. CON is good public policy because it has standards that, with the Legislature’s oversight, have evolved with the health care market. CON requires collaboration between hospitals and physicians at the community level on the necessity of creating new services, discourages unnecessary capital expenditures and therefore supports delivery of high quality care in Iowa.
Illustrations of health care markets without strong CON statutes can be found along Iowa’s border in Wisconsin, Minnesota, South Dakota and Nebraska. In Minnesota, a health care facility moratorium law is routinely skirted legislatively with lots of money thrown around in the process. In Wisconsin, Nebraska and South Dakota, health care providers exercise individual prerogative at the peril of a relatively finite number of health care consumers. More than one specialty hospital and/or ambulatory surgical center has opened in these markets only to be sold off to the highest bidder. In the absence of strong statutes to stop the “cherry picking” and profiteering that CON restrains in the establishment of health care services, Congress in 2010 stepped forward to place a ban on further construction of specialty hospitals.
This debate isn’t about a perceived “injustice”, “the money”, a constituent “problem” or a “slanted process,” nor is it about “saving taxpayer money.” This also isn’t an example of the proverbial David taking on the financial Goliath of hospitals. The IHA political action committee takes no corporate contributions and is funded by Iowans who support their community hospitals in all their endeavors, some political, most not. In fact, more than 800 Iowans voluntarily contributed to the IHA political action committee last year.
This is a story about giving an ambulatory surgery center that remains operational without the legal approval of the five-member, governor-appointed citizen board charged with making such decisions. The net effect of granting this political exemption is not just to legalize the operation of one practitioner’s surgery center, but rather to create an economic franchise for one Iowan that could be legally sold to any surgeon performing any type of service, not just ophthalmology. In effect, the Legislature would be allowing an end run of the process they publicly declare as “working,” which quite simply is not in the best interests of all Iowans.
If the General Assembly believes a more thorough discussion regarding the overall merits of CON is warranted, that is its legislative prerogative. In fact, the Legislature has conducted several interim evaluations regarding CON over the past 15 years and has always concluded the process serves the public interests.
But end-running the process by inserting an amendment into a budget bill is simply wrong-headed. Iowans expect and demand more from our elected officials.
The U.S. Supreme Court enters the third and final day of opening arguments on the various challenges to the health care reform law. Yesterday, the court heard arguments concerning the individual insurance mandate, Monday on the topic of whether or not a challenge can be raised against a tax that has not yet been imposed and today on the Medicaid expansion and whether the federal government overstepped its authority by requiring states to expand Medicaid programs nationwide. Finally, this afternoon the court will hear arguments on whether or not certain pieces of the law can be struck while leaving other intact – also known as “severability.”
At this juncture, it appears as if there are deep divisions between justices, in particular among the key “swing-vote” justices, those that generally tip the scale in favor or against an issue. With 9 justices, 5 are required to agree. The court is expected to rule on these issues in June.
For more information, IHA has developed a “Policy Brief” on the issues providing an in-depth view of the cases before the court.
by Dan Royer on Friday, March 23, 2012
The U.S. Supreme Court is set to hear opening arguments on a case challenging the constitutionality of the Affordable Care Act, or “Health Care Reform” law passed in 2010. The law is being challenged on a variety of grounds by 26 states.
The court’s decision, not expected until this summer, will have a major impact on the future of reform efforts. The court has a variety of options concerning this issue: 1) they can uphold the law in full; 2) rule that certain sections of the law are unconstitutional, while leaving some parts intact, 3) rule the entire law unconstitutional, effectively repealing it or 4) defer ruling based on an argument that a court can’t rule on a challenge to a tax that has not yet been assessed. Though a highly technical argument, which the court will hear first, it could punt this issue 3-4 years down the road.
The oral arguments will be as follows:
March 26 – 90 minutes on whether the Anti-Injunction Act (AIA) disallows the court from taking up the challenge against the individual mandate. The AIA prevents a court from striking down a tax before the tax is enacted. Even though the Affordable Care Act is current law, many of the provisions to not go into effect until 2014. Should the court rule in favor of the AIA, it would punt the court’s consideration of this issue into the future.
March 27 – 2 hours on the individual insurance mandate and whether the federal government has the constitutional authority to mandate a consumer’s purchase of health insurance. The federal government will argue that the mandate is constitutional because it falls within the authority of Congress to regulate interstate commerce. Meanwhile, the plaintiffs will argue that the law represents near limitless power of the federal government and that Congress cannot require an individual to enter into commerce under the interstate commerce clause of the Constitution.
March 28 – 1 hour on the constitutionality of the ACA’s Medicaid expansion. The plaintiff will argue that the federal government is overstepping its bounds by requiring states to expand their Medicaid programs.
Following the discussion the court will hear 90 minutes of argument concerning the ability for the individual mandate, should it be found to be unconstitutional, to be removed from the law, while leaving the rest of the law intact.
All of these possible rulings would set up a variety of challenges for hospitals, but perhaps most troubling is the scenario whereby the court strikes sections of the bill that would be beneficial to hospitals while leaving the existing Medicare cuts to hospitals also found in the bill. This “swiss-chesse” approach would punch holes in the law that could keep hospitals on the line for the $155 billion in Medicare cuts but hospitals would not benefit from the insurance mandate, should it be struck down, that would result in more insured patients.
Check the IHA Policy Blog for updates on this issue and for additional information and insight on the case.
by Scott McIntyre on Tuesday, March 20, 2012
In modern health care systems, it can be difficult to ensure that a patient’s end-of-life treatment choices are communicated and honored from one health care setting to another. To address this complex issue, Mercy Medical Center and St. Luke’s Hospital in Cedar Rapids and Jones Regional Medical Center in Anamosa collaborated to improve system-wide communication for both chronically ill and frail elderly populations. As a result of their four-year initiative, a communication tool called the Iowa Physician Orders for Scope of Treatment (IPOST) was developed based on the National Physician Order for Life-Sustaining Treatment (POLST) paradigm.
Now Governor Terry Branstad has signed House File 2165, the IPOST legislation. With his signature, the bill becomes law on July 1, allowing all communities across Iowa to utilize the IPOST form. IHA will work with the Iowa Department of Public Health to develop a uniform version of the form. IHA will then work with hospitals and other providers to educate the public about IPOST and get the form into the hands of those who desire it.
IPOST facilitates a consistent process in which treatment choices are based on patient and family discussions and are documented, communicated and honored across different health care settings – for example, as a patient moves from home, to a hospital, to a nursing home and then to hospice services. The standardized form acknowledges a patient’s advance directives and creates a portable and actionable set of medical treatment orders.
In collaboration with a physician, physician assistant or nurse practitioner, a trained health care professional may assist the patient and family in conversations that build an understanding of a patient’s values and goals of care. Their IPOST form is then completed, which will help ensure the patients’ treatment wishes are met no matter where they are being treated.
The one-page document allows a person to communicate their preferences for key life-sustaining treatments like CPR, general scope of treatment, artificial nutrition and more. People may refuse treatment, request full treatment or specify limitations. The form is primarily meant to be used by the chronically or seriously ill who have frequent contact with health care providers, a person with a life-limiting illness or the frail and elderly residing in a nursing facility or at home.
The portability of the IPOST form belongs to the patient and allows seamless documentation of treatment preferences. It complements an advance directive by translating patient wishes into legal medical orders, which due to the passing of this legislation, will now be honored in all health care settings across Iowa. IPOST also helps to facilitate conversations between family members and the physician in order to make a person’s wishes known.
“Passage of the IPOST bill is a crucial step for end-of-life care in Iowa,” said Stephanie Anderson, director of St. Luke’s Hospice and palliative care. “Our main priority has always been to provide the best care possible to all patients and honoring patient’s end-of-life wishes and IPOST is just one more way of ensuring that. Now patients will be able to have their health care treatment choices honored across health care settings, improving the overall care we provide throughout the state.”
