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A toddler gets his heart checked at Monroe County Hospital & Clinics in Albia.

A national survey that each year measures major trends affecting children’s well-being ranks Iowa as the top state for health and in the top three overall.

The 2014 Kids Count Data Book released this week by the Annie E. Casey Foundation lists Iowa No. 1 for health, third place for children’s economic wellness and third overall. The survey compares data from 2005 to 2012, the most recent year that statistics are available.  Iowa also moved up from seventh place to third in the nation for overall children’s well-being.

Four indicators were used to measure the health of those up to 19 years old:  low-birth weight babies, children without insurance, child and teen deaths per 100,000 and teenage abuse of alcohol and drugs.

From the Quad-City Times:

Marcus Johnson-Miller, who works in the early childhood program run by the Iowa Department of Public Health, pointed to the state’s efforts to encourage better care for low-birth weight babies.

In the past year, the state has worked on a regional system that pairs up low-birth weight babies with the hospitals that can best care for them.

In other words, he said, “High-risk deliveries are now done at the facilities that can handle the high-risk babies.”

Further, the state is examining ways to ensure that women carry their babies to full-term, or 40 weeks, he said. The rate of early elective deliveries in Iowa has at least stabilized or gone down slightly, he said.

Actually, Iowa hospitals have been working diligently to reduce the number of early elective deliveries – and with great success.  Reports from the Iowa Healthcare Collaborative show these deliveries have been reduced by more than 90 percent.

Iowa hospitals do constant work to keep children healthy, from providing free bike helmets to teaching babysitting classes to helping parents properly install child seats in their cars. Hospitals also help sponsor “safety fairs,” like this one in Vinton and this one in Iowa City.

Hospitals also work hard to make sure children are properly immunized, as the Times noted:

To Dr. Louis Katz, Iowa’s lofty ranking is because of the hard work done by many public health workers.

Katz, the longtime medical director of the Scott County Health Department, mentioned the many screening and immunization programs now available, saying that they are central to good health and finding potential medical problems early.

One example is the Flu-Free Quad-Cities initiative of Genesis Health System that offered free inoculations to almost 10,000 schoolchildren in Scott, Clinton and Rock Island counties last year.

Finally, another big reason Iowa’s children are healthier than others is insurance. The Kids Count data shows only 4 percent of Iowa children were uninsured – almost half the national average. As the Des Moines Register reported:

Iowa has long had some of the lowest uninsured rates in the nation. Marcus Johnson-Miller, who oversees early childhood programs for the Iowa Department of Public Health, noted that state officials have aggressively worked in the past few years to let parents know about options such as Medicaid and Hawk-I. The publicly subsidized insurance plans are for children from poor or moderate-income families. Johnson-Miller said the Hawk-I enrollment efforts have been supplemented this year with expansion of other types of insurance under the Affordable Care Act. The rate of uninsured children has probably declined even further since 2012, he said.

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mental health medicaidIn Iowa and across the nation, the positive effects of Medicaid expansion are now being quantified.  More than 105,000 people are now enrolled in the Iowa Health and Wellness Plan, where they are receiving health screenings, primary care management and overall access to the health care system—many for the first time in their lives.  Hospital charity care is moderating and the number of self-pay patients is declining.  It is doing the things that hospital advocates knew it would.

And now there’s further evidence that Medicaid expansion is working.  As part of Iowa’s behavioral health care system redesign, counties had to enter into formal regional alignments to provide mental health care programs across the state.  The new system became operational July 1.

Many feared that the new regional system would lead to service cuts as county per capita mental health tax levy rates were equalized.  But as the Des Moines Register recently reported, not only have those cuts not materialized, but many regions are now adding new programs to better meet the needs of Iowans.  The Register noted, “the (new) programs include efforts to keep people from deteriorating to the point where they end up hospitalized or jailed because of behaviors related to mental illness.”

And to what do we attribute that success?  Medicaid expansion.  As the Register explained, Medicaid expansion covers behavioral health care, meaning counties have now been relieved of many of the costs of psychiatric care, counseling visits, prescription medications and even inpatient psychiatric care for individuals previously covered only by county taxpayer funds.  Not only do these people now have more service options, but care can now be provided in earlier stages of distress, avoiding more expensive acute care episodes.  Medicaid expansion is the underpinning of the new regional system; without it, the success of redesign would have been far more problematic.

Other media outlets across the state are also reporting that the new system is working in all 15 regions, although to varying degrees.  Universally, however, things are moving forward and much of the credit is due to Medicaid expansion.

Although the topic of the Affordable Care Act remains a political hot potato, particularly at the federal level, there’s no denying that Medicaid expansion is working in Iowa.  The Iowa Health and Wellness Plan is not only providing coverage to thousands of Iowans previously left outside the boundaries of the health care system, it is quickly proving to be financially prudent at the state, county and hospital-specific levels.

It’s hard to believe that fully half of the states in America have not seen the wisdom of following Iowa’s lead in expanding Medicaid coverage to their poorest citizens.  It’s yet another example of how Iowa’s health care system can be a model for the rest of the nation.

And positioned squarely in the middle of that equation are Iowa’s community hospitals, which not only provide high quality care at conservative costs, but whose leaders are visionary when it comes down to the bottom line of caring for people.  At the end of the day, that’s what matters the most.

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(IHA is closely monitoring the impact of the Affordable Care Act and, in particular, Medicaid expansion, which is being implemented through the Iowa Health and Wellness Plan.  As we have shared, preliminary studies indicate early success in meeting the essential goals of health care reform.  With that in mind, IHA is one of 24 state hospital associations working with the Robert Wood Johnson Foundation [RWJF] on its Hospital ACA Monitoring Project, which is described below, to further study progress.  Reprinted with permission.)

HealthCareReformihaTo monitor the impact of health reform on hospital utilization, the Robert Wood Johnson Foundation has embarked on an important surveillance project, working in collaboration with 24 state hospital associations. The RWJF Hospital ACA Monitoring Project, or HAMP, collects data each quarter on all inpatient admissions and emergency department (ED) visits by payer. HAMP also collects some information on a subset of diagnoses and procedures that are believed to be sensitive to insurance status.

Clearly, there are a variety of ways in which health reform may affect hospital utilization. Conventional wisdom might suggest that coverage expansion will result in fewer preventable hospitalizations, and less use of the ED for ambulatory care sensitive conditions. However, we saw in the Oregon Medicaid experiment that increased Medicaid enrollment resulted in more ED use. Another possibility is that increased demand for primary care may overwhelm the ambulatory care system, resulting in increased use of the hospital for primary care treatable conditions, even among those who were previously insured.

The potential financial impact of health reform on hospitals is also unclear. While the reduction in uncompensated care is clearly a plus, there may be significant increases in utilization by patients who have payers that reimburse at relatively low rates. Further, there is a possibility of increased bad debt from patients with Marketplace plans, which require significant cost-sharing. Additionally, there are reductions in DSH payments and other simultaneous changes in Medicare payments.

The HAMP effort is designed to shed light on some of the effects of health reform on hospitals and provide extremely timely data to researchers, policymakers and hospital leaders. Seventeen state hospital associations submitted information from individual hospitals, while seven others submitted state-level data. There are approximately 1,700 hospitals included in this data set, which is roughly one-third of all hospitals in the country. The participating states and the number of individual hospital submissions are shown in Table 1.

The individual diagnoses and procedures being collected include three reasons for inpatient hospitalization that are considered to be preventable, and have been defined as such by the federal Agency for Health Research and Quality (AHRQ). These include short-term complications of diabetes, hypertension and urinary tract infection. Additionally, HAMP is monitoring admissions for knee replacement—an inpatient procedure that may be sensitive to insurance status. It is also monitoring ED visits for three specific diagnoses that are considered primary care treatable or at least ambulatory care sensitive: upper respiratory infection, urinary tract infection and headache. More details about these specific conditions are shown in Table 2.

The types of hospitals that participate in this project are shown in Table 3. While about 65 percent are acute care hospitals, there are a number of critical access hospitals, particularly in Western states and rural areas. The distribution of participating hospitals is shown in Table 4.

Baseline Data Offers Trends to Watch

Data from 2013 from participating states show great variation in the number of inpatient admissions and ED visits, as shown in Tables 5 and 6. Tables 7 and 8 show the payer mix in the inpatient and ED setting. There are clearly differences between the two. While only about 6 percent of inpatients are reported as being “self-pay”, about 20 percent of ED visits are attributable to the uninsured. The state variation in the percentage of admissions and visits which fall into the “self-pay” category are significant. This range can be seen in Tables 9, 10 and 11. It is clear that certain states have a relatively high share of uncompensated care. For example, 30 percent of South Carolina’s ED visits are in the “self-pay” category, as compared to about 11 percent of those in Nebraska. Inpatient admissions range from about 2 percent self-pay in Minnesota to about 12 percent in Wyoming. Table 11 makes clear that states with a high percentage of self-payers in the inpatient setting tend to also have a high share of self-pay patients in the ED. Tables 12-14 show similar patterns for Medicaid.

One thing that is clear from these tables is that some of the participating states that have expanded Medicaid were exposed to relatively little uncompensated care in 2013. This is the case for Minnesota, Michigan, Connecticut and New York. However there are also a number of expanding states (New Jersey, Nevada, Colorado and Kentucky) that in 2013 had a significant amount of self-pay utilization both in the inpatient and ED settings. Depending on the degree of eligibility and take-up among these uninsured patients, these states may experience a fairly significant change in utilization patterns upon expansion. Early reports from national hospital chains suggest increases in Medicaid utilization and decreases in uncompensated care in expanding states—and no change in Medicaid and increase in uncompensated care in non-expanding states. Similarly, data released by the Colorado Hospital Association showed similar trends in Medicaid and uncompensated care as a percent of charges in Q1 2014 in expanding versus non-expanding states.

Future posts will provide more information about payer mix and utilization by state and variation within states and for more specific diagnoses and procedures. Data for Q1 2014 are expected by the end of the summer.

Katherine Hempstead is RWJF Coverage team director and senior program officer.

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ace pyramidThis is how the day often starts for Dr. Daniel Taylor:  “My first patient was a two-week-old, born to a mother, 16, who was sleeping in the same bed with her infant.  The next child, a morbidly obese nine-year-old, was recently readmitted to our hospital for his third asthma attack this year.  With him came his brother, 10, with ADHD and learning issues.  Next up was an 18-month-old with speech delay whose parents are struggling with food insecurity. It was 9:30 a.m., and I still had nine more patients to go.”

Dr. Taylor goes on to reveal the common denominator for these young, struggling patients:  they live in the Pennsylvania First Congressional District, in the heart of Philadelphia, one of the poorest places in the United States.  That location is not unlike Camden, New Jersey, considered one of the nation’s most dangerous cities and the medical home for Dr. Jeffrey Brenner, who impressed a large and attentive audience at the IHA Summer Leadership Forum with his insights into population health and its impact on health care cost.

At the epicenter of Dr. Brenner’s work and that of his organization, the Camden Coalition of Healthcare Providers, are the “super users”, patients who churn in and out of the hospital at an astonishing pace.  Of the 79,000 residents in Camden, 386 constitute the top 1 percent of emergency department (ED) visitors.  In 2011, they made a total of 5,000 trips to one of the city’s three EDs for an average of 13 visits per patient.

Where do these patients come from?  Poverty and lack of access to medical and social services are clearly at the foundation of the issue.  However, there is a factor that many argue is even more important: adverse childhood experiences (also known as ACE or ACE events), including emotional and physical abuse or neglect, exposure to alcoholism, illicit drug use, mental illness, suicide or a household member being imprisoned.

In the mid-1990s, the Centers for Disease Control and Prevention and Kaiser Permanente conducted a large-scale epidemiologic study of the influence of ACE events on the origins of behaviors that underlie the leading causes of disability, health-related behaviors and early death.  In the study of some 17,000 participants, a simple scoring system was used where one point was given for each ACE experience.

The study found that compared to persons with an ACE score of zero, those with a score of four or more were twice as likely to be smokers, 12 times more likely to have attempted suicide, seven times more likely to be alcoholic and 10 times more likely to have injected street drugs.

At the Summer Leadership Forum, Dr. Brenner suggested that the ACE study is a road map to the origins of super users.  It’s no coincidence, he pointed out, that 50 percent of health care spending is attributable to 5 percent of the population, which is about the same portion of the population that has experienced six or more ACE events.

Iowa isn’t Philadelphia or Camden, one might argue, but then neither are all of Pennsylvania or New Jersey (which placed 17th and fifth, respectively, in the most recent Annie E. Casey Foundation “Kids Count” child well-being analysis; Iowa placed seventh).  In every state, in practically every community, there are pockets of social, physical and mental dysfunction that eventually present at the hospital’s doorstep in the form of a super user.

It’s a daunting task, but using tools like the ACE study and IHA ChimeMaps, health care providers can join with social services, law enforcement, education and other agencies to possibly derail the escalation that leads to the chronic mental and physical issues found among super users.  Communication, cooperation and data are the keys, along with the realization that prevention begins long before and far from the ED.

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aca thingAt a recent Citibank conference in New York City, large and not-so-large non-profit health systems presented their business strategies and financial statistics to Wall Street types responsible for financing much of the debt used to propel health systems forward.  Common themes emerging during the presentations were growth strategies largely dependent upon acquisitions in expanding health care markets coupled with significant planned reduction of expense, including debt in the next three to five years.  Also apparent was the pivotal role that public insurance exchanges are playing in the creation of new markets.

Other strategies included focusing on primary care with a strong emphasis on integration of behavioral services as well as focusing on building partnerships with for-profit entities to enhance quality and drive more value into services offered.  Most proffered long-standing views that care delivered closest to the patient was key to enhancing patient experience, lowering cost and providing optimum outcomes.

Interestingly, a key strategy to improve population health was premised on the need for success in the perceived growth area of Medicaid.

A couple of reports issued just this week add support to the premise of the role that Medicaid will play going forward.  First, the Centers for Medicare & Medicaid Services issued a report detailing that six million more people are insured by Medicaid and the Children’s Health Insurance Program (CHIP) in the first quarter of 2014 compared to the July to September time frame for 2013, a 10 percent increase.  Among states that adopted Medicaid expansion and whose expansions were in effect in April, Medicaid and CHIP enrollments increased by 15.3 percent compared to the July-September 2013. Iowa’s increase exceeded 18 percent.  All told, 65 million people (or more than 20 percent of the nation’s population) are now enrolled in Medicaid and CHIP.

The implications of this growth are detailed in a second report issued by the Colorado Center for Health Information.  Absent study, common sense dictates that revenue growth results when the volume of insured patients rises substantially, regardless of the source of insurance.  Believed, but undocumented until now, is the corresponding decrease in self-pay and charity care.

Certainly, these results are early, but the analysis included 465 hospitals across 30 states (including Iowa) with equal numbers (15) of states that have and have not expanded Medicaid.  Specifically, in the states that expanded Medicaid, the proportion of Medicaid charges increased nearly 23 percent (from 15.3 percent to 18.8 percent) while self-pay charges dropped 34 percent (from 4.7 percent to 3.1 percent).  In Iowa, Medicaid increased 12.6 percent (from 11.9 percent to 13.4 percent) and self-pay decreased 19.5 percent (from 4.6 percent to 3.7 percent).

In addition to these hospital data trends, a June 4 Des Moines Register article by Dr. Barry Engebretsen, medical director for the Polk County Federal Qualified Health Center (FQHC), points toward similar trends among FQHCs.

If one considers the Affordable Care Act as two parts insurance reform (the public exchanges and Medicaid expansion) and one part payment reform, (non-payment for re-admissions, bundled payment and Accountable Care Organizations), it’s increasingly clear from sources like the Citibank conference and the Colorado study that intended objectives are beginning to jell, if not solidify.

Is there any doubt where the “Wall Streeters” will place their smart money?

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