Think of why the police exist and that popular synonym for police, “law enforcement.” That term is casually applied, but its use and popularity has real meaning and implications. In contemporary America, police officers are viewed as responders: they get the radio call, they speed to the scene in their vehicles and then they take care of business by, literally, enforcing the law.
But is that really what the police are for? Sir Robert Peel, founder of Scotland Yard and the father of modern policing, wrote nine principles for policing, the first of which states, “The basic mission for which the police exist is to prevent crime and disorder.”
The primary tactic for upholding that principle was the police patrol – the beat cop, on foot, scouting the neighborhood and interacting face-to-face with citizens. But the very meaning of patrol completely changed when revolutionary technology, in the form of automobiles and two-way radios, hit the streets and took police officers off the sidewalks and away from people.
This fundamental shift from proactive prevention to after-the-fact reaction was not viewed as a problem for several decades. In fact, some concluded that making arrests was the best that police could do because crime was too big and with root causes too complex for the police, as “law enforcement,” to prevent anything.
Many criminologists believe this shift contributed to skyrocketing crime in the 1970s and 1980s. It wasn’t until the mid-1990s, with the implementation of “community policing” and “broken-windows theory” (which says petty acts like vandalism, if not immediately addressed, lead to more serious crimes), that crime rates, particularly in big cities, turned decidedly downward.
What does any of this have to do with health care? Sir Robert wrote, “The test of police efficiency is the absence of crime and disorder, not the visible evidence of police action in dealing with it.” It could also be said that the test of health care efficiency is the absence of illness and disease and not merely the visible evidence of providers delivering care.
Yet, our society remains largely convinced that with the help of crime-fighting gadgetry, we can still arrest our way out of crime (just look at how policing is still depicted on television; is there really any difference between “Adam 12” and “CSI” except the technology?)
It’s not quite so bad in health care; people understand, perhaps more than ever, that illness and disease can be prevented. Still, there are strong expectations (all reinforced by an antiquated payment system) that health care providers, like law enforcers, exist for exactly the reason the name suggests; that health isn’t possible unless care is being provided, often in an intense and costly manner, and that indeed we can treat our way out of poor health.
It is obviously vital for hospital leaders and other providers to address that misguided perception. How? Once again, we turn to Sir Robert, who wrote that the police are simply “members of the public who are paid to give full-time attention to duties which are incumbent on every citizen in the interests of community welfare and existence.” Can’t the same be said of health care providers? Isn’t there more than a little similarity between broken-windows theory and population health?
Health care, like policing, is a partnership between providers and communities, where in the name of prevention each shares, in-part, the other’s role. The future for an effective, efficient and sustainable health care system depends upon transparently connecting with key communities – including government, business and payers – to cultivate those partnerships and ensure shared priorities are understood and best practices are adopted.
Medicaid, with 560,000 insured Iowans, is the second largest health plan in the state, providing health insurance to more Iowans than Medicare. Medicaid is a $4.1 billion program (including state and federal contributions) that spends 58 percent of its resources on 168,000 severely disabled individuals. Correspondingly, it spends 42 percent of its resources on the other 392,000 participants.
Two months ago, the Branstad administration announced its intent to contract management of Medicaid to private companies. Medicaid is currently managed by the Iowa Department of Human Services. The initial request for proposals indicates that the administration is willing to pay up to a 15 percent contingency to successful bidders, of which there will be at least four, putting into play $645 million of earnings per year to be divided among these successful bidders. The state also wants its costs reduced by $100 million per year.
At least 18 companies have indicated initial interest in managing Iowa’s Medicaid program; all but one are non-Iowa companies. The timeline for selection of bid winners is July 31.
This timeline and the notion of moving the entire Medicaid program to management by private entities begs many more questions than it answers.
First is the potential impact on private insurance rates in Iowa. Since the adoption and approval of the Iowa Health and Wellness Program by the Iowa Legislature and Branstad administration, charity care and uninsured rates in Iowa hospitals have plummeted. During the first 11 months of 2014, the number of people hospitalized in Iowa without insurance fell by 47 percent compared with the same period in 2013. With more Iowans now insured, hospitals’ charity care losses fell 31.5 percent, yielding a total 11-month improvement of $103.3 million.
Everyone understands there is no free lunch in health care. The $745 million (earnings plus savings) meal price for Medicaid managed care will come at someone’s expense. It most likely will come at the expense of charity care and self-pay cost reductions.
Second are the implications of Medicaid managed care on Iowa’s Medicaid innovation program. In the last three years, health care providers have come to the table with the state and Iowa’s leading private health insurer to design a program that aligns public and private interests in bringing greater value to Iowa health care. This effort recently resulted in Iowa being one of only 18 states awarded $41 million to further improve Medicaid outcomes.
The chief objective of Iowa’s Health and Wellness Program and the State Innovation Model (SIM) for Medicaid is to move Iowa’s health care system to one that rewards care coordination, resulting in higher quality and more efficient outcomes. Achieving this goal of care coordination and community networks is the SIM’s central focus.
The Medicaid managed care initiative also hinges on the establishment of community care networks. But as proposed, these concepts appear to compete with one another. Based on initial interest, the Medicaid managed care proposal presupposes that those in the best position to establish relationships at the community level throughout Iowa are non-Iowa insurance companies. The lack of clarity on how the SIM coordinates with Medicaid managed care threatens the opportunity and possibly the funding for improvement through the SIM.
This is not Iowa’s first rodeo with Medicaid managed care. The state’s first major initiative with managed care was with the introduction of managed behavioral health services 20 years ago. The results of that experiment are written across Iowa’s health care landscape today as hospitals routinely search for inpatient bed placements, community access to sub-acute care remains virtually non-existent and hospital emergency rooms are, for many, the only point of access to Iowa’s mental health care system.
The state should slow down, resolve questions of fundamental competing concepts and set objective benchmarks for those seeking to assist in managing one of Iowa’s most important constituencies. Perhaps then, Iowa can avoid similar access concerns being imposed on Iowa’s entire Medicaid program.
It’s no secret that Iowa went through one heck of a winter this year. While this is always an area of concern from an emergency response perspective, new attention is being brought to helping give remote Iowans better access to care. This method is called telehealth and it seeks to help Iowans who may live long distances from their nearest hospital or are unable to travel by connecting them directly with their doctor over secure, advanced technological means.
The concept of telehealth is not exactly new. For more than 50 years, the idea of practicing medicine through telecommunications has had several different incarnations. The National Aeronautics and Space Administration (NASA) was one of the first telehealth pioneers. During the “Space Race” of the 1960s, NASA created technology to transmit astronaut vital signs back down to mission control. In fact, much of the history of telehealth has remained in the military and space technology communities.
In the later part of the 20th century hospitals began using telehealth by way of sending X-ray imaging, electrocardiograph data and other patient measures over telecommunications technology. Some will even argue that one of the most advanced forms of telehealth can be seen in the da Vinci surgical robot, in which a surgeon can literally operate on a patient in another room or even another country!
But for the most part, telehealth in its current form refers to the practice of medicine with patients in a videoconference setting. This practice looks to not only increase access for remote and/or elderly patients, but also reduce costs while improving outcomes for the patient. And for the most part, the United States is going all in on telehealth…with Iowa currently being one of a handful of exceptions.
That’s because as of right now, Iowa is only one of four states left in the country without a policy in place to help reimburse doctors and hospitals to use telehealth. That’s not to say that it isn’t happening in the state in earnest; many hospitals and health systems have moved forward with their own telemedicine programs.
However, if Iowa is going to see telehealth in every corner of the state, a fair payment policy needs to be put into law by elected officials. The majority of health plans pay for telemedicine services, but there are inconsistencies in Medicaid payments for telehealth services that must be mitigated. Through legislation, the state could put in place consistent payment structures that will result in adoption of telehealth resources across the state.
IHA has more information on this issue in its 2015 Legislative Agenda. Supporters of this effort can tell their friends and family to learn more about telehealth at www.IowaTelehealthNow.org or they can contact their legislator by clicking here.
Iowa’s community hospitals generate more than 121,000 jobs that add more than $6.2 billion to the state’s economy, according to the Iowa Hospital Association’s latest Iowa hospital economic impact report. In addition, Iowa hospital employees by themselves spend nearly $1.6 billion on retail sales and contribute $96 million in state sales tax revenue.
“Hospitals positively influence their local economies not only with how many people they employ and the salaries of those employees, but also through hospital purchases from local businesses as well as the impact of employee spending and tax support,” said Kirk Norris, IHA president/CEO. “Whether at the local level or statewide, there are few Iowa employers that generate economic activity comparable to hospitals.”
The IHA study examined the jobs, income, retail sales and sales tax produced by hospitals and the rest of the state’s health care sector. The study was compiled from hospital-submitted data on the American Hospital Association’s Annual Survey of Hospitals and with software that other industries have used to determine their economic impact.
The study found that Iowa hospitals directly employ 71,324 people and create another 50,131 jobs outside the hospital sector. As an income source, hospitals provide $4.2 billion in salaries and benefits and generate another $1.8 billion through other jobs that depend on hospitals.
In all, the health care sector, which includes offices of physicians, dentists and other health practitioners, nursing home and residential care, other medical and health services and pharmacies, contributes $14.3 billion to Iowa’s economy while directly and indirectly providing 293,758 jobs, or about one-fifth of the state’s total non-farm employment.
Complete information from the study, including economic impact data for each of Iowa’s hospitals, is available on the IHA website.
At the recent American Hospital Association Health Forum Rural Healthcare Leadership Conference in Phoenix, hospital leaders delivered a strong message to Congress urging it to protect community-based health care. Congress recently introduced several bills addressing rural hospitals and hospital leaders are urging support for rural policies. Two Iowa hospital CEOs attending the conference shared their perspective on these important issues:
Mike Myers, CEO of Veterans Memorial Hospital in Waukon:
Todd Linden, CEO of Grinnell Regional Health Center