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Health Care ReformThe Affordable Care Act has now been in place and functioning for a year and many are wondering, is the law fulfilling its core goals?  The New York Times recently provided an expanded analysis of the law and generally concluded the law is succeeding, though more time is needed to know for certain.  Here is a summary of the Times’ findings:

Fewer Uninsured

The main goal of the Affordable Care Act was to reduce the number of Americans without health insurance.  Since the law was enacted, the percentage of uninsured Americans has decreased by about 25 percent within one year, or approximately eight to 11 million people.  Much of this is because of state Medicaid expansion, with at least as many people enrolled in Medicaid as have signed up for private insurances.  Although the Affordable Care Act will never bring universal health insurance coverage, it hopes to continue closing the gap and over the next four years it is projected to expand coverage to millions more Americans.

Affordable Coverage

For millions of Americans, the Affordable Care Act has provided access to comprehensive coverage at an affordable price.  Of the 7.3 million people who signed up for private insurance through online exchanges, 85 percent qualified for government subsidies to reduce the cost of premiums.  Although the law has made insurance affordable for some, it has also created high deductibles and out-of-pocket expenses for others, and has caused premiums to raise for some who already had insurance or were not eligible for subsidies.  Additionally, while trying to keep costs down, insurers may be too restrictive about allowing consumers to use doctors outside of the company’s network.  With wide variations in pricing between states, it is difficult to know who will find plans unaffordable, but evidence suggests middle-income people who don’t qualify for subsidies will struggle the most with health insurance costs.  A 4 percent median premium increase is expected for 2015, so consumers will need to shop around for the lowest prices.

Improved Health

Currently, there is not enough data on the entire population to determine whether the law is improving the nation’s overall health.  Some early data does suggest that the law is having a positive impact on young people.  Because the law permits young Americans to remain on their parent’s insurance plans until reaching the age of 26, the share of 19-to-25-year-olds without health insurance declined to 21 percent in the first quarter of the year, a reduction of about four million people.  Outside the young adult group, there were very little changes in a variety of health measures, such as the number of flu shots received or whether people had a regular place to go for medical care.  However, preventative screenings, especially for colon cancer, have increased 8 percent since 2010.  More time is needed to determine if the law will positively impact the nation’s health in the long run.

Financial Stability for Providers and Insurers

Both Wall Street analysts and health care experts say the Affordable Care Act has helped the health care industry financially.  The insurance industry has seen the greatest benefits thus far, because of new customers and growth in demand for private insurance. The number of insurers participating in the online health exchanges is also expected to increase in 2015, an indicator of the profitability of the marketplace and the business the law has created.  The law also brought new paying patients to hospitals and new prescription users to the pharmaceutical industry.  Although hospitals are being hurt by a provision of the law that cuts their Medicare payments by $260 billion over 10 years, they are estimated to save $5-7 billion in uncompensated care costs this year because more people have insurance, according to the Department of Health and Human Services.  Iowa hospitals have seen a significant decrease in charity care over the last year.

Expanded Medicaid

The expansion of Medicaid, the government health care program for low-income citizens, is a crucial part of the Affordable Care Act. Medicaid expansion is optional for all states and 27 states and the District of Columbia (as well as Iowa) have expanded.  These states, including Iowa, have seen a significant reduction in uninsured people, while states without expanded Medicaid are seeing a coverage gap in health insurance for people who earn too much to receive Medicaid, but too little to receive federal subsidies to reduce premiums.  Pressure from hospitals that can get federal funds from Medicaid expansion has caused some states to consider expansion.  Federal officials say 8.7 million people have been added to Medicaid rolls since last October; however, with so many new people in the expanded program, there are growing concerns with the shortage of doctors.

Controlling Health Care Spending

While the Affordable Care Act was intended to slow down health care spending, the amount of money being spent on health care had begun slowing even before the law was put in place.  There has been a significant slowdown in the growth of health spending, due to the recession, higher-deductible policies that discourage people from seeking health care, a decline in the development of new and costly prescription drugs and the reduction of unneeded care.  In the short term, the law could actually increase health care spending because of the expansion of health insurance to millions of Americans.  The real test of the Affordable Care Act will be whether or not the declined spending continues, even with the amount of new insured people in the system.

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(An expert on population health, Dr. Jeffrey Brenner recently spoke to Iowa hospital executives and trustees at the IHA Summer Leadership Forum.  In this interview with Kaiser Health News reporter Lisa Gillespie, he discusses how providers can better coordinate the care of chronically ill patients.)

Jeffrey Brenner doesn’t believe in blaming a person for showing up at an emergency room for a cold or an ear infection, even if the illness could have been treated in a doctor’s office at much lower cost. Instead, he faults the health care system, and he wants to prove that if providers, employers and insurers work together more effectively, that person will stop going to the ER.

Jeffrey Brenner. (Photo by MacArthur Foundation)

Brenner, a 2013 MacArthur Fellow and executive director of the Camden Coalition of Healthcare Providers, is testing this theory with a randomized controlled trial. Findings are due out in 2016.

The trial extends what the Coalition has been doing for years in hospitals and primary care offices that serve the low-income neighborhoods of Camden, N.J. For the past decade, the nonprofit has worked to bring together hospitals, physician offices and other providers to create programs to better coordinate care for the high proportion of Medicare and Medicaid patients in the region. Brenner’s team flags patients with multiple hospital visits — the so-called “super utilizers” — and sends a care coordinator to their bedside. The goal is to find out why they went to the hospital instead of a doctor’s office. Then, a nurse, a health coach and a social worker meet regularly with patients, and determine how to address their continuing needs.

Employer health plans also have super-utilizers who rack up medical bills, prompting some employers to experiment with ways to control these costs.

Q: Can you explain the randomized trial? What are you trying to show? 

A: We identify the patients … who have had two or more hospital admissions, and then they get randomized into the control [group] — care as usual — or they have 90 to 120 days of intensive wrap-around coaching. [We] will track them for a year and possibly longer. The end point [measures] are [whether we achieve] a reduction in ER and hospitalization utilization. We also look at [the] patients’ overall wellbeing.

We’re trying to prove that we’re using the wrong methods to approach these patients. You don’t need new money [to care for patients], you just need new service delivery systems. We have to stop giving up on poor people. There is a feeling that it’s the patients’ fault that their care process isn’t going well, and that the health care system has done everything it can do and the rest is up to the patient.

We spend money in the wrong places delivering the wrong services at the wrong time, and this is about rethinking how we deliver care. As I meet with congressmen, hospital CEOs, the numbers of stories told behind closed doors of family members getting lost in the health care system is tragic. As baby boomers age, more and more families are experiencing what it feels like to get lost and have too much unnecessary stuff done to a family member.

Q: So the trial is looking at a high proportion of Medicaid and Medicare patients, but do you think the findings could also prove helpful to employers regarding the health costs of workers’ and retirees’ coverage?

A: A lot of the failures happening for poor people are happening for the middle class. [We] are all trying to solve a similar problem: how do you engage very sick people and help them work their way through problems? In every population that you look at, a small percentage of patients is responsible for most of the costs.  So for employees and their dependents, you’ll find the same pattern — that 1 percent of patients account for 25 percent of costs. Whether you’re middle class or poor, the health care system falls apart when you’re a complex patient. We need to coordinate care and have engagement models for the sickest patients.

Take for instance a middle class woman with a master’s degree getting care at a five-hospital integrated system, connected electronically. She was going to the ER repeatedly and, in a three-and-a-half-year period, she had 79 CT scans to the head. A group of family medicine residents got to know her and found out she had severe anxiety, so they got her working with a psychologist and she stopped going to the ER.

These hospitals were electronically connected. They could have seen the other CAT scans, but they did not. So I don’t think the phenomena we’re talking about is exclusively for poor patients. If you have good insurance, you can also have an enormous amount of unnecessary care.

Q:  Are public and private insurance plans already doing some of this coordinated care you’re talking about?

A:  There are lots of examples: Boeing has a patient-centered medical home for employees, and Bravo Health has a Medicare Advantage plan in Philly.

There’s been a big shift amongst health care plans because telephonic health case management isn’t effective. It takes boots on the ground to shift the trajectory. So you’re seeing more and more insurers get into the work of delivering care. Bravo Health has built two physical offices to deliver care, with shuttles and vans picking people up and [with] phenomenal hospitalists. They’ve put these in two of the poorest neighborhoods in Philly. They’ve made incredible profit, and Cigna bought them and now they’re trying to scale the model. That’s evidence that there’s money to be made on delivering coordinated care.

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walmart clinicAnd then there was Walmart, primary care provider.

In recent months, the retail giant has opened a half dozen primary care clinics in an aggressive move to become a one-stop shopping destination for medical care.  The push is making news because it’s a step beyond the dozens of bare-bones, acute care clinics Walmart has opened – and, in many cases, closed.  In other words, Walmart is looking to jump well ahead of its traditional competition like CVS and Walgreens and possibly go toe-to-toe with hospitals.

The scenario becomes more interesting for Iowa because these first few expanded clinics are showing up in small, rural markets.  But a closer look shows Walmart’s strategy may be more sophisticated.

The new clinics are in South Carolina and Texas, two of the poorest, least healthy and under-insured states in the nation.  That might seem like a blunder by Walmart as it appears to overlook the billions of dollars being pumped into states like Iowa that have expanded Medicaid (South Carolina and Texas have not and, in all likelihood, never will).

But it’s no mistake, because with low-cost care (appointments start at $40), Walmart can position itself as the option to Medicaid in states and communities that desperately need that option.  As the mayor in one of the South Carolina communities put it, “I think this is good news and bad news…The bad news is, I guess, the two (clinics) are being opened in Florence and Sumter because we have lots of people who need service.  The good news is that it is affordable…We have to have every access point possible in the system.”

According to its website, Walmart’s “expanded scope of coverage enables us to be your primary medical provider.”  What’s not clear is how the retailer defines “primary care.”  However, in addition to the uninsured, Walmart appears to be targeting chronically ill patients.  Not a bad move, given the enormous sums spent caring for that relatively small population.  The question is, can a retail-based clinic effectively manage disease?

The answer from hospitals and other traditional providers has been quick and clear. “There’s not a role for retail clinics to take care of chronic, ongoing problems like that,” Dr. Robert L. Wergin, president-elect of the American Academy of Family Physicians, told the New York Times. “It can provide a service, maybe an entryway into a system.”

Whether or not the place where you can pick up pork rinds and Pall Malls can (or should) serve as a medical home is certainly up for debate, but right now it’s a little beside the point.  What is clear is that Walmart has a sound, consumer-friendly strategy of low price and easy access that traditional providers must be prepared to counter.

In the post-Affordable Care Act world, where high-powered innovators like Walmart are anxious to find a lucrative niche, patient needs and preferences are changing.  In response, providers need to understand what patients value and the relative importance they place on different components of value.  What really matters to the patient: how close the clinic is, how quickly the patient is seen or who the patient sees?  You might be surprised (and you can certainly learn a thing or two about it at this year’s IHA Annual Meeting).

In any case, there’s no ignoring Walmart, which has more than 60 Iowa locations, nearly all of which are a very short distance from a hospital.  Everyone knows the old saying about 800-pound gorillas.  Well, Walmart is more like an 800-ton behemoth that combines both power and agility and that, more than ever, is looking hard at hospitals’ side of the jungle.

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For decades, organizations like the American College of Obstetricians and Gynecologists and the March of Dimes have been promoting the importance of full-term pregnancies – those naturally reaching at least 39 weeks gestation – yet early elective deliveries in many states account for 10-15 percent of all deliveries.

Numerous studies show early elective deliveries are associated with increased maternal and neonatal complications for both mothers and newborns, compared to deliveries occurring beyond 39 weeks and women who go into labor on their own.

Babies born before 39 weeks are more likely to have feeding and breathing problems and infections that can result in admissions to neonatal intensive care units than those who are born later, studies show.  The elective deliveries can also cause developmental problems that show up years after birth.  Inducing labor early also carries risks for mothers because it increases the chances they will need cesarian sections.

Decreasing the rate of early elective deliveries means more mothers get safe, evidence-based care and infants improve their chances for good physical and developmental health.  Additionally, it means lower costs for public and private payers because they’re performing less caesarian sections for failed inductions, they have less neonatal intensive care unit admissions and less associated complications for the newborns.

In Iowa, hospitals and physicians working through the Iowa Healthcare Collaborative and the national Partnership for Patients initiative have made a concerted effort to reduce early elective deliveries.  In fact, “hard-stop” policies implemented by Iowa hospitals have all but eliminated such deliveries, as the video below discusses.


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(Eric Greitens will be a keynote speaker at the IHA Annual Meeting on October 9.  This column originally appeared on the TIME magazine website and is republished with permission.)


Eric Greitens

The Department of Veterans Affairs is facing an emergency.  Deception in record keeping, manipulation of data, lies to families, secret lists, systemic corruption at health centers.  Yet this crisis of credibility is more than a short-term emergency at the department that pledges to fulfill Lincoln’s promise to “care for him who shall have borne the battle, and for his widow, and his orphan.”  There’s also a long-term challenge.  To meet it, the VA leadership will have to move boldly to address questions both strategic and cultural.

I’ve worked with thousands of veterans since returning from Iraq in 2007.  My team has honored nurses and doctors in the VA who saved lives, and there are many stories of the sweat and courage of VA employees that are too infrequently told.  Many veterans are satisfied with the care they receive, and the VA has model programs for some illnesses.  Yet almost every veteran has at least one story of VA dysfunction.  Too much VA heroism is about fighting the VA itself by going above, under or around its beastly bureaucracy.

After the Pentagon, the VA is the single largest department of the government, spending more than $160 billion dollars a year and employing 300,000 people.  Leading any organization of this size through a crisis would be difficult.  At the VA, new leadership will have to build a team, shape a culture and develop a strategy to face the twin challenges of restoring credibility while also leading transformation.

At the moment, the VA is facing a crisis of demand.  Veterans who need care can’t get it from VA hospitals.  Because of the wars in Iraq and Afghanistan, many people believe that the veteran population is growing.  It would be easy to think that the answer is simple: hire more and spend more.  But in fact, we’ve lost more than 6 million veterans over the last 30 years, and veterans now represent less than 7 percent of the population.  We face a future with millions fewer veterans in a country with millions more people.  Over the long term, the VA will have to adjust to a shrinking population with changing needs.  The right kind of planning will rely less on predicting the future and more on building a flexible system that responds quickly to shifting needs.

The current structure of VA health care makes that kind of planning difficult.  A patient-centered approach would incorporate lessons from other hospital systems to create structures for physicians and hospitals to deliver excellence while providing flexibility for patients to go wherever they can to get the best care.  This is easy to write and hard to do.  But it’s the kind of thinking and planning that the VA must do if they are going to preserve centers of excellence and avoid the waste of half-filled hospitals and ghost town clinics.  Solving this challenge will require close work with Congress on a sensible plan for consolidation in some areas, while expanding excellent care options for all veterans, especially those living in rural and remote areas.

Unlike the military, almost every function performed by the VA (health care, home loans, scholarships, cemeteries) has a clear private sector counterpart.  Innovative leaders have to look to public/private partnerships and market competition and ask, “What works best?”  We should rethink what services we want the VA only to pay for and which ones we want it to provide.

In addition, through increased collaboration the VA can take far greater advantage of the work of high-performing non-profit organizations that are providing quality services to veterans.  Perhaps more than at any time in American history, the average citizen is ready and willing to help veterans.  But for reasons of privacy, health, and quality, the VA has built a high wall around its patients.  (Some of these walls are necessary; there are many people with good intentions who create no results, and the field of those who say they want to help veterans includes people who are fraudulent and manipulative.) The VA should create a certification system for quality, proven organizations to make a difference in the lives of veterans who would benefit from the healing presence and helpful service of their fellow Americans.

In a similar vein, civil service reform may not seem exciting, but it’s essential.  With 300,000 employees and a crisis of accountability, the VA must find ways to remove poor performers, promote and reward excellence and attract and retain top talent.  Insisting on excellence is the best way to preserve, promote and celebrate the public service ethic shared by many VA physicians who forego higher salaries to serve veterans.  Done right, reform at the VA could point the way toward a more dynamic and effective civil service.
Finally, any discussion of the structural and strategic challenges facing the VA has to include technology.  Both the inability of the Pentagon and the VA to smoothly transition a service members’ health records and the VA backlog of disability claims have been well documented and much discussed.  But without a fix, serious problems will persist.

In addition to these structural issues, there are cultural issues that must be tackled as well.  Thus far, the VA has failed to fully integrate this generation of veterans into its systems or culture.  Combat-injured veterans from Iraq and Afghanistan with pressing needs too often continue to wait in horrific lines.  Their signature injuries—traumatic brain injury and PTSD–have still not been effectively addressed.  And despite some women’s health centers, the VA too often thinks of veterans only as men, when female service members now make up 14 percent of the force.

The “pop a pill” approach to pain in general and to PTSD in particular is also hurting.  There’s a place for prescription medication for some patients, but the side effects of overmedication too often include addiction and suicide.  Exercise, service in the community, work with dignity and meaningful relationships all seem to have a lasting effect on relieving PTSD.  These are not things that a government can provide for its citizens; all people, veterans included, must be partners in the protection and promotion of their own health.  The VA needs to encourage therapeutic plans that reinforce a culture of responsibility.

The disability system itself has also devolved into a cumbersome check-writing scheme unattached from commonsense understanding of disability.  (Because of that, I and many others make a point of donating “disability” checks to charity.)  Veterans who were disabled by war and need financial assistance to lead a dignified life should get it.  Veterans who do not need disability payments should be able to easily opt out of receiving them, while not forfeiting their future eligibility should they suffer a setback.  Lost eyesight rarely returns and limbs don’t grow back, but where a disability can be overcome, veterans should be aided by a system that incentivizes progress toward health rather than simply paying for disability.  The money we save could be redirected toward programs that help reintroduce veterans as contributing citizens to society.

Many people who work with veterans are frustrated by media stories that focus on “troubled” veterans: stories of suicide, sexual assault, homelessness and crime.  But the journalists who cover these issues are often veterans themselves, and many spent time embedded in military units.  When they draw attention to flaws at the VA, they should be thanked rather than shut out.

Criticism of the media counts for little if veterans don’t join the conversation.  Perhaps more than anything, new leadership at the VA must help the public to know the men and women I know: men and women who served with courage overseas and who’ve come back home to help us build stronger communities.  The leader of the VA serves as the most visible and powerful spokesperson for veterans in the country.  As such, he or she must help the country understand not only what veterans deserve, but also what they offer.

Many of these problems have roots that go back more than 50 years.  They won’t be solved in five months.  Still, discussions about veterans have been buoyed for too long by the rhetoric of intentions.  We know that everyone wants to do well by veterans, but there is a vast difference between wanting a result and creating one.

The veterans that came home from World War II shaped a nation.  The generation that came home from Vietnam shaped a culture.  What will be the legacy of this generation?  The men and women I served with were never afraid to do hard things.  This too will be hard.  But it’s what we all want: veterans, honorable employees inside the VA and every American who believes it’s time we got this right.

Eric Greitens, a Navy SEAL and founder and founder of The Mission Continues, was a TIME 100 honoree in 2013.  He was recently named by Fortune Magazine as one of the 50 Best Leaders in the World.

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