Telemedicine – connecting health care providers and patients via computer or smart phone for diagnosis and treatment – has been making it easier, and more cost-effective, to “see” the doctor. Using a camera-enabled computer or smart phone, patients with common health concerns can get some diagnoses without leaving their homes. Emergency room doctors and nurses are able to communicate with their peers in larger trauma centers via computer, as well.
Now a new University of Iowa study, published recently in the journal Pediatrics, shows that parents with children on the autism spectrum are able to have a specialist address challenging behavior in these children by interacting over the computer, too – and at less than half of the cost of receiving similar care in person.
“A lot of kids who are on the autism spectrum have significant problems with behavior,” says Scott Lindgren, Ph.D., professor of pediatrics in the Stead Family Department of Pediatrics at University of Iowa Carver College of Medicine and lead author of the study. “These kids may have trouble following directions, or have problems when there are changes in their schedule or routine. They also don’t always have good enough communication skills to be able to explain to someone why they’re getting upset or having a meltdown.”
Parents are often frustrated, Lindgren says, because they don’t know how to communicate with their child to find a way to prevent or stop a meltdown. What adds to frustrations, he says, is that many Iowa families live in areas where services for children on the autism spectrum may be hard to come by.
“There are a limited number of professionals with the training and expertise needed to work with these children, which means a lot of families can’t get access to the services they need,” Lindgren says. “That’s the situation we have in Iowa.”
With the availability of telemedicine, he says, families with limited access – particularly those in rural settings – will be able to connect with their provider without causing a big disruption to their child or their family.
Additionally, the study showed that total costs for treating a child for challenging behaviors was cut from nearly $6,000 per child to just over $2,100 through the use of telemedicine – or telehealth, as it is often called. Cost savings were seen in various areas, including travel expenses and staff hours that were saved when no travel was involved.
In the study, Lindgren, who is co-director of the UI Children’s Hospital Autism Center, and David Wacker, Ph.D., professor of pediatrics in the Stead Family Department of Pediatrics at UI Carver College of Medicine, along with other UI colleagues, examined whether these families could be served by using telehealth to train parents to use applied behavior analysis (ABA), a common intervention for children with autism spectrum disorder (ASD).
The group studied 107 children ages 21 months to 6 years old with ASD or other developmental disabilities and who were treated between 1996 and 2014. The children were divided into three groups: 52 kids treated between 1996 and 2009 who had a behavior consultant come to their home; 23 children treated between 2009 and 2012 whose parents went to a clinic near their home to be coached via telehealth; and 32 children who were treated between 2012 and 2014 as part of a trial in which their parents were trained in functional communication training (FCT), a type of ABA treatment, via telehealth coaching at home.
Researchers found that not only are specialists able to successfully train parents to use ABA procedures using telehealth, and at a fraction of the cost, but they are also able to provide the training to families in outlying rural areas who might otherwise not have access to care.
“When we were starting to do this with telehealth a few years ago, a lot of people said there’s no way to work with children with autism without seeing them in person,” Lindgren says. “Usually the way they had been managed was that the family would come to the hospital and see Dr. Wacker and he’d evaluate the children.” Behavior analysts were then sent out to the home to work with the family, Lindgren says.
As telehealth services evolved, he says, families would go to one of 14 regional clinics around the state and be coached by a behavior consultant via an internet connection between the hospital and the local clinic. It saved families from having to drive to the hospital, but it still involved leaving the home and disrupting the child’s routine.
With the most recent approach of using in-home telehealth, parents and consultants could connect via a computer at home, which often gave consultants a glimpse into where the child was most comfortable and where most challenging behavior occurred. The parents would then receive coaching in functional communication training at home.
“This coaching is more than having a casual talk with families,” Lindgren says. “It’s setting up a variety of situations in which problem behavior may occur, and helping parents find ways to address problems constructively, and to better understand why that behavior is occurring. For 90 percent of the kids we evaluate, we can find a social reason for what that child is doing.”
Lindgren said he’s been pleased with the results of the consultations via telehealth – and so have been families.
“It’s been impressive to me to see how well this works in different settings,” he says. “Almost all of the parents do well enough in this training to be able to help their kids a lot. And that reduces stress on the family and helps kids succeed in school and in life.”
Other UI researchers involved in this study include Kelly Pelzel, Ph.D., Todd Kopelman, Ph.D., and John Lee, BA.
Iowa is now two weeks into Medicaid managed care, with sharply differing views on the success of the plan’s roll-out. While significant issues are already emerging for both providers and beneficiaries across the state, Governor Branstad last week said the transition was “smooth,” despite more than 3,000 calls pouring in the Iowa Medicaid hotline on the first day of implementation.
“Smooth” is indeed in the eye of the beholder; if you’re one of the thousands of disabled Iowans who were left high and dry for transportation to your job, or someone whose prescriptions suddenly were unable to be filled, or those just learning that their physicians no longer accept Medicaid patients, you likely have a different adjective to describe the experience.
In the hospital community, IHA is already hearing concerns about upticks in emergency room use, requirements to change laboratory contracting arrangements, prior authorizations for swing-bed admissions taking as long as two weeks and patients showing up without membership cards or any idea about changes in Medicaid. And this is just the tip of the iceberg. Wait until hospitals run into billing questions, payment denials and the sheer administrative complexity of dealing with three separate Medicaid payers.
At a press conference last week week, the governor and managed care organization (MCO) representatives touted more beneficiary services and benefits than ever before. This includes access to nearly 17,000 physicians (compared to less than half that many physicians being licensed in Iowa and lots of news about physicians abandoning the program) and access to more than 2,000 occupational/physical therapists (compared to 900 such professionals participating in Medicaid just two weeks ago). The number of participating hospitals is conspicuously left off the list, perhaps because IHA called the question on an earlier report of 570 hospitals (again, there are only 118 hospitals in Iowa).
Additionally, the governor states Iowa’s existing Medicaid program had zero value-added benefits, while the MCOs promise more than 80 such services, including gym memberships, GED support, mobile health units, financial management programming, medication adherence programs, caregiver training, Boys and Girls Club memberships and post-natal coaching. It seems like everything except the keys to a brand new car!
As IHA has been pointing out for more than a year, the statistics and claims from those defending Medicaid managed care are beyond incredulous. Nowhere in the country have MCOs deployed these strategies in a widespread manner to improve care or to lower costs. Adding in the new costs of their “value added” programs can’t effectively cut 15 percent from Iowa’s $4.2 billion Medicaid program, especially in states (like Iowa) whose Medicaid programs have been efficiently managed. Much more common are strategies that deny patient access and cut provider reimbursement while siphoning taxpayer dollars to out-of-state insurance companies.
That’s the lesson to be learned from the experience of other states. It’s what Iowa can now expect. Check back in a month, six months or in a year to see if the transition is still “smooth.”
– Pink Floyd
It’s been said that the worst thing about having a disability is that people see it before they see the person. That could be the primary message behind David Gilmour’s “On the Turning Away” and perhaps also an overarching problem with Iowa’s Medicaid privatization.
Don’t accept that what’s happening
Is just a case of others’ suffering
Or you’ll find that you’re joining in
The turning away
Even in a small state like Iowa, Medicaid is a tremendous undertaking that involves more than a half million people and $4.2 billion. For those focused on Medicaid policy, it’s easy to turn away, however unintentionally, and focus on the law, the numbers and the deals to be made. But for privatization proponents, the turning away has been more intentional, and the fact that there are real people within those numbers, people whose health and lives are impacted daily by deals in which they have no voice, is beside the point.
It’s a sin that somehow
Light is changing to shadow
And casting its shroud
Over all we have known
For thousands of Iowans, Medicaid is hope – hope for better health, for more opportunity, for a productive future. Medicaid allows them entry into the health care system and once through that door, a chance to gain control of something nearly all of us take for granted. For those with multiple, complex conditions (or, more likely, those who care for them), this is not simply finding a doctor but organizing and coordinating a team. It can take years to find the right people.
But those teams are being decimated and that light of hope, if not altogether shrouded, has been made gray, ambiguous and chaotic by those who claim to have the patients’ best interests in mind. For the managed care organizations (MCOs), that’s not a problem – they have been down this road dozens of times before. They bide their time knowing who must be convinced, who can be appeased and who can be ignored. And with the state’s chief executive willing to force things along unilaterally and to implement a turbocharged timeline, all the MCOs’ stars eventually aligned.
Unaware how the ranks have grown
Driven on by a heart of stone
We could find that we’re all alone
But why Iowa and why now? Certainly Iowa’s expansion of Medicaid made the state more appetizing to the MCOs. On the other hand, Iowa Medicaid’s history of administrative efficiency held them off – until the administration provided to the MCOs, in writing, the ability to triple those costs.
Still, the MCOs are willing to lose millions in Iowa – in the short-term. And the short-term is all the further the “must-do-something-now” state administration is reacting to. Once the MCOs play their full hand, including opening their own clinics and case management agencies, the nature of this supposed partnership with the state will be revealed in countless devilish details and privatization supporters will find themselves in a very lonely place.
Is it only a dream that there’ll be
No more turning away?
Gilmour’s song ends with a question mark and on April 1, there will still be many questions left unanswered about Iowa Medicaid privatization, including a huge one: how will the MCOs be made accountable? There are those who would let the MCOs write their own rules, answer their own questions and meet their own goals.
That’s a turning away that Iowa hospitals, and anyone who cares about Iowa and Iowans, simply cannot allow.
The number of Iowans on Medicaid – about 560,000 – is not a trifling figure, not in a state of 3.1 million people. For starters, that is more people than live in Cedar Rapids, Davenport, Sioux City, Waterloo, Iowa City and Ames – combined. It is also more than all of the state’s public school children.
Because of age, infirmity or poverty – or a combination of the three – Iowa’s Medicaid beneficiaries arrived at that designation out of circumstance. It was not something they pursued. It was not a choice. It was not greed. It was need, pure and simple.
Medicaid was created to meet that need. Americans, as a society, agreed to commit significant public resources to protect the health and welfare of our most vulnerable citizens. As President Lyndon Johnson put it to Congress in 1965, “At this point in our history, we are privileged to contemplate new horizons of national advance and achievement in many sectors. But it is imperative that we give first attention to our opportunities – and our obligations – for advancing the nation’s health. For the health of our people is, inescapably, the foundation for fulfillment of all our aspirations.”
With Medicaid (and Medicare), the federal and state governments took up that obligation and codified their commitment. It is that commitment which has brought Iowa to a perilous juncture: one in six Iowans are now covered by Medicaid, but unless proper oversight is put into law, that coverage and access to the care it promises will be compromised with Medicaid in the hands of out-of-state, for-profit managed care organizations (MCOs).
We know the history of managed payment brought on by the MCOs in other states – it’s a sad history that repeats itself in the news media (and, sometimes, the court system) with regularity. It’s a history that Iowa will be swept into should Iowa Medicaid advocates – including hospital leaders – let themselves be swept aside.
In so many ways, Iowa is poised for greatness, but we cannot reach for the stars while stepping over those less fortunate. With one in six Iowans covered by Medicaid, we all are our brother’s keeper – or if not our brother, our neighbor, co-worker or customer or their child, parent or grandparent. Last week, as Medicaid advocates converged on the Capitol, Iowa legislators were reminded of this obligation, one they must not be allowed to step away from.
As about 200 Medicaid recipients and their supporters proclaimed at the Statehouse last week, “Nothing about us, without us.”
Hospitals and clinics largely serve patients who are, in some way, below their ideal level of health, often to an extreme degree. These patients are at an increased risk for infection or complication due to their bodies’ natural defenses being devoted to whatever brought them to the hospital in the first place. Providers strive to “do no harm” by reducing this innate risk, but human error and split-second, life-or-death situations are limiting factors to the effectiveness of even the best health care providers’ efforts.
The brutal reality is that thousands of Americans die from infections acquired while they were in the hospital and many, many more are injured. The intent among all health care providers is to eliminate as many of these instances as possible, because one medical error is one too many.
It is from the desire to move persistently closer to the goal of zero medical errors that the Iowa Healthcare Collaborative (IHC) was created. Led by provider, consumer and business representatives, IHC is a patient-focused nonprofit organization dedicated to improving the quality of care delivered for all Iowans. Over the past 10 years of efforts facilitated by IHC, significant improvements have been made in the realm of patient safety.
The Partnership for Patients (PfP) campaign is a national initiative sponsored by the Centers for Medicare & Medicaid Services (CMS) which specifically focuses on reducing harm to patients. The IHC, working as a Hospital Engagement Network (HEN), led these PfP efforts in Iowa. The results in a little less than four years are not only promising, but downright impressive. In the 128 participating hospitals (115 in Iowa, eight in Nebraska and four in Illinois), the following improvement results were reported:
- Adverse drug events decreased 99.9 percent.
- Early elective deliveries, which can lead to many serious issues in newborns, decreased 95.5 percent.
- Pressure ulcers decreased 89.4 percent.
- Central line-associated infections decreased 34.7 percent.
- Surgical site infections decreased 19.5 percent.
- Falls decreased 10.4 percent.
- Readmissions decreased 9.7 percent.
- Catheter-associated urinary tract infections decreased 8.6 percent.
Because of these improvements, Iowans have seen an avoidance of 3,310 adverse events, 15,603 fewer days in the hospital, and more than $50 million in cost savings.
One-hundred percent of the hospitals in the Iowa HEN agreed to participate, voluntarily reporting their adverse events, caused by both system inadequacies and individual mistakes. In this environment of trust and collaboration, these hospitals wanted to – and still strive to – report what went wrong so they can improve and then share their findings with others. Over the past four years, healthcare in Iowa, while already ranked highly in the nation, has improved significantly due to these efforts and the dedication of Iowa hospitals and health care professionals.
These efforts are impressive, sure, but the work is not done. Iowa clinicians and hospital leaders know we have to do better – we can do better.
One medical error for one patient is one too many.
Tom Evans is President and CEO of the Iowa Healthcare Collaborative.