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.
(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.)
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.
It’s becoming more and more apparent that the struggle to expand insurance coverage in Iowa through Medicaid was well worth the effort. As these pages have recently noted, coverage is up and uncompensated care is down in both Iowa and other states that expanded Medicaid. That trend has impacted more than medical care and finances; it has helped smooth Iowa’s mental health system reform and contributed to Iowa ranking as best in the nation for children’s health.
In other parts of the nation, the positive impacts are also being documented, including actual lives saved. In Massachusetts, which adopted insurance expansion in 2006, a study published last spring determined that mortality declined almost 3 percent relative to control counties in the four years after the state’s health expansion was rolled out. Mortality related to health care-amenable conditions fell by 4.5 percent.
As IHA’s successful campaign stated and restated in 2013: coverage matters.
Unfortunately, it also matters for the 24 states that have so far turned their backs to Medicaid expansion (though a few are on the fence). An Urban Institute survey found that the uninsured rate among adults under 65 had declined by 6.1 percentage points in states that expanded, compared with only 1.7 percentage points in those that didn’t.
The situation in these states has put hospitals in peril. Carolinas HealthCare System, which has some 900 care locations including 7,640 licensed beds in North and South Carolina, reported an astounding 53 percent drop in earnings. Had North Carolina expanded Medicaid, it would have covered 500,000 additional people and brought an additional $413 million to the state. Meanwhile, Fitch Ratings had this blunt assessment: “We expect providers in states that have chosen not to participate in expanded Medicaid eligibility to face increasing financial challenges in 2014 and beyond.”
What’s more, many of these states, by many measures, were among the least healthy in the nation long before the Affordable Care Act (ACA) became law. Look at the Kids Count Survey which Iowa led and you will see Louisiana, Alabama, Mississippi and other far-southern states struggling with every sort of children’s health issue, from low-birth weight babies and infant mortality to childhood immunization rates and the number of children struggling with mental health issues. Amazingly, seven of the 10 states with the highest uninsured rate (for total population) are not moving forward with Medicaid expansion.
On top of all this, the United States Court of Appeals for the District of Columbia Circuit ruled last week that ACA does not allow the federal government to offer financial assistance to people buying insurance in states not running their own insurance marketplaces. If that ruling stands (keep in mind another federal court ruled the subsidies are fine), it could mean that millions of residents in 36 states, including Iowa, would lose access to insurance through ACA.
Having expanded Medicaid, Iowa remains well-positioned for the future. However, many states (including four of the six bordering Iowa) have declined the offer, leaving millions of Americans even more on the fringes of the health care system. In that way, ACA has fallen short as a national solution for providing health care access to uninsured Americans.
The need remains – in fact, it has only become greater. The question is, given the unexpected curves and bumps thrown in front of ACA’s otherwise admirable progress, what can or should be done to get states that have been left behind back on track? Furthermore, how will their lack of progress impact states like Iowa that have done the right thing and continue to make great strides in providing high-quality, high-value health care?
The concept of patient-centered care has long recognized the value of each patient’s family and friends as an integral part of both the healing process and wellness in general. It’s arguable that this support system is as important as the care services themselves.
With that in mind, many hospitals in Iowa and around the nation have done away with “visiting hours” and replaced them with 24/7 visitation policies that are presented something like this: “We encourage family and friends to be with their loved one while in the hospital. We view family and friends as our partners in the patient’s care and we support their presence and participation in the patient’s caretaking and decision-making, but only to the extent that the patient would like.”
Visiting hours may be as ancient as hospitals themselves – or maybe not, since early hospitals depended greatly on family members as caregivers. More likely, visiting hours are a lingering contrivance of “modern” medicine and professionalization of providers, ostensibly designed to benefit the patient but able to hang on because of staff preferences.
With a greater focus on patient-centeredness and safety, the necessary involvement and encouragement of “care partners” has been duly recognized. By reducing fear and anxiety, they support the healing process. By serving as scribes and advocates, they increase understanding (for both providers and patients) and help reduce the likelihood of errors or readmissions.
In a 2014 Health Research & Educational Trust survey of U.S. hospitals, about 58 percent of hospitals report that they have a policy or guidelines that exist across all units in the hospital that facilitate unrestricted access to the patient by families or partners in care, according to patient preference. This is good news for patient-centeredness, but there is clearly still work to be done.
For the majority of hospitals that have set aside restrictions, perhaps the next step is to formally eliminate the concept of “visitors.” Some hospitals have done this by transforming their visitor policies and developing an official “welcoming policy.”
One of the leaders in this development has been Contra Costa Regional Medical Center (CCRMC), a public hospital in Martinez, California. The hospital’s website explains the policy: “We have implemented a new Welcoming Policy to make the hospital accessible 24 hours a day to family and loved-ones of those receiving care in the medical center. Recognizing that family and loved-one presence supports safe and high quality care, we have worked over the last year to replace our ‘visitor policy’ with this Welcoming Policy.”
Implementing the policy was a rigorous process at CCRMC that involved physicians and nurses as well as front-line staff, security personnel, patients and families. Anna Roth, the hospital’s CEO, noted that a 24/7 welcome policy is not without boundaries; safety, security and patient preference remain priorities. The hospital is tracking the policy with data; since implementation, more than 5,000 after-hours (8 p.m.-7 a.m.) “welcome moments” have been recorded with zero complaints.
Roth explained, “Our old policies treated family members like visitors, until we realized that we are the visitors in people’s lives, not the other way around. This was a huge cultural shift, and one that the staff here was courageous enough, bold enough and caring enough to undertake.”
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.