The following video is the first in a two-part series of interviews conducted with a couple of the forum’s esteemed speakers. IHA had the chance to speak with Herb Kuhn, President and CEO of the Missouri Hospital Association (Jefferson, MO), on how health care reform will impact states like Iowa and Missouri.

Part two of the series will be posted next week and will feature David Swenson, Associate Scientist, Dept. of Economics at Iowa State University.

YouTube link: http://www.youtube.com/watch?v=nWSOlXI7qiA

IHA also includes hospital losses to Medicare and Medicaid in its community benefit report.  This is because those losses – more than $310 million in 2009 – impact the hospitals’ ability to provide community benefit. 

Providing community benefits is an essential mission of non-profit community hospitals (117 of Iowa’s 118 hospitals are non-profit) and it is also required under federal laws that cover these hospitals’ tax-exempt status.  However, those laws do not specify an “amount” of community benefit from each hospital. 

Instead, hospitals are given the flexibility to determine how to meet the specific needs of their individual communities through these programs and services.  IHA believes that flexibility is important because community needs vary, not only from hospital to hospital and community to community, but from year to year – even from month to month.  A one-size-fits-all approach to community benefit would negate that flexibility and undermine the ability of hospital boards, administrators and employees to react to community needs in a timely fashion – if at all. 

In the coming weeks, IHA will be sharing more about the unique programs and services Iowa hospitals provide to their communities.

Senate Majority Leader Harry Reid (D-NV) (Credit: AP)

Senators Ben Nelson (D-NE) and Joe Lieberman (I-CT) voted with all Senate Republicans to block the $120 billion bill.  The measure failed having only received 56 “aye” votes.

Of key concern for hospitals is the enhanced Medicaid funding in the bill that would extend the increased federal share of Medicaid dollars for states.  Iowa’s state budget currently relies on nearly $150 million that would cease to exist should the Senate not pass this legislation.

In addition the bill contains an temporary patch for physician Medicare payments that are currently in limbo.  A flawed payment mechanism in the Medicare program causes physicians to face huge annual cuts that, until now, had been prevented by Congress.  Physician Medicare claims have been held by the Centers for Medicare & Medicaid Services for the past week and will likely have to be held longer.

IHA supports this legislation and urges the Senate to take final action to ensure appropriate funding for state budgets and fix the physician payment cuts.

What the scientists found as they were gauging consumer understanding of evidence-based medicine was that many consumers follow a conventional wisdom, believing the best care is provided in large, expensive and shiny new doses.  As one focus group participant put it, “I don’t see how extra care can be harmful to your health. Care would only benefit you.” 

Fully one-third of the study participants agreed with this view.  Telling them that not all care meets accepted quality standards and that more or new (and therefore unproven) care could actually be harmful simply did not compute.  (The Associated Press took on this issue in a six-part series last week).

The good news (sort of) is that 40 percent of consumers weren’t sure either way, meaning that they are open to the concepts of comparative effectiveness and evidence-based medicine.  Most consumers trust their providers implicitly and generally believe that what their physician prescribes is best for them. 

However, this kind of passivity also means they may not be prepared to challenge or even engage a provider – most don’t bring any kind of research to appointments or even take notes.  Forty percent said they didn’t ask questions because the physician seemed rush or they were unsure how to talk to him or her.

Confused or intimidated consumers could also be swayed another direction, toward those who couch evidence-based health care as “rationing” or worse.  More than a few consumers in the Health Affairs study were already in that camp:  “Using medical guidelines sounds like…your doctor can’t give you other treatment without approval,” one said.  “It’s taking away your choice and putting the decision in somebody else’s hands.”

Such is the double-edged sword of empowered consumers and their role in high-value health care.  But with transparency, patience and well-planned outreach (the researchers have produced a communications toolkit for providers), health care consumers will embrace evidence-based medicine and join high-value hospitals, like those in Iowa, as allies in assuring that they receive the right care, in the right place and at the right time.

The two scientists go on to point out several factual errors and misrepresentations in the article.  Among the errors: the Times claims Dartmouth data does take into account quality of care; Fisher and Skinner show that the atlas does indeed contain quality data.  The article also claims that “neither patients’ health nor differences in price are fully considered by the Dartmouth Atlas”; the scientists respond that risk adjustments are included in their studies.  As for price, they point out that because their investigations focus on actual measures of utilization, price adjustments are not necessary, though fully price-adjusted expenditure data is also available on the Dartmouth Atlas Web site, just the same. 

Rather than the Times article, which cites “critics” of Dartmouth’s work but fails to present any substantial criticism (or at least none that can hold up to scrutiny) and Skinner and Fisher describe as “superficial,” the researchers urge readers to take the time to read their initial but very thorough responses to the reporters’ questions, which the Times posted as a sidebar. 

In an article that ran in the Dartmouth campus newspaper, Fisher reiterated that the Dartmouth Atlas findings – essentially, hospitals that spend more on high-intensity health care “are less likely to deliver safe and effective care” – remain largely undisputed in the scientific community.  

“All of this research and all the findings they cite [in the Times’ article] are consistent with ours,” Fisher said. “The Times is not helping advance the public’s understanding of what’s going on.” 

Fisher went on to say that the potential remains to save “about 20 to 30 percent of health care spending” if more hospitals engage in “better performance measures, greater accountability and payment systems that reward improved performance.”

Like the scientists at the Dartmouth Atlas, IHA and Iowa’s hospitals are committed to understanding variations in health care delivery for the purpose of ensuring access to high-value health care.

 The New York Times, meanwhile, appears less interested in improving health care and more interested in creating controversy where there is none.

Dartmouth is a natural for this sort of endeavor primarily because it is home to the Dartmouth Institute for Health Policy and the Dartmouth Atlas of Health Care, which have been studying variation in health care delivery and spending for a couple of decades.  But while the Atlas gives Dartmouth the data, the college’s home state, New Hampshire, isn’t exactly a shining example of health care value. 

At more than $7,800 per Medicare recipient per year, New Hampshire spends nearly 20 percent more than Iowa ($6,686).  Of course, that’s not nearly as bad as nearby Massachusetts ($9,568) or New York ($9,995), both of which should provide convenient laboratories for what not to do for value-based health care delivery. 

This is worth noting because of something Dartmouth’s president, Jim Yong Kim, mentioned when the center was announced over the weekend.  According to Associated Press coverage of the story, Kim and state leaders have “discussed using the center to make New Hampshire a model for innovative health care.” 

This brings one thought immediately to mind: Why not Iowa? 

Obviously, Dartmouth has every right and reason to focus on its home state.  But this deserves serious consideration in Iowa, where IHA has made “value” a health care watchword.  Certainly, the tools and the people are there. The Iowa Healthcare Collaborative has united hospital and physician interests under the value flag and, like the Dartmouth Atlas, has become a vast data collector.  

The University of Iowa (UI) and Des Moines University both offer excellent schools of health care administration and medicine with easy access to not only urban medical centers but also nearby rural referral centers and Critical Access Hospitals, many of which are on the cutting edge of innovative health care delivery models.  The schools of engineering at UI and Iowa State, along with major businesses (including hospitals) that have adopted ideas like Lean and the Toyota model of process improvement, offer expertise and laboratories for systems analysis. 

What Iowa doesn’t have is seed money, like the $35 million that was anonymously donated to fund the Dartmouth center.  Perhaps if we can broaden our state leaders’ views on what drives a healthy economy (hint: it’s more than wind turbines and gambling halls) and quality of life (more than good schools and smooth roads) to realize the impact of high-value health care, some investment capital might emerge.

The rules do not go into effect until September 23, although several insurance companies across the nation, including Wellmark Blue Cross and Blue Shield of Iowa, have elected to implement the policy earlier.

Trends show that patients in the young adult age group are less likely to have insurance, which places burdens on hospitals in areas with high volumes of young adults. Mike Tretina, CFO at Mary Greeley Medical Center in Ames, home to Iowa State University, says that the hospital has budgeted $670,000 in uncompensated care to offset the cost of treating students or other young adults who do not have insurance.

Tretina hopes that the new provision will help to encourage parents to add their children to their coverage to reduce the number of young adults who are uninsured, and thereby reduce uncompensated care costs for hospitals.

Since 2008, Iowa law has allowed young adults up to age 25 to stay on their parents coverage.  The new federal provision adds an additional year, but it’s up to parents and young adults to take advantage of these benefits.

Nationwide, according to a White House fact sheet, estimates show that young adults comprise the largest percentage of uninsured of any age group, with an estimated 1 out of every 5 uninsured American falling in this age group.

Flu vaccine is given in mist form to a young girl at Greene County Medical Center in Jefferson.

The 2009-2010 flu season is coming to a close.  Except for localized cases in the Southeast, Maine and Hawaii, current H1N1 flu information from the Centers for Disease Control and Prevention indicates sporadic activity in most of the U.S. and no activity in Iowa and most of the Upper Midwest. 

Evaluation is underway and official reports will be published in the coming months, but one conclusion is obvious: the flu season was expected to be much worse than it actually turned out to be. 

Why? 

While the official and scientific response to that question is in the works, an interesting bit of data was provided by a recent post on the Gallup Web site.  Since September 2009, Gallup has randomly called 1,000 Americans a day and asked them, “Were you sick with the flu yesterday?”. 

For seven of the eight months between September and April, the percentage of people who self-reported flu symptoms was lower in 2009-2010 than during the 2008-2009 flu season.  The same was true for people who were asked if they had a cold the previous days.

So, surprisingly, on any given day fewer people were sick this flu season compared to that last one.  The reasons are complicated and, as noted, being figured out.

But at least partial credit for this decline goes to efforts to inform and educate the public about the flu, how to prevent its spread and, of course, constantly pushing people to get vaccinated, Gallup concluded.  People washed their hands, sneezed into their elbows, stayed home when they were sick and went out of their way to get their shots.  And they reminded their families and friends to do the same.

A sheriff's deputy gets his flu shot at Mahaska Health Partnership in Oskaloosa.

Hospitals played an important role in all of this.  Hospitals were not only a source of vaccine, but also a source of expert information that was disseminated to the community through a large corps of knowledgeable, trusted health care professionals. 

In most communities, no other entity – public or private – could have fulfilled the mission that hospitals did during the 2009-2010 flu season. 

Hospitals also increased their credibility in this potential crisis by setting the example – by diligently enforcing hygiene policies and pressing employees to get vaccinated.  This is why, nationwide, hospital employees had higher vaccination rates than all other health care workers – nearly 75 percent, versus about 50 percent for all other workers.  Hospitals that required vaccination had a 97 percent rate. 

Final results are still being tabulated, but expect Iowa hospitals to fall somewhere between 80 and 90 percent for their employee vaccination rates.  Not a bad result, but you can count on hospital leaders to be pushing their staffs to do better.

Donald Berwick

Bringing real value to government-supported health care will be Dr. Berwick’s foremost challenge.  And with health care reform set to trim billions of dollars from the Medicare program while adding millions of new enrollees to Medicaid, it is a formidable challenge, indeed. 

But Dr. Berwick has two things going for him.  First, he knows what he is talking about.  His work and leadership at the Institute for Healthcare Improvement (IHI), which he cofounded nearly 20 years ago, has led to changes in the way hospitals provide health care that have saved lives, lowered costs and improved quality.  IHI’s current initiative, it’s “Improvement Map,” is perhaps its most ambitious.  

The Improvement Map is an interactive, Web-based tool designed to bring together the best knowledge available on key process improvements that lead to exceptional patient care. It offers clear guidance through the often confusing health care landscape, helping hospitals set change agendas, establish priorities, organize work and optimize resources.  The Improvement Map is also a testament to IHI’s dedication to shared learning, which it established from its beginning through collaboratives, learning networks and mentor hospitals (among these are Mercy Medical Center and St. Luke’s Hospital in Cedar Rapids, University of Iowa Hospitals and Clinics in Iowa City and Buena Vista Regional Medical Center in Storm Lake). 

But leaders succeed only when they energize followers, and that is Dr. Berwick’s other strength.  Throughout the medical world, Dr. Berwick is highly respected not only for his ideas but for his ability to bring key players to the table and keep them there.  Time and again, Dr. Berwick has been described as “a visionary.”  Hospital leaders in Iowa continue to be pleased about his nomination: 

“I was very excited to hear of the nomination of Dr. Don Berwick as the administrator for CMS,” said Jim FitzPatrick, CEO at Mercy Medical Center-North Iowa in Mason City.  “Dr. Berwick has spent his career on a quest for improving quality in the nation’s health care system.  His passion for improving processes for our patients and keeping focus on the ‘big dot’ issues to eliminate defects in care makes him the perfect leader for CMS. 

“Dr. Berwick’s appointment to CMS would be very positive for the health care industry,” said Eric Lothe, administrator at Iowa Lutheran Hospital in Des Moines.  “He has a long history of setting transformational goals for health care quality and then achieving great results.  Dr. Berwick would continue the focused work of IHI to help physicians and hospitals improve quality, reduce errors and eliminate adverse events.” 

The real question is, can Dr. Berwick’s ability to unite diverse interests come through in a U.S. Senate that remains bitterly divided over health care reform?  Can he show that not only can Medicare and Medicaid lead the way in improving care, but they can do it at less cost?  And can he hold his ground should talk of “rationing” and perhaps even “death panels” rear its ugly head? 

Answers should come fairly quickly, as Dr. Berwick’s first stop will be in front of the Senate Finance Committee and its ranking Republican, Iowa’s own Chuck Grassley.

Dr. Donald Berwick

One of the great minds and motivators behind the national movement to improve health care quality is slated to become the next administrator of the federal Centers for Medicare & Medicaid Services (CMS).  In anticipation of his nomination by President Obama (not yet official, but confirmed to multiple major media outlets by administration officials), Iowa hospital leaders are pleased with the thought of Dr. Donald Berwick running these important programs. 

They should be.  Much of what is right about Iowa health care – low-cost, high-quality, patient-centered and primary-care based – is what Dr. Berwick would like to see happening in the rest of the country.  If Dr. Berwick is confirmed to the post (something that probably won’t happen quickly, given the tumult surrounding the recently passed health care reform legislation), it wouldn’t be surprising to hear him talking about Iowa early on and often. 

As many Iowa health care providers know, Dr. Berwick runs the Institute for Healthcare Improvement (IHI), which focuses on “cultivating promising concepts for improving patient care and turning those ideas into action.”  One of IHI’s recent initiatives was “How Do They Do That?,” which provided regional case studies of high-value care.  

Out of hundreds of hospital referral regions (HRRs) around the country, 70 met IHI’s selection criteria.  With all eight of its HRRs meeting the criteria, only one other state had more representation than Iowa among the final 70 (California, which has two dozen HRRs, had nine that met the criteria).  One of the 10 HRRs selected to share their How Do They Do That? story was Cedar Rapids, and the CEOs of both of the city’s hospitals are excited about the prospect of Dr. Berwick leading CMS. 

“The selection of Dr. Berwick by President Obama to lead CMS is an inspired choice, particularly at a time of unprecedented rethinking of health care in our nation,” said Tim Charles, CEO at Mercy Medical Center-Cedar Rapids. “In 2003, our hospital joined with IHI because of Dr. Berwick’s commitment to the triple aims of improving patient experience, per capita cost and population health. I am certain these principles will act as his ‘true north’ as he guides CMS. 

“I have come to know Dr. Berwick more personally this past year and respect his commitment to our health care system. His identification of Cedar Rapids as a model suggests he would bring to his new role the recognition that our community is well down the road to achieving both its potential and promise as a provider of high-quality, low-cost care. We look forward to working with him.”

 “CMS could not be in more capable hands if Dr. Berwick is appointed its director,” said Ted Townsend, St. Luke’s Hospital president and CEO.  “I had the privilege of getting to know Don on a personal level after he invited a contingent of health care leaders from Cedar Rapids to IHI’s National Conference last year to talk about how Cedar Rapids provides high-quality, low-cost care.  Additionally, in his role at IHI, Don has worked with St. Luke’s and countless of other hospitals across the county to reduce errors, waste and preventable deaths. He is the perfect person to engage hospitals, doctors and health care providers to constantly strive to provide high-quality, low-cost and safe care.” 

Other hospital leaders have also spoken up in support of Dr. Berwick. IHA will share their thoughts in an upcoming post.