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The Turning Away from Medicaid

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On the turning away
From the pale and downtrodden

– 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.

medicaid statehouse2The 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 Stand with Medicaid Recipients

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medicaidAt last week’s meeting of the Iowa Health Policy Oversight Committee, dozens of Iowans came to the Capitol to oppose privatization of the program, while a handful of non-Iowans were brought in to counter the wave of criticism.

It was an odd, but telling dichotomy. Here was a crowd of actual Iowa Medicaid beneficiaries and their family members and caregivers who, day-in and day-out, live the program and are now dealing with the frustrations brought on by a huge change for which the state – and, consequently, the vulnerable Iowans it serves – is clearly not prepared.

On the other hand, there was not a single Iowa citizen speaking in favor of privatization. Sure, there were a few speakers who claimed to be “neutral,” but at the end of the day their concerns and criticisms of the state’s ill-conceived, overly rushed plan were practically dittos of the Medicaid beneficiaries’.

Supporting the plan were, of course, the managed care organizations (MCOs), who continue to insist that everything is fine, but still fail to produce the evidence to support such optimism. They offered endless assurances about network adequacy, staff preparedness and infrastructure readiness, but their happy talk flew in the face of actual experience. Medicaid beneficiaries, one after another, shared tales of woe regarding lack of information, misinformation and disconnected calls. Yet, these incredibly vulnerable people are up against a deadline to make life-altering decisions that they are simply not prepared to make.

Then there was the testimony of the out-of-state beneficiaries. No doubt, these are good, sincere people, but the fact that they were brought in by billion-dollar MCOs and stood alone as proponents only raised more doubts, and more cynicism. Their stories fell flat among those who continue to wonder, “What about Iowans on Medicaid? What about us? Who speaks for us?”

One thing these anxious Iowans must be assured of is this: That their hospitals are on their side. Perhaps more than anyone else, health care providers know these Iowans. Hospital staff see and talk to them every day. They know Medicaid beneficiaries’ struggles and their fears. From front desk volunteers to unit clerks, physicians, nurses and technicians, hospitals know these are extraordinary patients who daily have much to overcome – and much to lose.

And understand this as well: these Iowans and their families trust their hospitals. Virtually no negative words were spoken about providers (or about the current Medicaid program, for that matter); it was clear they cherish and value the health care professionals with whom they work. They know that coordinated, patient-centered, high-quality care is not a marketing concept, but a way of practice that is realized every day in Iowa hospitals.

Hospitals must recognize and own that trust and they must stand by their record of service excellence, innovation and continuous improvement. Medicaid beneficiaries, who have been jaded by the shallow promises of the MCOs, must see that their hospitals are beside them not coincidentally, not because of politics and not because of revenue streams.

Their hospitals are beside them because that’s the right place to be. Because privatization is still wrong for Iowa and, most importantly, wrong for Iowans.

Would You Buy a Used Car from These People?

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car guyLast January, the state of Iowa went shopping for a vehicle that would carry out the governor’s order to implement Medicaid managed care by New Year’s Day of 2016. What’s transpired since then would not pass even the most fundamental test of how to shop for and obtain real value.

Any value-conscious shopper knows that a good deal starts with identifying and meeting established needs with the intent of doing more – more efficiency, more savings, more value. At the end of the day, the goal is to have something better and never to back-track.

That goal was not a priority as Iowa pushed out its request for proposals to the managed care dealers – and the results show it. Instead of new and innovative vehicles customized to respond to Iowa’s needs, the state got the base models with straight-off-the-shelf ideas and approaches. Not only did the proposals bring no innovation, they shoved Iowa’s population health progress off the road. The state didn’t even blink; its goal was seemingly not so much to have something better but to just have…something different.

And so the contracts were awarded and the managed care dealers delivered their vehicles, all shiny and new on the outside with plenty of fancy “Iowa” branding. But under the carefully polished surface were the decades-old creaky chassis and clunky drive trains that have plagued health care providers and Medicaid beneficiaries from coast to coast.

Undeterred, the dealers slapped Iowa license plates on their jalopies and state officials took them on the road to “listening sessions.” Iowans, who know a lemon when they see one, gave them an earful, with most of their sentences ending with exclamation points or question marks (or both). The state (and the managed care dealers who tagged along) “listened”…and moved on.

So Iowans talked louder. They wrote letters, sent emails and posted on social media. Their newspapers wrote stories showing how these vehicles have consistently underperformed and uncovering the questionable business practices and legal misdeeds of the managed care dealers. Then they published editorials wondering how and why the state ever made these deals. Hundreds, if not thousands of Iowans flooded the phone lines when the federal government asked for input.

Meanwhile, unable to hold up against a combination of the state’s pedal-to-the-metal timeline and growing scrutiny – not to mention virtually no public support – the managed care vehicles have started disintegrating as more issues and problems emerge. Where were the beneficiary packets? How can there be an out-of-network payment penalty when there are no networks? What about this lawsuit and that lawsuit? What about the judge who says one of vehicles needs to be recalled and junked? Where is this $51 million in savings going to come from? What will happen when all the various grace periods run out?

The state replied: stop being afraid, all is well. Don’t worry about the speed, the lack of safety (who really needs a seat belt?) or the bits and pieces shaking loose from the duct tape and chicken wire.

But Iowans don’t respond well to bad deals or condescension, so their completely understandable demand for the state to put an end to its headlong rush into the unknown and unnecessary continues.

And their hospitals – the professionals they trust more than anyone else – are right there with them. Together, we seek only what’s right for Iowa and what’s best for Iowans. And like Iowans always do, we demand value – for health care providers, for taxpayers and for 560,000 vulnerable Iowans who want and deserve real answers.

employee wellnessIHA and Iowa Business Council have partnered to produce a new report designed to help businesses, health care providers and employees work better together to improve health and control health care costs.

Using case studies from 19 large Iowa employers, “Partners for Health: How Iowa Businesses, Health Care Providers and Employees are Collaborating to Create Value” offers specific real-world examples of successful programs Iowa businesses have implemented to engage employees in their health and improve individual and organizational wellness. Sectors represented in the report include manufacturing, retail, health care, education and energy.

“Iowa businesses are deeply invested in the health of their employees,” said Michael Wells, chair of the IBC board and president and CEO of Wells Enterprises Inc. in Le Mars. “But we realize we must do more than provide health care coverage. We must engage employees in their health, incent and support good habits and work with health care providers. These case studies show collaboration is crucial.”

We applaud Iowa businesses that have joined with their employees and health care providers to ensure good health,” said Marie Knedler, chair of the IHA board and president of CHI Health Mercy Council Bluffs. “We know in the health system that coordination of care is necessary for successful outcomes. We also realize that coordination not only involves providers, but our patients and their employers working together toward prevention and wellness. That is how value is cultivated in health care.”