Health Reform and Medicaid Managed Care

I keep lists. While I do not believe there is a name for someone who keeps lists as there is for one who collects stamps — a philatelist, or a keeper of postcards, known as a deltiologist — I am simply a keeper of lists. One list is of names that are actually what the name says the object or geographic location is. For example, in the South Island of New Zealand, southeast of Queenstown, there is a range of mountains called the Remarkables. They are pristine, beautiful and truly remarkable. Another example is a swamp in northern North Carolina and Virginia called the Great Dismal Swamp, the largest remnant of a swamp habitat that once covered more than a million acres. A final example is the Trail of Tears. It was the route that more than 16,000 Cherokee Indians took from their homelands in the southern United States to Oklahoma. It is estimated that more than a third of those Cherokee people died on the Trail of Tears. Another list I keep is names that do not signify what the name indicates, such as the Big Ten Conference in collegiate sports, which has 14 teams, or the Fox News Network, whose motto is “fair and balanced.”

Iowa is currently undertaking a new program to turn its Medicaid program from a state-government-managed program of medical help for poor and disabled populations to a for-profit, private managed-care approach to administer the medical needs for these populations. The title of this program is the Iowa High Quality Health Care Initiative. I am holding judgment as to which list this program with the ambiguous name would more likely be appropriately added.

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Health Reform and Patient-Centered Health Goals

Every other Wednesday morning, I attend our hospice interdisciplinary team meeting. This meeting is one of the highlights of my week. Four years ago, we began introducing each discussion of new and current patients with that patient’s stated goals. I always make notes directly on the printed list of patient names provided at this meeting when certain facts and information about a patient catch my interest. Often, it is the patient’s goals that I write down. The goals are many and varied. A common goal is for patients to stay in their own homes. Other goals include family events, such as attending a wedding or awaiting an upcoming birth in the family. I have heard goals including finishing a scrapbook, continuing to work on a classic car, taking a grandson to a basketball game, or traveling to see relatives. The personal nature of this way of starting the discussion of a patient’s status at the hospice-team meeting places the focus precisely where it should be — on the patient.

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Health Reform and Aligned Incentives

In further discussing the now-dissolved CoOportunity Health, as well as Governor Branstad’s proposed plan to turn over the Iowa Medicaid program to a private managed-care company or set of companies, I was going to title this blog entry Health Reform and the Need for Nonprofit Entities, which may, in the end, be what the readers of the blog may feel is my conclusion. Instead, I chose the current title to reflect a refinement of my views over the years. To understand this refinement, I want to start this post by going back to 1993.

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Health Reform and CoOportunity Health

It is with sadness that I acknowledge the takeover of the cooperative health-insurance company, CoOportunity Health, by the Iowa insurance commissioner. I have touted CoOportunity Health many times in this blog, and I have strongly felt it was a critical part of the current health-reform efforts in Iowa. My sadness is even greater for the 100,000 individuals who had insurance with CoOportunity Health. These individuals’ confidence and coverage are jeopardized because of this action. The health and peace of mind of friends, family, and patients who I know are insured by CoOportunity Health are a major concern for me at this time.

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Health Reform and Drugs, Drugs, Drugs

The good news. On Wednesday, November 19, CoOportunity Health, the Iowa-Nebraska health-care-cooperative insurance entity that I have touted in several blog posts, insured its 100,000th person for health-care coverage. As I have said before, its projection for the end of this year, its first year of operation, was 15,000 policyholders.

The bad news. CoOportunity Health announced that next year, 2015, it would not participate in the Iowa Medicaid expansion for individuals whose incomes were between 100 to 133 percent of the federal poverty level (FPL). CoOportunity Health simply could not sustain the financial losses for this group of 11,000 Iowans. From my non-insurance and non-actuarial level of understanding, the major issues were 1) the federal government being unwilling to allow for a separate, more accurate actuarial premium amount for this population of newly insured individuals and instead requiring this population to be part of the entire population’s actuarial projection of CoOportunity Health’s premium holders, and 2) the high cost of drugs for treatment of diseases such as Hepatitis C and HIV. For now, this group of individuals will be part of the Medicaid program instead of utilizing the Exchange and being part of the private insurance system.

In this post I’ll discuss several incidents of how the high cost of medicines has negatively affected my patients and the health-care system. The question is: Can health reform, or for that matter the health-care system, survive the upward trajectory of the price of medications?

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Health Reform and the 2014 Iowa Senate Race

I ask the few remaining independent voters — those who have not yet decided for whom they will vote in the U.S. Senate race between Iowa State Senator Joni Ernst and U.S. Congressman Bruce Braley — to give me two minutes of your time.

I am Dave Carlyle, a family physician and hospice medical director from Ames. I grew up in Denison. This is where, during my summers home from college, I learned the value of hard work by sweating 10 hours a day at the Iowa Beef Packers slaughterhouse. After medical school at the University of Iowa and family-medicine residency in Waterloo, I practiced nine and a half years in Kossuth County. I have now practiced 21 years in Ames. My family has been serving Iowans for 160 years. My two daughters, both of whom are physicians, also care for Iowans.

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Health Reform and Health Coaches

Preparing for this blog entry and for an upcoming talk regarding health coaches, I asked one of my health coaches to share a memory she had about when she had connected with one of my patients in an especially meaningful way. To put this memory in perspective, my health coaches see my diabetic patients and patients who are having Medicare physicals before I see these patients. My health coach shared a memory from one of these preparatory visits with a diabetic patient who had recently learned of the violent death of her sister. My health coach spent a few minutes with this grieving patient before I entered the room. Because the patient had known and worked with this health coach for more than a year, they were able to connect, and I believe that the patient felt fully supported by my practice in the person of this health coach.

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Health Reform and a Governor Hatch Administration

One of my proudest moments, which was photographed — the photo is displayed in my office at the clinic — is the 1998 signing ceremony for the Healthy and Well Kids in Iowa (HAWK-I) program. I stood with representatives of several medical societies and an Iowa family that included a mom and three daughters while Governor Branstad signed into law a program that helped to make Iowa a leader in the nation in the percentage of insured children.

I worked long and hard with Democratic legislators, Republican Representative Brad Hansen, who also is in photo, and Republican Senator Nancy Boettger to create a program made possible by federal funding that created a public-private system to insure children. For my efforts, in 1999 I received a national Public Health Award from the American Academy of Family Physicians. During the negotiations for the HAWK-I bill, I clearly remember that then-Governor Branstad did not want a quasi-independent board to supervise the program.  He stated that in his administration he did not want to add “silos” that prevented him from overseeing the actions of state government.

Fast forward to 2013-2014.

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Health Reform and Reminiscences of Hospice Patients

This blog is dedicated to a good friend and patient of mine who died last month in hospice. I had taken care of her for 15 years. We had many remarkable and enjoyable conversations regarding her growing up in a home where her father was a physician. She thought very highly of her father and the profession of medicine. She knew the value of good medical care and how much it means to all of us, even physicians and their families. She had seen the human side of medicine in its effects on her father and her family.

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Health Reform and Answers from Iowa Candidates

Over the past months I have been inundated with requests for campaign contributions, and I looked for a way in which to make informed decisions about which candidates to support. In last month’s blog post, I shared two questions I posed to Iowa candidates running for U.S. Congress, the Iowa governorship, and the Iowa Legislature. The questions asked were an effort to engender better knowledge of just two of the complex issues surrounding the Affordable Care Act (ACA). At that time, I said I would make a $1,000 campaign contribution to the candidate who provided the most-specific answers to my questions and allow the responses to be posted on this blog. If I received thoughtful responses from several candidates, the $1000 contribution would be shared.

To date, I have received only one response, that of Senator Jack Hatch, who is running for Iowa governor. I have posted his response below. I sincerely appreciate Senator Hatch’s response. The opportunity for candidates to submit a response to my questions remains open until August 15. S.S. McClure, editor and publisher of McClure’s Magazine, once said, “The vitality of democracy depends on popular knowledge of complex questions.”  I seek candidates’ answers for just two of the many complex questions surrounding the ACA. Please let the candidates you support know about this campaign-contribution opportunity. Help me share “popular knowledge about complex questions.”

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