Opinion Column

Answers From Iowa

The Des Moines home of the Chicago Cubs’ AAA farm team boasts of being “one of the top minor league facilities in the country.” This might also be an accurate description of the State of Iowa’s political status, in which its quadrennial presidential caucuses help determine who advances to the Big Show.

If this were a presidential election year, a recent report by the Iowa Committee for Value in Healthcare would be reaping a lot of attention. Its sponsors say they know the “secret sauce” that allows Iowa to care for one of the highest percentage of “old old” in the country on modest Medicare reimbursement and yet still score near the top of the nation on a slew of quality indicators.

Alas, the report was released in Iowa in an off year, so it has passed underneath the radar. But since the inveterate do-gooders who sponsored this work offered me an all-expenses-paid trip from Chicago to Des Moines to moderate a panel unveiling it, I can’t resist sharing its conclusions.

First, let me set the scene. The Iowa committee’s three sponsoring groups are the Concord Coalition, a national, non-partisan group advocating government fiscal responsibility; the University of Iowa College of Public Health; and the Iowa Healthcare Collaborative, a physician-led “partnership for quality, patient safety and value.”

Now, imagine a two-hour panel that includes a current and former president of the state medical society with no mention of malpractice as the key to health care reform. A panel where a private employer explicitly rejects increased cost shifting as a viable long-term strategy. And a presentation in which two state legislators in the audience, one Republican and one Democrat, spend the entire time listening carefully. Clearly, we weren’t in Washington anymore.

The Iowa report doesn’t suggest how to provide health insurance for every American. What it does address, however, is how to structure our health care system to provide the highest quality care for the least amount of money. That’s a pressing question of national economic security today and will be even more so if (when?) we begin adding insurance coverage for tens of millions more Americans.

Its five principles are: achieve fiscal sustainability through high-value care; innovate through collaboration; expand the role of primary care; increase wellness and prevention; and promote individual involvement in obtaining high-value care. Those principles aren’t new. What is intriguing are the details.

Take “fiscal sustainability.” Iowa receives the eighth-lowest per capita Medicare reimbursement, has the second-highest percentage of residents aged 85 and over and yet ranked second in a Commonwealth Fund report of high-performing state health care systems on a slew of quality indicators. The Iowa Committee says that regular public reports on provider quality and targeted initiatives to improve care efficiency and safety are paying dividends. Please note that saving money and lives in health care is linked here explicitly to changes in the delivery of care, not insurance for it – a theme repeatedly sounded by Dr. Michael Kitchell, a neurologist at the McFarland Clinic and president of the Iowa Medical Society. Yes, reimbursement incentives must change, but there is plenty we can do today.

Collaborative care efforts in Iowa, meanwhile, showed a startling diversity. I’ve never seen an industrial union (the United Auto Workers) and an agricultural advocacy group (the Iowa Farm Bureau) paired in an initiative to improve care. In Iowa, providers joined both of those groups in the Iowa Chronic Care Consortium to launch an innovative telehealth program.

In another effort, Pella Corporation, the window maker, joined with providers and the community to reduce high rates of emergency room use. However, instead of just increasing employee co-pays, Pella did an analysis of root causes that resulted in it sponsoring construction of an off-hours outpatient clinic and tracking usage and employee health status. “Our challenge is how to drive the costs down without shifting the cost to our people,” said Karin Peterson, Pella’s vice president of human resources.

The theme of seeking long-term solutions that benefited all community stakeholders resonated through each of the examples of grassroots change. These included establishing a safety net system based on primary care; bringing in a foundation devoted to amateur sports to help run a “Lighten Up Iowa” weight-loss initiative in the central part of the state; and promoting consumer involvement in health care decisions through a health literacy program.

I asked Dr. Tom Evans, founder and president of the Iowa Healthcare Collaborative, whether the Hawkeye State’s recipe would work elsewhere. Evans, former chief medical officer of Iowa Health System and a past state medical society president, responded that every community thinks it’s got the toughest challenge. That’s true whether it’s New Yorkers boasting of their famous skepticism or Iowans noting that in the small towns of the Midwest, you’ve got no choice but to match words with deeds.
“We don’t just need more reimbursement with the current fragmentation,” said Evans. Instead, he intoned three key attitudes all stakeholders had to adopt: relationship, responsibility and communication.

None of those attributes can be mandated by Congress and none is on any interest group’s wish list. Nor has Iowa achieved health care nirvana. There are plenty of political disputes and nagging problems, not least of which is the shortage of primary care physicians.

Still, what Iowa has achieved is significant. The state has shown that stakeholders as diverse as farmers and big corporations can work with a public-minded group of doctors, hospitals and health services experts to make chronic and acute care more efficient and effective. Perhaps the political and media elite shouldn’t wait for an impending presidential election to pay attention to what Iowa has to say.

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of
Demanding Medical Excellence: Doctors and Accountability in the Information Age.