Buckle your seatbelts, it's going to be a bumpy ride

Oh, boy...hang on to your hats!
It looks like it is going to be a bumpy ride for healthcare providers as the federal government wrestles with the deficit. President Obama recently released his recommendations for reductions over the next ten years and compared to MedPAC (the advisory board to Congress on Medicare issues) and the Congressional Budget Office, the President's proposal is the most moderate. But that said, he is still recommending a cut of $320 billion on top of the $155 billion that was already part of the Affordable Care Act. Ouch! This would mean massive reductions in staff and services in the nation's hospitals as a result.
There is no question that if you are going to make a meaningful reduction in the federal deficit you are probably going to have to look at Medicare and Medicaid since they make up such a big part of the deficit. At the same time, when the economy continues to be on the rocks, these cuts will most certainly mean big reductions in jobs in the healthcare sector. This is going to be a tough decision for lawmakers and given the unbelievable partisanship going on in Washington right now, I really don't think an agreement is likely.
Are there any other answers to reducing the costs in Medicare and Medicaid in this country? Sure. There were several huge disappointments in the Affordable Care Act including a total lack of personal responsibility for people to take care of themselves. There is a lot of money in the law for improving health, but little incentive for individuals to be accountable for their own health. Think about it - the law really starts shifting the financial responsibility for improved health to the providers. One of the centerpieces of the law is the Value Based Purchasing (VBP) which incents providers to improve care and reduce costs for Medicare beneficiaries by holding back some of the payment at the front end and letting hospitals compete on improved quality and patient satisfaction scores. The quality measures are moving toward looking at outcomes for Medicare patients and will reward those providers with the best outcomes.
I fully support the government buying healthcare based on value. We actually expect that Iowa providers will do very well with this provision of the law given our high quality scores and lower expenses compared to other parts of the country. However, why not also incent the beneficiaries to be partners in their health? The physician can provide all the right advice to his or her diabetic or hypertensive patients, but if they won't improve their diet or take their medication, the provider gets punished by the system and ultimately there will be no cost savings.
I just got back from Mississippi where the obesity rate is the highest in the country. No offense, but folks there appear to really like their fried food. While I was there, I heard a local doctor on a panel of presenters. He did some of his training in Colorado where they have the lowest obesity rates. He said many Colorado residents like to hike in the mountains and eat granola. It is a concern if Mississippi doctors are going to be evaluated then punished for how well their patients control their diabetes compared to his medical counterparts in Colorado. Shouldn't the patient take some responsibility to be compliant and accountable for their health and the recommendations their doctor makes?
I realize it is going to be extremely difficult for a politician to stand up in front of voters and say, "I am going to work on legislation that will likely have an impact on the lifestyle choices people are making."
The largest and fastest growing part of the federal budget is related to Medicare and Medicaid. I believe it is time for us all to realize that if through taxes we are going to pay for the care of seniors and the poor, we will never afford it if beneficiaries are not required to take some responsibility for living a healthy lifestyle.
In the meantime, if the federal budget is going to be balanced by slashing reimbursements to hospitals and physicians for providing Medicare and Medicaid to a growing population and one that seems to be less healthy, I do believe we are indeed headed for a very bumpy ride.

A Mighty Band Travels to DC

On April 25, a mighty band of GRMC advocates made our way to our nation's capitol to fight for fair and equitable Medicare and Medicaid payment as part of the American Hospital Association's Annual Meeting. Susan Witt (board chair), Ed Hatcher (board chair-elect), Michelle Rebelsky, MD, (physician board member), Rachel Cain (UI graduate student and our summer intern), and I all left Iowa on a gloomy day hoping to get our voices heard.

We arrived to 90 degree weather in Washington, D.C. The temperature was the perfect metaphor for the red hot debates on healthcare reform and sizzling presentations from some Beltway insiders we witnessed. By now, anyone who reads my blog knows GRMC is a so called "tweener" - too big to be a critical access hospital and receive cost based reimbursement and too small to be a rural referral center, which also has better payment levels. As for GRMC, we got paid some $7 million below our costs last year for providing care to Medicare and Medicaid patients. Our simple goal is to push for legislation that would level the playing field and improve payment so we can continue to provide the care our patients have come to expect and deserve.

The highlights of our trip included a meeting of tweeners from around the country pledging to work together to coordinate our efforts and build a stronger voice to get our message heard. We also got educated on the latest efforts by our law makers and the Obama administration to reform healthcare. There seems to be a great deal of optimism that we will see legislation yet this year that will fundamentally change the way healthcare is delivered and paid for in our country. As we heard over and over again, "the devil will be in the details." We wait to see just exactly what Congress will develop.

When talking to many Congressional leaders specifically about GRMC's payment issues, we were heartened to hear not only a thorough understanding of the unfair payment we receive, but a strong commitment to get the issue addressed this year. We had the great fortune to have dinner with Congressman Boswell on Monday evening and lunch with Congressman Braley on Tuesday. We also meet with both Senators Grassley and Harkin later that afternoon. There is no question that our congressional delegation is leading the effort to both reform healthcare and also address this specific issue that plagues GRMC. I am grateful for their efforts. I took along stories from more than 40 GRMC patients. You can read them here.

I also want to assure everyone that GRMC leaders are watching our pennies as we push for payment improvements. I am willing to bet that members of our delegation were the only ones attending the AHA annual meeting who shared hotel rooms - the ladies in one room, the gentlemen in another. Best of all, there was a power outage in our hotel Sunday night for eight hours. After we asked, the hotel agreed to not to charge us for that day. We took turns covering meals and taxis, and several of the board members covered their own costs. I believe this is going above and beyond, given these individuals are donating their time to go and advocate for the patients served by GRMC. Finally, I personally paid the cost for our intern to attend the meeting and will also cover her summer stipend. The legislation we are pushing for would increase GRMC's Medicare payment from between $800,000 and $1.6 million per year - so obviously the investment in travel to Washington is worth it if we can make it happen!

We managed to do some sightseeing between meetings and visits on Capitol Hill. Here are a couple photos of interest:


Standing in the "Soup Line" at the FDR Memorial hoping for a little relief from our lawmakers on our Tweener issue.


Ed and Michelle contemplating the day standing at the foot of Abraham Lincoln looking at the Washington Monument in the distance.


Taking our message to Capitol Hill.


We even stopped by the "Senate ATM" to try to get our share of the Federal stimulus funds, to no avail.


Finally, Ed thought maybe he could just jump over the fence at the White House to talk directly to President Obama. We talked him out of that idea!

The postings on this site are my own and don’t necessarily represent GRMC’s positions, strategies, or opinions.

Too Important to Fail

Rural hospital CEO’s like me have a role that our counterparts in larger communities and urban areas rarely have. We usually find ourselves on contact committees for community economic development efforts, meeting with potential business leaders for possible business expansion or relocation. Competition is very high for this kind of development. I have had the good fortune to serve on the Poweshiek Iowa Development, Grinnell Renaissance, and the Waterford Group board of directors over my years here.

So, what does a hospital have to do with economic development? Plenty. Business owners consider many factors when shopping for location. Is there a supply of qualified workers? What is the real estate market? What about quality of life? Are the schools able to provide a good education? What about healthcare? No doubt, high quality and affordable healthcare is key to new business growth in any community. The goal of course is to attract new organizations to locate in our greater Poweshiek community and help grow our economy. Clearly that helps everyone…including Grinnell Regional Medical Center. Besides helping to tell the community’s story and helping to recruit new business to the area, I also have the opportunity to promote the medical center. I get valuable feedback on how we are doing. All around it is a vital part of my job.

Community hospitals in rural areas are often among the largest employers in town. We provide professional-level jobs, salaries, and wages that support the local economy. At GRMC, half my co-workers live outside of Grinnell including myself (I live in nearby Brooklyn, Iowa) and we impact the economies of several communities. GRMC is but one part in a larger healthcare sector of physician practices and their staff, pharmacies, therapists, and more. The excellent retirement communities in Grinnell rely heavily on a quality healthcare system to care for their residents who tend to use healthcare services more frequently. And, accessibility to quality health care influences the decision people make to retire to Grinnell.

It all ties back to my determination to correct the unfair Medicare payment system for tweener hospitals like GRMC, for better reimbursement rates for physicians, and more.

America’s community hospitals are too important to residents who rely on having quality, accessible, and affordable healthcare to fail. We are too important to area economic development and the local economy. We’re not asking for a bailout, we’re just asking for a level playing field.

Bringing D.C. to DSM

I had the opportunity to attend the President’s Forum on Health Care Reform in Des Moines on March 23. This forum was one of four held throughout the country to gather ideas and input on what folks want to see in healthcare reform.

Sen. Tom Harkin, Rep. Leonard Boswell, Gov. Mike Rounds of South Dakota, and Nancy-Ann DeParle, the Obama administration’s health care reform advisor, were all present at this forum, moderated by Iowa Governor Chet Culver.

Tackling healthcare reform is a monumental task. There are so many layers that are interconnected. Accessibility, cost, insurance coverage, Medicare, Medicaid, facilities, and more…it’s hard to know where to begin.

Rep. Boswell made two opening comments…one about the inequity of Medicare payment between states, with Iowa at the bottom of the list and one about the Medicare tweener hospital issue that affects GRMC, seven other Iowa hospitals, and about 400 community hospitals across the country. It was great to hear our Congressman tell our story to another audience. He actually handed our advocacy materials on this issue to the new Healthcare Reform Leader in the Whitehouse, Ms. DeParle.

I feel hopeful that the beginnings of reform will happen this year and that the tweener issue will be addressed. Senate Finance Committee leaders Sen. Grassley and Sen. Max Baucus, (D-MT) are in the best position to make sure our legislation moves forward. Both have gone on record in support of fixing the unfair Medicare payment system and the situation it has created for tweener hospitals like GRMC.

I’m gearing up for another visit to Washington, D.C. in a few weeks for the annual meeting of the American Hospital Association along with several of our board members. Many of you shared some incredible stories about your experiences with GRMC for a publication I’m taking to my meetings with Congressional leaders during that time. Thank you for taking the time to do this. My intention is to put names, faces, and the words of real people who appreciate what is available at GRMC in front of these decision-makers to illustrate why communities like ours need a strong and healthy hospital.

In the meantime, I keep telling GRMC’s story to make a change for the better.

You Never Know Who You Might Meet

While I was in Washington, D.C., recently, I had a few interesting moments.

The first night, I was waiting in the hotel bar waiting to meet other NRAC (National Rural Advisory Committee) members for dinner. Two people sat down next to me and were discussing restaurants in the area and they asked the bartender if he had heard of a particular hot spot. He had not, so they asked me and I reported that although I had heard of the restaurant, I had not dined there. It seemed to me that they were looking for recommendations, so I pulled out the list of about 20 restaurants the concierge had printed off for me and began to point out places where I had eaten in the past and which ones I thought they might enjoy. The gentleman then inquired about what I thought about the hotel and I said I thought it was a great place to stay. This is the hotel the government uses for the NRAC when we are in D.C. for this meeting. He smiled and told me he was glad to hear I liked the place, since he was the general manager! The hotel was the Sofitel, a French hotel. He then bought me a glass of wine and we had a delightful conversation until my colleagues arrived.

The next day, I was leaving the meeting room on the second floor and was invited into one of the elevators with the general manager and two other gentlemen. He greeted me and asked me how my dinner was the night before. I told him it was excellent and went on to say with a smile that we had eaten in his restaurant. The other men were speaking French. The elevator abruptly stopped and the control panel went dark. We were stuck! One of the men in the elevator with us was the French ambassador to the United States. He had just given a speech to the media down the hall from our meeting room. We engaged in a wonderful conversation about our new president and his popularity in Europe, French versus California wine (we agreed to disagree on which was better), and his take on the global economy. Meanwhile, the general manager nervously talked in French on his cell phone to his maintenance staff outside feverishly trying to open the door.

At one point the lights went off so all four of us powered on our cell phones to light up the elevator. I showed them a silly picture I had taken the day before of the U.S. Capitol when I was on the Hill meeting with staff members of our congressional delegation on building support for the legislation they have introduced on the “Tweener” Medicare payment issues. I explained I tried to take the roof off the Capitol to see if Mr. Obama was inside!



The maintenance staff opened the door about 40 minutes later and we were all pulled up and out of the elevator which had been stuck between floors. I saw the general manager again later that evening and he bought me another glass of wine with a twinkle in his eye and said although he had never been stuck in an elevator before, he was sure glad to have been in there since the ambassador was on board. I must admit, I was glad to have been there as well, because it is not everyday a country boy from Iowa gets to have a one-on-one conversation with an ambassador!

On my flight home from Washington, Karen and Jim Nussle were on the same flight. Unlike the French ambassador, I do know Jim pretty well going back to his days as the U.S. Congressman from northeast Iowa. We worked together on a number of rural health issues. He was a member of Congress that truly cared about rural healthcare, understood the issues, and was a strong voice. I had not had a chance to talk with him much since has appointment as the Director of the Office of Management and Budget. You know; the guy responsible for helping to draft the federal budget and responsible for managing the largest financial enterprise in the world…the U.S. Government! Basically he was the CFO for America. We talked between flights for about a half hour and I was just mesmerized as he talked about daily meetings with the President…sitting in Situation Room at least one day a week. He was in the room for every major decision made by the President over the last couple of years!

For a government wonk like me, the conversation was tantalizing. What was President Bush really like? How about Chaney? Jim was gracious and friendly as always and seemed to enjoy talking about it all in past tense. I asked if he was relieved to be out from what must have been overwhelming stress and a look of relief spread across his face. He did say it was absolutely fascinating…the understatement of the week!

You just never know who you might run into when traveling to our nation’s Capitol…for me it was a very memorable 24 hours.

The postings on this site are my own and don’t necessarily represent GRMC’s positions, strategies, or opinions.