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King v. Burwell
Another Summer ‘Blizzard’ is Upon Us

Summer BlizzardA blizzard in late June? Is it even possible? Yes, and I’m afraid it will only continue…

Late this month, the Supreme Court is expected to issue their decision on King v. Burwell – a highly charged case that challenges the legality of health insurance subsidies to low- and middle-income people enrolled in federally-based exchanges or marketplaces.

More specifically, if these people live in Iowa and 33 other states where the federal government operates the health insurance marketplace, future subsidies will be at risk.

If the Supreme Court rules in favor of those challenging this critical piece of the Affordable Care Act (ACA), how would subsidized Iowans be affected? Thanks to a newly released Kaiser Family Foundation interactive map, we can view 2015 enrollment data (Source: U.S. Department of Health and Human Services) that is broken out by each state’s marketplace.

The Kaiser map looks at the total number of residents in each state that would lose premium assistance, and the total dollars in subsidies that would be lost. In addition, should the Supreme Court nullify the subsidies provided through the federal marketplaces only, this interactive map shows the size of the lost subsidy for the average resident and the potential increase to their premiums.

On a national basis, about 6.4 million Americans could lose subsidized coverage, worth about $20.4 billion annually. Those who currently receive subsidies for their health insurance coverage would see an average premium increase of 287 percent if they were to pay the full cost of coverage.

Based on the 2015 enrollment – if federal marketplaces are not allowed to provide subsidies – here’s what it would mean for Iowa:

  • 34,172 Iowans would lose tax credits. (Iowa would rank 27th compared to other states in terms of people losing subsidies.)
  • Total monthly tax credit dollars at risk: $8,987,236 (Iowa ranks 8th lowest when compared to other states.)
  • Average tax credit per Iowa enrollee: $263 (Iowa ranks 20th highest, with the national average being $273.)
  • Percent increase in average premium: 244% (Iowa ranks 20th highest, with the national average being 287%)

Many more Iowans qualify to receive subsidized premiums in the Iowa marketplace but have elected to remain outside this exchange. In fact, based on an earlier Kaiser Foundation report, Iowa ranks second among other states with having the lowest percentage of its population enrolled in the public marketplace. A May 11th Des Moines Register article suggests that just 20 percent of Iowans who could have qualified for premium subsidies in 2014, took advantage of them.

The upcoming Supreme Court ruling has a multitude of implications in Iowa and around the country. Political and legal uncertainties continue to cause a seemingly unending blizzard in our healthcare snow globe. It’s never too early to prep your snowblower!

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Healthcare Information:
Converting Water Drops to a Tsunami

Water Drops Become TsunamiI am a firm believer in the people. If given the truth, they can be depended upon to meet any national crisis. The great point is to bring them the real facts.
Abraham Lincoln

A free-market system is most efficient when consumers have relevant facts about the products and services they desire. After all, knowing the cost, features and benefits of each consumable good or service is the first step in having informed purchasers.

But unfortunately, this is not yet reality within the U.S. healthcare ‘system.’ A group of highly-imaginative, energetic people armed with the world’s largest chalkboard could not purposely design a more complex, dysfunctional system if they had tried. To put it mildly, our currently-structured healthcare system is so complicated and rife with economic conflict that every attempt to simplify it actually complicates it further.

An April Health Tracking Poll from Kaiser Family Foundation indicates that very few Americans use quality and cost information on hospitals and doctors – and the reasons are numerous. First of all, finding access to updated comparative quality information is a hit-and-miss process, with only 13 percent of Americans claiming to have seen quality information comparing hospitals or doctors (10 percent) during the last 12 months. Of those people, only four percent used the information for hospitals while just six percent for doctors. As for pricing information, a scant six percent saw comparative pricing information for hospitals or doctors in the past year, and only half as many actually used the information.

These numbers are dismal. But the results should not suggest that Americans are indifferent in desiring this information. It is the complexities of our system that are preventing those who seek quality and affordable healthcare.

‘Reputation’ and ‘location’ appear to dominate the choice of providers we use, possibly trumping any immediate urge to seek ‘quality’ and ‘price’ information. For the time being, we haven’t made much headway in the development of reliable quality and price information. This is unfortunate since the healthcare sector sucks up about one-fifth of our economy!

Healthcare data needs a ‘Steve Jobs’ moment. As many Apple products revolutionized social and recreational connectivity through innovation, the creation of a huge data ‘bank’ can revolutionize healthcare. But this will only become reality when we desire to make the connection of quality and price to serve our best interests.

Can this be done? You bet it can.

Mount RushmoreIf humans can put a man on a moon using technology from the 60s*, dig a tunnel under the English Channel (31.4 miles long), chisel four American presidents from a granite mountain top, build pyramids in the middle of a desert (approximately 4,700 years ago), and perform other countless miraculous marvels – why can’t we figure out how to consistently deliver basic healthcare information to Americans (utilizing advanced technology we have today)?

The common thread that ties together each of these amazing feats is just one thing: Having the WILL to succeed. When it comes to healthcare, we appear to be a fractured country. We have failed to define our goal to engage Americans to be more involved with our health and, consequently, our subsequent care. Yes, our own behaviors determine our health, but we should not have to blindly seek the care we need.

Metaphorically, each of us represents a drop of water, placed in a vast ocean. By ourselves, we cannot cause a tsunami of change (or revolution) without first coming together with a massive number of other water drops to make the difference in how we desire to receive care in the future. Tsunamis have developed in other markets, and it is only a matter of time before we have monster waves appear in healthcare.

Each drop of water can make a difference!

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*Some Americans believe that having a man on the moon was merely a fabrication in the back lot of a studio!

Medical-Error Fatalities in Iowa?
Here’s a Calculated Guess –
Up to 4,300 Iowans Annually

Guessing Medical Errors…Yes, an’ how many deaths will it take until he knows
That too many people have died?
The answer, my friend, is blowin’ in the wind
The answer is blowin’ in the wind.
Bob Dylan, Blowin’ in the Wind

In healthcare, we have oceans of data but only puddles of useful information. The data comes in various forms, typically from healthcare providers who care for us and from the insurance vendors who enroll and cover us. Without question, the data generated within our healthcare system is abundantly voluminous.

During the last year, I have spent time writing and presenting about preventable medical errors. I recently was asked by two individuals (one representing the insurance industry and the other employed within the healthcare provider community) to render a guess about specific medical error data within Iowa borders – relating to the number of patients who were lethally harmed. I assured them that I could not find anything local – only national estimates were available. With this said, national patient safety experts, such as Dr. Ashish K. Jha, Dr. Peter Pronovost, Dr. Don Berwick and Rosemary Gibson, among many others, confirm that patients harmed in our country is nothing short of a national epidemic.

In a strange way, this request was similar to the Wizard of Oz being asked to provide a heart, brain and invoke courage. But in this particular case, I was asked to unearth local data about the medical errors found in Iowa. I suspect not even the Wizard could provide this treasure trove of critical public information!

But, out of curiosity, what IF we backed into these numbers using national estimates? After all, national data on medical errors are estimations that emanate from available (but imperfect) empirical knowledge.

Yes, many types of national and local organizations are working diligently to make our healthcare delivery system safer. But until we have a true measurement on the actual prevalence of medical errors to serve as a starting point on a local and national basis, how can we possibly improve or assume progress is being made? For example, are we measuring ‘process’ rather than ‘outcomes’? Are study methods rigorously evaluating improved care in a transparent way? To legitimately improve quality outcomes, we must measure what matters most, not just what is most convenient. Easier said than done, but many times we confuse activity with progress, which only prolongs egregious results.

From information found in past studies, reports and evidence, we do know that about 25 percent of all patients are harmed in our country by medical mistakes. The Institute For Healthcare Improvement estimated 15 million medical mistakes occur in our hospitals each year. In 1999, the Institute of Medicine (IOM) released ‘To Err is Human,’ suggesting that perhaps as many as 98,000 Americans die in our hospitals each year as a result of preventable medical errors. In 2013, another report was published in the Journal of Patient Safety conveying that up to 440,000 Americans die in our hospitals due to these mistakes.

So which number is most accurate – 98,000 or 440,000? We simply don’t know. Dr. Lucian Leape, a physician and professor at Harvard School of Public Health and a pioneer on patient safety, was a key contributor to the IOM estimates. Dr. Leape has since acknowledged the 440,000 estimate is more likely to be accurate.

Using federal and state data from the Kaiser Family Foundation website, total hospital admissions in the U.S. during 2012 was 34.8 million. Of this, Iowa had about 340,000 total facility admissions, a number substantiated by Iowa Hospital Facts.

By calculating the death per admissions nationally, using 98,000, 440,000 and an arbitrarily-selected mid-point of 250,000 lives, we can then use each ‘conversion’ factor to determine what the estimated fatalities are for individual states based on each national estimate.*

The slide below illustrates the estimated number of medical error fatalities for Iowa and five neighboring states, using the three national estimates. When factoring the 98,000 fatalities as reported by the IOM, Iowa would have an estimated 959 lives lost annually within our hospitals due to preventable medical errors. This number is similar to the population of the city of Lansing, Iowa. If national fatalities are about 250,000 lives annually, a calculation of 2,444 patients die annually within Iowa, or about the size of the city of Kalona. Finally, the 440,000 estimate equates to about 4,300 Iowans dying annually due to hospital medical errors – roughly the size of the city of Jefferson.

Estimated Medical-Error Fatalities

Within the slide, due to the larger populations of Minnesota, Missouri and Illinois, Iowa compares favorably with lower-estimated fatalities. However, the estimated fatality numbers found in Iowa are greater than those found in the less-populated states of Nebraska and South Dakota.

If any of the guesstimates are correct in the next 10 years, Lansing becomes the size of Norwalk, Kalona the size of Marshalltown and Jefferson the size of Ankeny. Isn’t it time to start reporting, measuring and documenting ‘actual’ data and stop guessing and theorizing? Unfortunately, we live with faceless statistics when it comes to medical errors.

Bob Dylan had it right. How many more lives have to be lost before we do the right thing?

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*CAUTIONARY NOTE: Using the same national factor for every state assumes that outcomes from each state are equal to one another, which is a BIG assumption. Thanks largely to the Dartmouth Atlas of Health Care, we do know that care-quality varies wildly in different parts of our country, state and even across town. Healthcare, like politics, is all local, but we don’t know whether using a national norm is better or worse than the Iowa ‘norm’ because fatality metrics due to medical errors within each state are elusive. Therefore, quality-adjusted care was not baked into these estimates.