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					                                 Advisory Group
                                Meeting Summary
                            Tuesday, January 22, 2008



Members Present
Chris Atchison, University of Iowa College of Public Health
Jane Borst, Bureau of Family Health, Iowa Department of Public Health
Todd Buchacker, Planned Parenthood of Greater Iowa
Steve Eckstat, DO, Iowa Academy of Family Practice
Kelly Huntsman, Primary Health Care, Inc.
Kathie Lyman, Polk County Medical Society
Julie McMahon, Iowa Department of Public Health
Eric Nemmers, Iowa Medical Society (for Karla Fultz McHenry)
Andy Penziner, Child Health Specialty Clinics
Kate Puetz, Iowa Pharmacy Association (for Tom Temple)
Dana Shaffer, DO, Des Moines University
Mikki Stier, Broadlawns Medical Center
Sara Schlievert, Oral Health Bureau, Iowa Department of Public Health (for Dr. Bob Russell)

Guests
Senator Jack Hatch
Doreen Chamberlin, Iowa Department of Public Health
Marvin Firch, Iowa Department of Public Health
David Fries, Iowa Prescription Drug Corporation
Cheryll Jones, State Board of Health
John L’Estrange, Iowa Prescription Drug Corporation
Rochelle Spinarski, Rural Health Solutions
Jodi Tomlonovic, Family Planning Council of Iowa
Cece Zenti, Polk County Medical Society
Student (attended with Dr. Eckstat)

Network Staff – Iowa/Nebraska Primary Care Association
Sarah Dixon Gale
Bery Engebretsen
Deb Kazmerzak
Tori Squires

Welcome & Introductions
Chris Atchison, Advisory Group Chair, welcomed the group and asked everyone to introduce
themselves.




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Legislative Commission on Affordable Health Care Plans for Small Businesses and
Families Update and Discussion
Senator Jack Hatch thanked the group for their invitation to speak and noted the importance
the Network has had to patients and providers who did not have a voice before the Network
was established. Sen. Hatch indicated that the Network’s emphasis on providing health care to
the underserved has filled a needed gap in the state.

Sen. Hatch provided an update about the Commission, noting the Commission was stakeholder-
driven and led by an outside facilitator from the National Council on State Legislatures.
Comprehensive data can be found in the final report, which includes recommendations in the
following key areas: universal coverage, medical home, telehealth, chronic diseases, workforce,
wellness and prevention, and cost containment.

Sen. Hatch then provided specific information about the five bills he plans to introduce based on
the work of the Commission. The first bill will include universal coverage, medical home,
telehealth, and cost containment. Specifically, the bill will move toward universal coverage for
children under 18 years of age initially. The goal is to mandate coverage for children under 18
by December 31, 2009, as 44,000 children in Iowa do not have health insurance. Of the 44,000,
21,000 qualify for Medicaid or hawk-i, while 23,000 are from families with higher incomes.
After all of the children are covered, adults will be added as funding is available based on a
sliding scale with priority given to low income adults. A Medicaid waiver will be pursued as a
way to provide coverage to uninsured adults.

The medical home portion of the bill will mandate all persons receiving health care through a
public program have a medical home. The provider can be a physician, a nurse practitioner, or
a physician assistant. Creating medical homes will allow the State to place greater emphasis on
the prevention of new diseases and the management of chronic diseases. Providers will be paid
to offer preventive care and services. The National Committee for Quality Assurance’s (NCQA)
definition of medical home has guided the development of the medical home initiative.

The telehealth system portion of the bill will allow the State to take advantage of the Iowa
Communications Network and a system already being used by Iowa Health Systems, which was
funded by a grant from the FCC. This system will tie all of the rural hospitals into one network
and an E-Health Council will be created to provide guidance throughout the development and
implementation of this system. The competitiveness and business factors among the hospitals
will be considered as well.

Sen. Hatch touched briefly on the other four bills, which will focus on the promotion of wellness,
a consumer advocate for health care (mainly insurance), workforce shortages, and whistle-
blowing.

Atchison asked if there were questions or comments and asked Sen. Hatch to expand upon his
thinking around providing care to underserved populations. Sen. Hatch responded that
Community Health Centers (CHCs) have traditionally served as medical homes, as have Rural
Health Clinics (RHCs) and free clinics. These entities serve a population below what was
typically considered to be the safety net provided by Broadlawns and The University of Iowa
Hospitals and Clinics. In the guiding principles agreed upon by the Commission, the group
underscored the need for medical homes and prevention. Additionally, Sen. Hatch reported he



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had reviewed several articles where medical home initiatives within CHCs eliminated racial
disparities. The goal is to treat people while they are healthy and the long term goal is to
establish a medical home for all Iowans. There is an inherent right to health care and if the
State does not meet its obligation of providing universal coverage to all Iowans, the State has
failed.

Borst asked how barriers other than income are being addressed, citing several examples of
children who financially qualify for Medicaid, but who are not allowed to enroll because of
barriers such as legal resident status or having some catastrophic coverage. Sen. Hatch
indicated these types of barriers will be addressed and referenced a Health Insurance Company
Association resolution, which aims to prevent exclusion of health insurance based on preexisting
conditions, and which will allow for portability and a minimum standard of benefits. The goal is
to have an individual mandate for insurance, but this has to be a transition and it will require
the public and private sector to work together. Sen. Hatch also explained the concept behind
the Health Care Insurance Exchange, which will help the state move toward universal coverage.
Private insurance companies will be allowed to bid on plans developed by the Exchange. The
Commission also wants to allow individuals up to 25 years old to remain on their parents plan
unless they get married.

Penziner noted that attempts at universal access have been complicated with high
administrative costs and asked Sen. Hatch how the State plans to address this issue. Sen. Hatch
responded that universal access is the goal and that he does support a single-payer system.
This is a lofty goal, which the State had to move away from for the time being. If the State
does not begin to address this issue, there will be a catastrophic event that will force the State
toward a single payer system, but it will not be easy or pretty. If all of the stakeholders come
together now, this transformation can occur more easily and less painfully. High administrative
costs may be an issue the State has to deal with.

Engebretsen referenced several Commonwealth Fund studies, which looked at health care
initiatives and reform in other countries. Each country is doing something well, but none of the
countries are doing everything well. The goal should be to pull all the great initiatives and
policies out of these countries to make the best system possible. Sen. Hatch agreed and noted
that much of the transformation has to do with changing and bending culture. The federal
government is going to have to get involved, too. While States can serve as test sites, a
national strategy will be required to fix the broken system.

Shaffer noted that access is more than a medical home issue. Issues such as transportation,
particularly for patients accessing IowaCare, also need to be considered. Sen. Hatch agreed,
but noted that the concepts behind a medical home would solve the transportation issue.

Atchison commented that there is a need for an integrated delivery system to enable successful
medical homes and asked what parallel efforts will support the public system’s development.
Sen. Hatch replied that there is a need for more support for the public system. The
reimbursement rate for Medicaid is always an issue and there is a need to reward safety net
providers and medical homes with higher reimbursement rates.




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Jones added that prevention is the top priority. The State has to do a better job of integrating
the public and private sectors. There is an economic disincentive for private providers to see
patients funded through the public system.

Penziner noted that boundaries are placed between oral, mental, and physical health, which
seems to make system change difficult. Sen. Hatch responded that medical home is supposed
to support the provision of all the different types of health care services, including visual health.
The Exchange discussed above will most likely be placed within the Department of Management
to get away from some of these boundaries that have unintentionally been created. Sen. Hatch
also updated the group about how he and Rep. Foege plan to handle the development of the
bills. There will be a joint chamber dialogue between the House and Senate so the bills in each
chamber are as similar as possible.

Chamberlin responded that collaborative work has already been happening across State
agencies and suggested that the RHCs and Community Mental Health Centers need to connect
with the FCC telehealth grant since many of them are housed within hospital systems. She also
indicated that there is a need for health sector involvement in the regional transit authority local
planning work.

Atchison thanked Sen. Hatch for his time, insights, and for spearheading this major initiative.
Sen. Hatch thanked the Network for allowing him to provide an update and encouraged the
Network members to advocate for real health care reform. He also thanked IA/NEPCA for
providing information and ideas around medical home.

Legislative Strategy Discussion
Atchison asked Engebretsen to provide an overview of the response to the Commission’s
recommendations, which was drafted by Network staff. Engebretsen noted that policy should
drive funding and highlighted key points in the document shared with Network members.
Engebretsen asked for feedback, which will be collected and considered during the development
of the final response, and will be submitted to Sen. Hatch.

Chamberlin shared the workforce report recently completed by the Iowa Department of Public
Health and indicated the report will be helpful in framing the workforce issue.

Penziner commented about Legislative Action Step #5 noting that the response deals more with
data that can be shared, not the mechanism for sharing data, which seems to be the intent of
the action step. Several members also noted the need to better understand which organizations
around the state are using telehealth as well as develop a common definition of telehealth.

Shaffer commented that there is already an effort underway to define telehealth at the national
level and suggested that should be used to inform this discussion. Firch and Chamberlin also
noted that Great Plains Telehealth Resource and Assistance Center has a telehealth definition
that could be considered. Starting with a common definition should serve as a building block.
Eckstat reported that he had a conversation with Sen. Hatch where he highlighted the need to
consider telehealth and EMR/EHR as pieces of a larger category.

Lyman shared that efforts at the national level need to inform the EMR/EHR discussion. The
Centers for Medicare and Medicaid Services (CMS), for example, is determining standards and



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until they are released it does not make sense to undertake an enormous effort. EMR is
unaffordable to most organizations and implementation is premature.

Jones agreed citing a Commonwealth Fund study that showed that virtually no EMR systems
have been successful. There are huge problems and the systems can costs millions of dollars to
purchase and a lot to maintain. Jones would like to see input obtained about successful
telehealth systems noting that her organization has a web-based system. The solution has to go
beyond an EMR.

Chamberlin indicated that a definition of telehealth was offered in the workforce report.

Atchison noted that he was hearing affirmation that an integrated delivery system must exist in
the public sector. The Network tries to be this system, but what does this mean within the
collaborative as the state tries to define medical home?

Engebretsen responded that there are a lot of challenges just at the safety net level, but that a
pilot around medical home at this level could go a long way to improving health outcomes.

McMahon noted that population-based services are a piece of this, too. The Network needs to
foster the public/private collaboration and a statement to this affect needs to be included in the
response to the Commission report.

Eckstat commented that access to all of the information about a patient is important, but not
necessarily immediate access. EMRs are not necessary, but telehealth should be pursued for
access reasons. Eckstat asked if Engebretsen agreed and Engebretsen commented he did not
necessarily agree that EMRs are not important. Engebretsen added that CCR, which is a type of
client record, can be put into a simple format.

Lyman noted that it will be a long time until two systems integrate electronically. Chamberlin
added that telehealth can mean a lot of different things and that continuing education is an
issue. Firch added that integrated systems like Mayo have been studied and “hand offs” are an
issue. If the Network could focus on “hand offs,” it would have a huge impact. Spinarski also
added that telehealth can have a huge impact on recruitment and retention efforts.

Puetz updated the group on a statewide med. card initiative, which includes the Iowa Medical
Society, Iowa Pharmacy Association, Iowa Hospital Association, Iowa Foundation for Medical
Care, and the Healthcare Collaborative. Funding is provided through a grant from The Wellmark
Foundation. The project is based on an effort called Medication Matters and it is not electronic.
Everyone should start to see materials referencing the “Know It, Show It, Tell It” approach and
the goal is to get a med. card into the hands of all Iowans. There are starter kits available and
the involvement of all the safety net providers could really help make the project successful.
The Network could also play a role in providing funding to sustain the effort. Puetz agreed to
share information with Network staff for dissemination to members.

Update of Network Initiatives
Maternal and Child Health, Local Boards of Health, and Specialty Care RFPs – Kazmerzak
provided a brief update noting that the decisions of the review teams cannot yet be released
given extenuating circumstances that are being negotiated with the State. Network staff are



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working with the Iowa Department of Public Health to resolve the issues and the award notices
should go out to all applicants soon. The Polk County Medical Society Specialty Care grant has
begun.

Provider Awards, Data Collection, and Communication Center – Squires noted that to date the
Network has received seven requests from free clinics (there are 28 free clinics eligible for
provider awards) and 28 requests from RHCs (there are 142 RHCs eligible for provider awards).
Last year, the Network awarded funds to 25 free clinics and 77 RHCs. Squires has been working
to follow up with the free clinics and Rural Health Clinics to encourage their participation as the
deadline is January 31. There are data reporting requirements to receive the funds. This is the
first year for provider awards for family planning agencies. The deadline for family planning
agencies is February 15 to coincide with a mid-February federal reporting deadline, and the
reporting requirements are the same for these agencies. Squires also encouraged members to
sign up for the Communications Center, which allows for quick information-sharing. Instructions
will be sent out again to members. Finally, Squires reported that April 1 will be the Network’s
day at the Capitol and the event will be held in the afternoon. Members will receive additional
information as plans for the day are finalized.

Pharmacy – Kazmerzak asked Fries to update the group regarding the pharmacy initiatives.
Fries provided several handouts to the members, which show the growth in the drug donation
repository over the last year. Fries also shared a map of the state indicating where local
repositories are located. The Iowa Prescription Drug Corporation (IPDC) has also been
contacting specialists in order to disseminate specialty drugs and there has been an enthusiastic
response. The Medication Discount Card is being rolled out to RHCs, which will allow patients to
access discounts on medications ranging in cost from $8 to $16. Penziner asked about the
dependability of high cost, ongoing medications. Fries responded that the distribution has been
successful so far and the medications collected have kept pace with demands. There could be a
situation where IPDC could run out of those high cost, ongoing medications. Chamberlin asked
which major health care issues the patients are being treated for. Fries indicated IPDC tries to
keep data, but since many of the local repositories are free clinics, the data requirements have
to be pretty minimal. IPDC hopes to partner with The University of Iowa and Drake University
pharmacy programs to review records to gather additional data. Engebretsen asked if there are
any remaining regulatory barriers that impact the program. Fries responded that there is one
change to the statute that could be made. It would allow IPDC to distribute the really high
demand drugs more quickly and would extend the expiration date requirements.

Next Meeting Date & Adjourn
Staff will send out options for the next meeting date to Advisory Group members based on
Legislative activity and the need to be responsive to Network or other safety net legislation.




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