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On this edition of Iowa Press.

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For decades, Iowa Press has brought you political leaders and newsmakers from across Iowa and beyond celebrating 50 years of broadcast excellence on statewide Iowa PBS.

This is the Friday, December 1st edition of Iowa Press.

Here is Kay Henderson.

On this edition of Iowa Press.

We'll be talking about the health and future of Iowa's 117 hospitals.

Our guests are Chris Mitchell.

He is the president and CEO of the Iowa Hospital Association, and Kevin Kincaid.

He is the CEO of the Knoxville Hospital and Clinics.

Gentlemen, welcome to Iowa Press.

Thank you.

Appreciate the opportunity.

Also joining the conversation are Tony Leys.

He's the former Des Moines Register health care reporter.

Now he's the rural correspondent and editor for KFF Health News.

And Erin Murphy.

Here is the Des Moines bureau chief for the Gazette in Cedar Rapids.

So, gentlemen, before we get to into the weeds here, I just wanted to get the perspective from each of you on, as Kay noted, the health of Iowa's hospitals.

So, Chris Mitchell, we'll start with you from your perspective with the Iowa Hospital Association.

What is the status of Iowa's hospitals?

What I would tell you, as as was mentioned earlier, there's 117 hospitals in Iowa, 82 of those are critical access hospitals and 92 of those are considered rural.

And what I would say about the primarily rural membership we have here, hospitals are in a very improving position coming out of the COVID, coming out of the pandemic.

And I'm happy to report that hospitals remain lifeblood of the communities.

They are across the 99 counties of Iowa.

And from our perspective, a financially viable hospital leads to a financially viable state.

And so we are working very hard to make sure that continues.

Kevin Kincaid And he mentioned rural hospitals obviously you have a perspective on that as well.

What's your view?

Yes, So we would really tag along with what Chris just mentioned coming out of the pandemic.

I mean, when we went through that, our in our financial lifeline had been completely cut off and we were left with a lot of the uncertainty that everybody faced.

And and we came out that other side, okay.

You know, and so really what we're facing now is trying to adjust to record levels of inflation and all the challenges that hospitals face as that Iowa hospital and the financial leaders have always done a nice job of pulling a rabbit out of the hat every time the financial picture changed.

We're worried we might be getting low on rabbits.

So it is something that we're really concerned about moving forward.

But this is a little bit of a rabbit question, I guess, for Chris.

Other states, including Missouri, have seen a lot more hospital closures than Iowa has.

We've had just the one so far in Keokuk, why is that?

And if I live in small town Iowa, how confident should I be that my hospital is going to stay open?

Now, I certainly appreciate the question, me being fairly new to Iowa.

I came here two years ago to assume this position, and I was quick to find out what a powerful rural health care system Iowa has.

We have seen record amounts of closures over the past 10 to 15 years.

Only one in Iowa was closed in the last 20 years, and I attribute that to very good partners at the state and federal level working with Iowa hospitals to find policies that will keep them viable.

I would also lean on the leadership and expertise of the hospital administrations across the state who have a commitment to each community they are in.

And I would also say it's the communities themselves.

These community hospitals only thrive when they have the support and they have the support and the support and the really just the support of the community.

Did you want to address that question?

Well, yeah, I can maybe add something to it.

Like, I, I really wouldn't have any inside knowledge on what happened to those Missouri hospitals for then in that example.

But I can say in Iowa, when I started my health care career in the military and then bounced around the country a little bit, then I came back to the state that I was born and raised in.

I can see something that's a little bit unique about Iowa and Iowa hospitals.

We also look out for each other and we have been supportive of each other, even if we're competitors.

And I think that that has really added to the strength of Iowa hospitals across the state.

And I think that we'll probably talk a little bit about collaboration a little bit more in the interview.

But clearly we are very collaborative state and I think that helps to keep us all healthy.

Was Iowa's decision to immediately embrace Medicaid expansion?

How much did that help?

I think that, you know, from our perspective and I'll just kind of give me give you my world view on that is that when when people have coverage and some certainty of financial protections, when they want to come to the hospital, when it's a low level issue, being a community hospital, I know for a fact that's a good thing.

And that expansion, I believe, kept Iowans healthier and by extension kept our hospitals healthier.

Kevin, there have been nursing home closures, many of them in Iowa, and people often don't realize that nursing homes are often a key part of the care chain when someone leaves the hospital.

How difficult is it to have someone who's discharged after maybe a hip replacement finding a position in a nursing home when many of them are, you know, limiting admission?

Yeah.

So that's the challenge that I face with families every day.

Probably when I go back to the hospital this afternoon, I'm going to have a family want to talk with me about their loved one, the payer wanting to have them discharged a little sooner than the family feels that they're ready for.

So it's something that I deal with on a daily basis.

So we have really been kind of pushing on the gas pedal a little bit to keep people knowledgeable about what sorts of decisions that they're making when they sign up for insurance plans to make sure that that things like your premium is not the only thing that you should be considering.

And so we've been talking with the public about that.

We've been talking with key stakeholders across the state.

But it's just an ongoing problem that you really don't know about until you're personally in that situation.

Chris, what's your view of of the connection between Iowa's 117 hospitals and nursing homes?

And does the Hospital Association have a role and maybe being an advocate for nursing homes here?

Yeah, What I would say is Kevin outlined the challenges that I think hospitals are facing across Iowa and frankly across the country when it comes to needing to be able to transfer patients in a timely manner.

And we continue to work with our friends in the nursing home community to try to find common sense solutions.

And so I guess to answer your question more directly, I said yes, we certainly have a role from our perspective in ensuring that our patients have an adequate place to go when it's their time to be discharged from the hospital.

So we haven't seen hospital closures like in other states, as we talked about, but we have seen the closure of birthing centers and in some areas psych wards.

Why is that happening?

Is that a concern for each of you gentlemen?

And Chris, we'll start with you on this.

And is that a trend that's going to continue?

I think, to, to answer your question, I would say yes.

Certainly we are paying attention to the reduction of services across the state, whether that's OB or behavioral health or any other services that our members are looking at.

I think there's a number of reasons why that happens.

I mean, one, it's sheer volume issue.

If you're not doing a lot of a certain procedure, does it continue to make sense to continue to do that, or would you let another hospital like Kevin's, who might specialize in that and transfer the patients down there, really as we take a look at the different services that our members are offering, we just want to make sure that policies are in place to ensure that a critical health care delivery system is accessible to all Iowans across the state.

Kevin, When I hear the word volume in there, I immediately think is that even more pronounced in a rural hospital?

Oh, it's it's paramount.

And so there's kind of a if I think about like when you use example OB services, there's kind of a three legged stool there from the perspective of clearly there's economic drivers around when you have low volumes of births.

And then you also have, which I find to be much more pressing issue is around quality.

The more you do of something, the more you tend to be a little better at it.

And then on the third leg of that is workforce.

So when you have OB nurses that really that's their passion, that's their calling in life to come to a facility that only does a handful of births and then they're floated to other departments, that's not what they're looking for.

So a lot of these rural hospitals were faced with an economic problem and a quality concern.

And then throw on top of that, they can't keep the staffing to where they need it.

And all that stuff is interconnected.

And we used to make these decisions like OB whether we were going to continue those services or not, just as a local decision.

And now through some of the Iowa Hospital Association conversations, I first heard the term OB desert like it's not just what's going on in my service area, what's going to happen?

Can the hospital down the road pick up those deliveries?

And does that provide the maternal care that our communities deserve?

We just happened to be close geographically to Des Moines and most of our mothers were working in Des Moines and this is where they chose to deliver.

And so we kind of had a bit of an easy answer.

But if you're in more rural Iowa, you have to think about that, and we're doing a much better job of it.

So, Chris, what's the answer from a public policy perspective to ensure that there aren't these deserts for women who are expecting?

Well, as Kevin mentioned, it's a multiple pronged approach.

I think we've got to make sure that the primary payers for these births, whether that be Medicaid or commercial care, are covering the cost to deliver that service.

We've got to ensure that we have an adequate workforce here for prenatal birthing and postnatal network across the state.

And we'll continue to advocate and work with legislative leaders to ensure that the all of the hospitals are 26 of the critical access hospitals who are still delivering and still delivering babies to ensure that they're able to do so in a meaningful way and provide that service to their communities.

So you're talking about raising reimbursement rates?

Sure.

How much how much should they be raised?

I mean, I think there's there needs to be a frank conversation between continued between the hospitals, the hospital association and the state lawmakers there.

But I'm not, you know, prepared to put a dollar amount on the table today.

Kevin, Erin also mentioned psych beds.

And there's been a long debate at the statehouse among legislators about increasing access to services, especially for children and having a children's mental health care system.

Why is that so hard to achieve?

Well, I wish we could turn this into a two hour program and just focus on on that for a while.

Something I'm wildly passionate about and I've been involved with for many years.

And it's like you said, why are we not moving the needle as fast as we would like on that?

So being a community hospital, pretty much any day I'll have 1 to 2 core committed patients in our emergency room that I simply cannot take care of.

I'm not equipped for that.

There is no place for them to go.

They are always going to be there for hours, sometimes days, sometimes weeks, till we can find placement.

So.

Well, why is that?

Well, we used to really talk about there just aren't enough acute critical care beds to get these people to.

And even though there has been some movement with the beds now, I don't just say bed shortage.

There might be open beds, but they don't have staff to staff those beds.

And there and and these are intensely complex patients to take care of and the the human resource that goes into taking care of someone.

If you think about your typical med surge patient where one nurse might be able to take care of five or six patients very well in these situations, these can be intensely two on one.

These are very difficult people trying to keep everybody safe and get them the care they need.

It is very complex, it's very expensive.

And we're just going to need to keep at this until we make this situation better.

Tony.

Chris, I want to ask about the new Rural Emergency Hospital program.

Can you briefly explain to folks what that is and why at this point?

I think the only hospital that's publicly expressed an interest in Iowa is Keokuk.

Why aren't the other hospitals?

Yeah, no, I appreciate the question.

I guess, in short, the rural hospital designation was created to provide another avenue for hospitals looking at different payment models and health care delivery models.

And essentially, in short, what the Rural Emergency Hospital would do is it would forego its inpatient beds but still maintain hospital outpatient services so individuals could still come to the hospital 24/7, 365, but there wouldn't be traditional inpatient beds that people think about when they think about going to the hospital.

To answer your question on why haven't many hospitals in Iowa gone down this route, I would say, one, it is fairly early on or very thankful for one, Senator Grassley's leadership getting this across the finish line at the federal level.

And also thankful to Governor Reynolds for her support and passage of a state licensure bill that went into effect this year.

As you mentioned, one hospital and I was looking at it.

We do know that there's about 18 hospitals across the country only that are moving to do that.

And what I would tell you is it's really early.

If we go back to 20 years ago, in 2003, there were zero critical access hospitals in Iowa.

Fast forward 20 years.

The vast majority of hospitals are critical access hospitals.

So I think as time moves on, we continue to work and tweak the legislation.

You'll see more hospitals taking a closer look at it.

Just for the benefit of viewers, what is a critical access hospital?

Oh, yes, a critical access hospital is a hospital located in a rural area and it has 25 beds or less.

Underneath that designation, they do receive cost based reimbursement for Medicare, which allows them to continue to operate in those rural areas and ensure that folks in those communities have access to a hospital.

Thanks, Tony.

So talking about hospital beds, a lot of treatments and operation ones that used to be inpatient are now outpatient, or even if you are an inpatient, it's often for one or two nights tops.

Do do we have too many hospital beds, especially in some small towns that we could have a hospital with no inpatient services and it would work because of that.

So, you know, in kind of talking about that and to kind of that's where maybe that rural emergency hospital because when I talked about OB and deliveries and quality and staffing and all those sorts of things, we have hospitals that may have an average daily census of two or three.

Mm hmm.

So if you look at that on a spreadsheet, taking care of two or having a whole hospital system to take care on average two or three people in an acute setting, it's easy to say, well, that doesn't make sense.

Stop doing that.

Now put somebody's name on there that your grandparent now does not have a bed locally and needs to go to another community for that.

So so those are all these really hard decisions.

When you go changing hospital designations like that, that requires a lot of community dialog, a lot of community leadership to explain why that must be done.

And that just kind of weighs in to that.

So to answer your question, it's not very efficient use of resources.

There's a better way to do it.

But one of the things that we know people do better when their family and friends are close by.

And so we need to make sure that we don't create inadvertently inpatient deserts.

We need to make sure that happens because it's reasonable to ask somebody to maybe drive 20 miles down the road with family and friends.

But you start pressing that distance and we're going to have unforeseen problems.

And we may be sitting around talking about inpatient deserts like we do OB deserts if we're not thoughtful.

One of the actions that the 2023 Iowa legislature took was to pass a medical malpractice bill.

Kevin, have hospitals seen their premiums fall?

Which and in Iowa, premiums were not what they were in other states already?

Yeah, so that's a very timely question that you just asked me.

So we are just getting all of our new insurance premiums and I'm taking them to the board.

And there's a lot of oh my gosh, that went up how much for all of our different insurances that we have?

Our malpractice insurance had a 0% increase with a note on our premium to thank us for tort reform because it allowed them to pass that savings on to us.

So it really mattered.

Is that what you're seeing at other hospitals, Chris?

Yeah, I'm hearing similar stories from from from across the state and once we get through this round of renewals, well, we might have some more sound data more than anecdotally to share as well.

We're in a center.

Last 5 minutes or so, you both mentioned at the top the pandemic and how hospitals have recovered from that.

Chris, let me start with you on this.

What lessons did hospitals learned that you feel will help them prepare for if this were to happen again?

Yeah, I think I think there's so many lessons learned here.

So let me let me hit the top list.

I think one, the the importance of the connectedness between hospitals and local public health.

I think what we saw in Iowa and across the country, that there were varying levels of engagement and arrangements together and really sitting down with local public health and taking an opportunity to make sure that they're operating on the same page.

I think that's one, I think two, you know, as somebody who's been advocating for health care for the better part of two decades, I would say that the health care of the hospital community has never been more directly aligned in some of the messaging and what needs to be done by the elected officials to get through the pandemic.

And I think that connectedness and that speaking with one voice is a lesson that we've carried into the last legislative session that had several victories, most most notably on the medical malpractice reform as well, too.

I think I'll let Kevin talk a little bit about the collaboration amongst hospitals in the delivery of health care across the state, too.

I think the big thing that I would like to add to that is that I used to wrongly, if that's the right word, only think about my local service area that if I take care of my service area really well, that's my responsibility and I don't need to worry about the rest of the state.

The pandemic put a spotlight on Knoxville, Iowa, deeply cares about what's going on with Sioux City and Dubuque and across the state because we are interconnected more than we ever realize.

Doesn't matter what system we might belong to or whether we have a competitor down the down the road.

We count on each other.

And many of us in the rural setting took a lot of that for granted.

And it's a it's a very difficult thing when you think about a patient that you would really like to transfer to a higher level of care and then that's not available.

And so it really shined a light on how collaboratively we need to do our work together to ensure that there's a system of care across the state.

Kevin, really quickly, I know that hospitals have been among those who have had concerns about the speed at which bills under Medicaid managed care at the state level are being paid.

Has that been fixed?

So that to say that, to say that that's fixed, that that wouldn't that wouldn't be accurate.

But that certainly there has been a lot of lot of work that's going on and we have moved the attention of that.

And we have some good things that are beginning to unfold in that space as it relates to our ability to take care of the most vulnerable.

Iowans on Medicaid and the governor's office has been very a very good partner with us to be able to work on that and to unfold some really good things to address issues like you just mentioned.

What's the delay right now?

The well, I think the the delay is the complexity of the system of how things work and then also having some accountabilities as to we need to be very specific about how quickly these things must be done and to be able to have a good common understanding that these are our expectations and this is what happens when it doesn't.

Well, we are done with this conversation today.

Gentlemen, thank you for joining us on this edition of Iowa Press.

Well, thank you very much.

Thank you.

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