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Views from across Iowa

Oct 10, 2013

Waterloo-Cedar Falls Courier, Oct. 6

The circus comes to the Capitol


It’s like the big-top circus came to town in national news last week.

The federal government shutdown played the role of the lion show, with the nation’s eyes glued to the center stage, glancing briefly at the clowns while paying rapt attention to see who would flinch first inside the cage.

However, high above and drawing less attention, the high wire act involving the new health insurance exchanges made its much anticipated debut performance. It’s a good thing there’s a safety net below.

The exchanges have been in the works for four years. Even with that amount of lead time, almost everyone expected problems with the launch. In this case, almost everyone was right.

When the exchanges went live Oct. 1, the Internet portal to the new world of health insurance was overloaded. Iowa decided against creating its own exchange and instead became one of 36 states to use the federal system. Potential customers in those states were greeted with long waits to get into the system — then typically had troubles registering for an account once they got in.

“We knew that with the many shoppers, browsers and others who may be merely curious about the site, their huge numbers were likely to put a strain on the system. That seems to have been true,” said Tom Alger, spokesman for the Iowa Insurance Division. “Since we are not in control of the site, and since we don’t really have any inside access to its operation, we are at this point just monitoring its status.”

It wasn’t an auspicious start, even with the less-than-high hopes going into the program.

The partial shutdown of the federal government didn’t help the situation. Kathryn Sebelius, director of the Department of Health and Human Services, said her department was operating at about half its normal staffing level, just as questions about the ACA peaked shortly after the health exchanges opened.

“We have built a dynamic system and are prepared to make adjustments as needed and improve the consumer experience,” read an agency statement in response to the initial troubles.

Of course, all is not lost with a bumpy start to the health exchanges. Even if one signed on for insurance Oct. 1, that coverage wouldn’t take effect until January. Those looking to buy insurance still have nearly three months before they could even get coverage. Beyond that, the window to purchase 2014 insurance on the exchanges is open until March.

“We advise people to try again when the crush of site visitors has cooled, and to then check out their options in the marketplace to see if those coverage options fit their needs,” Alger said.

If one is inclined to view the glass as half full, then look at the fact that web sites don’t just crash for no reason. They bog down because of excessive traffic. On Tuesday the Department of Health and Human Services reported more than 2.8 million people visited the HealthCare.gov web site. So there seems to be significant interest in the new health care plans on the exchanges.

Let’s hope the coming acts of this circus go more smoothly than the debut.

– – –

The Des Moines Register, Oct. 6

Medical board sets a troubling precedent for using ‘telemedicine’ in Iowa


Once upon a time, heart patients traveled to a cardiologist’s office for routine pacemaker checks. Now they have a small monitor at home that connects to a phone line. It collects all the same information that would be gathered during an in-person visit to the clinic and transmits it to the doctor.

Technology has advanced. So has medicine.

Today a surgeon in New York can oversee a procedure in California using real-time videoconferencing. Psychiatrists also use videoconferencing to evaluate, diagnose and decide which drugs to prescribe to patients hundreds of miles away. Radiologists read test results. Burn specialists evaluate victims remotely. So-called telemedicine allows physicians to treat more patients. It saves health care money. Perhaps most important, it provides Iowans access to services they may not otherwise have.

Then along came the Iowa Board of Medicine.

The state board has not crafted administrative rules setting guidelines for telemedicine. Its policy statement on the practice was adopted in 1996 — about the same time many of us were getting our first email accounts.

But the board decided to wade into this 21st-Century method of delivering health care last month by focusing on the use of telemedicine for a single health service: doctors using a videoconferencing system to dispense abortion-inducing drugs to Iowa women.

The board approved an administrative rule requiring physicians to perform exams on these women. A nurse can’t do the exam. Or a physician’s assistant. Or another doctor. The rule states that the same physician dispensing the drug must perform the exam. The board also required the doctor to be in the same room with the woman when she swallows the pill and must schedule a follow-up visit at the exact same location 12 to 18 days later.

The requirements obviously eliminate the telemedicine system that has been used to deliver a health service to Iowa women for five years. Of course, that is exactly what board members appointed by Gov. Terry Branstad wanted to do.

But the board did something else, too: The members’ attitude toward videoconferencing calls into question the use of this technology by countless Iowa physicians. The concerns the board cited in the abortion case jeopardize numerous other health services used by thousands of Iowans, from children to seniors.

The board argues that the remote system for dispensing abortion-inducing drugs puts women at risk. It insists that a physician “must establish an appropriate physician-patient relationship” and that an “in-person medical interview and physical examination for the patient are essential to establishing that relationship.”

A doctor and patient must be in same room to establish a relationship before an elective medical service?

That could pose a problem for University of Iowa psychiatrists in Iowa City who evaluate, diagnose and treat children with mental health problems at five locations around the state using real-time videoconferencing.

“I talk to the child and their parents and we do a full evaluation just like they were here in the clinic. Then we decide if the kids need medication, talk to the family about risks and benefits and prescribe over the phone,” said Dr. Jennifer McWilliams, one of the U of I psychiatrists. “We used to have doctors who would go to the clinics, but I can see three kids for the time it would take me to drive there and back.”

McWilliams treats hundreds of young Iowans. She never meets most of them in person. She is not required to personally perform a physical examination. Does the medical board object to this in a state with a severe shortage of psychiatrists?

And how can the board do nothing while U of I doctors evaluate and treat stroke victims 85 miles away?

“We’re in Iowa City and they’re in Clinton,” said Dr. Harold Adams, a U of I neurologist. Using a robot with monitors, cameras and microphones, a physician in Iowa City watches an emergency room patient move his arms and legs, checks vision and evaluates speech and language. “We can basically do almost the entire neurological exam,” he said. “Iowa is a rural state with many small communities and few neurologists.”

Perhaps the Board of Medicine would prefer that Iowans at rural hospitals not have immediate access to specialists who can save their lives.

Also, if visiting a physician in person is so critical, will the board place limits on an electronic system being used to evaluate nursing home residents? A rolling cart with a computer, moveable arm and videoconferencing system contains an electronic stethoscope, otoscope, dentalscope and EKG. A medical provider at another location can access the health information collected.


What about inmates in Iowa prisons? Spine, shoulder and urology clinics at the U of I use telemedicine to treat prisoners. Videoconferencing was used for 11,000 inmate appointments with mental health professionals in 2012. Perhaps the medical board would rather the state drive the prisoners to another location 11,000 times.


In trying to limit access to abortion, the Iowa Board of Medicine employed a rationale that jeopardizes the future of all telemedicine in this state. Because if this board thinks a doctor needs to stand next to a woman to watch her swallow a pill that poses little risk to her health, imagine what it might dictate for a neurologist remotely treating a stroke victim facing death.




Sioux City Journal. Oct. 8, 2013.


Leave traffic camera decisions to local leaders, residents


Decisions about red-light and speed cameras within city limits should be left to individual municipalities, not the state.


The Department of Transportation has proposed a new set of rules under which cities would have to justify, in annual reports, the use of traffic cameras on state roads. The first public hearing on the proposed rules is today.


The big state concern seems to be whether cities are installing traffic cameras for reasons of safety or revenue.


We say, let local leaders and local residents sort all of this out.


Take Sioux City, for example. With input from the local police department, local elected leaders decided to install traffic cameras in our community, and local citizens should and will hold them accountable for those decisions. If residents view local traffic cameras as nothing but a money grab, they should and will demand evidence to the contrary.


This is as it should be, in our view.


Decisions about traffic cameras on roads (yes, even state roads) within city limits should be made not by state leaders, but by city leaders - including local law enforcement officials - based on what they believe is best for their community and what the people who live there want or do not want.


Earlier this year, we also opposed a bill sponsored by Rep. Walt Rogers, R-Cedar Falls, under which municipalities would have been required to turn over revenue produced by traffic cameras to the state’s road fund. As we said then, whatever revenue derives from local decisions about traffic cameras is local, not state. Not unlike revenue produced by other traffic and parking citations, this money should stay within local communities and be used for local budgets.


If the state believes these cameras are bad, then ban them. So long as they remain legal, though, let cities decide whether and where to use them and what to do with the money they produce.




Globe Gazette. Oct. 8, 2013.


E-cigarettes should be snuffed out


We are opposed to e-cigarette use in public.


No, some don’t have dangerous nicotine and that foul odor or the cancer threat of secondhand smoke or make your clothes smell bad — you know, all the cool things about smoking cigarettes.


But they do look a lot like real cigarettes, and we think that seeing their use in public could lead to the perception that cigarettes themselves aren’t harmful to users. We’re especially concerned about the impact on young people.


Plus, there are more than 250 brands of e-cigarettes and not all are made the same since there is no regulation.


No one seems to know what’s in that “smoke” — it’s actually a vapor — they give off, and who’s to say one is safe while another’s not?


No, there’s too much uncertainty involving e-cigarettes to allow their use in public and they should be put on the banned list just like cigarettes are.


As it is now, e-cigarettes, which aren’t lit but do emit that vapor “smoke,” have become a hot item. They’re in advertising everywhere you turn and in the news as major manufacturers are snapping up some e-cigarette companies. Tobacco giant Lorillard, for example, bought a United Kingdom manufacturer for $50 million. You can bet there’s going to be some pretty extensive marketing to get a return on an investment like that. The target? We’d wager that young people will be right in the line of the advertising fire, so to speak.


State governments aren’t sitting still on the issue. Attorneys general in 41 states, including Iowa, have asked the U.S. Food and Drug Administration to issue rules on e-cigarette regulation by the end of October. They want to find out just what the federal government considers safe and doesn’t, and thus whether regulation is possible.


Until then, the Iowa Department of health has no position nor does Gov. Terry Branstad. They should.


However, “We’re waiting for more research to be done, and we’re looking at the (federal Centers for Disease Control and Prevention) and the FDA for guidance,” said Jerilyn Oshel, interim director of the Department of Health Division of Tobacco Use Prevention.


We don’t need any more research. Because of the perception of smoking real cigarettes, because some do have nicotine and because of the vapor issue, we think the state should ban them in public, or at least tax them heavily as cigarettes and other tobacco products are now, to discourage their use.


We have enough young people hooked on smoking. That ought to be reason enough to discourage anything that would add to their number.

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