Panopto at The University of Iowa

This is just an announcement about the educational offering through The University of Iowa known as Panopto, Video Capture and Management Platform | Panopto. Using this approach, we can offer free, open access Category 1 Continuing Medical Education (CME) available through University of Iowa Carver College of Medicine Health Pro Network. Because the list of presentations grows constantly and is continually being updated, there may be temporary slow loading issues, so be sure to return often to check availability and new offerings. While the CME interface is updating you can still view the presentations at Sessions: Panopto Web Management Interface. Searching is easy. For example just type my name in the “search all sessions” box and see what I’ve uploaded so far. They’re also on the menu on my blog home page below the The University of Iowa Hospitals & Clinics headings.

This enterprise is particularly important as the annual Open Access week approaches, Open Access Week. In fact, I’ll have a blog post on the University of Iowa Libraries (UI) web site, Transitions- The University of Iowa Libraries. See the main UI libraries page at Home – Transforming Scholarly Publishing – LibGuides at University of Iowa Libraries for more information about scholarly publishing.

Why Come to Iowa?

“Courage, confidence, and honesty.”
I walked into the wrong meeting the other day. Have you ever done that? I was looking for a going-away party for a cherished junior faculty member who decided to relocate to Alabama, largely because her daughter wanted to attend Emory University, a little over two hours away from Montgomery where my friend and colleague would live and work. Anyway, I made it to the party. We laughed, we cried, we drank punch, etc.

But that other meeting I crashed and missed had been about how to keep attracting more and more psychiatry residents to Iowa. I didn’t know that at the time; I just grabbed a cookie and slunk out when I got the withering who-invited-you stare. I found out about their agenda only later when I stopped by the Residency Coordinator’s office and dropped off a copy of the July/August issue of The Carlat Psychiatry Report (The Carlat Psychiatry Report |) for which I and a recently graduated Chief Resident had written a piece. The focus of the issue was Bipolar Disorder and we had written what might plausibly have been a tepidly provocative article entitled “Is Bipolar Disorder Over-Diagnosed?”

Anyway, the Residency Coordinator filled me in on the high points of the discussion about not just maintaining our already pretty strong recruitment efforts, but boosting them. I wondered why, obviously aloud. She said a lot of resident recruits come from all over and a few of them have the notion that Iowa is nothing but border-to-border corn field. She asked me to share any ideas I might have about putting a little extra turbo into the recruitment effort.

I’m not sure why I thought of the Iowa Writers’ Workshop a little later. In fact I try to avoid thinking about it. That’s because I’m a would-be writer, always have been, always will be. That’s why I blog. I could never get into the Writer’s Workshop (you almost don’t have to put Iowa in the title–it’s understood). They would throw rocks at me. Ah, but I wanted them to throw rocks at me, meaning I’d have given my left little toe (Hey, I don’t like pain) just to get within a mile of that rarefied atmosphere.

So if Iowa is the center of the universe for writing, why does anyone think we’re just a cornfield? Did that sound grandiose? Remember, I co-wrote an article suggesting that it’s at least conceivable that bipolar disorder is overdiagnosed, so I’m not manic. I remember the words from the video describing what could be the Iowa Writers’ Workshop mantra, “Courage, confidence, and honesty.” I have never had the courage to stand up to the heat in that kitchen.

But I think you describe a lot of Iowans that way because we typically value and show “courage, confidence, and honesty.” I’m not so sure that anyone truly believes that men and women who want to be good writers can’t be taught. There are good reasons why the Writers’ Workshop is in Iowa. I’ll tell you what they are just as soon as I think them up.

I have a better sense of why men and women who want to be good psychiatrists keep coming to Iowa, though, despite the cornfield obsession. It has a lot to do with mentoring, a devotion not just to data, but to empathic, respectful relationships–and corn on the cob. That slipped!

People come to Iowa for the collegiality, the warm connections to be made, and the connections to opportunity near and far. I guess that’s my contribution to the recruitment effort. I have to run my manuscript over to the Writers’ Workshop. This time, I’m going to wrap it in asbestos, so they have to at least unwrap it before they burn it.

The Geezer Tries to Understand the Affordable Care Act: The Iowa Response

A recent item in the AMA MorningRounds caught my eye. I’m a roll-up-your-sleeves Consult-Liaison psychiatrist and I don’t pretend to understand the Affordable Care Act (ACA), either the law itself or the Supreme Court decision about its constitutionality. But I did try to educate myself a little about it, as any physician ought to try to do. But first the news item; Iowa Governor Terry Branstad declined to expand Iowa’s Medicaid program under the ACA. He’ll forgo the federal funding that would allow about 150, 000 low-income Iowans to enroll in the state Medicaid program. Branstad joins several other Republican governors in this regard, including those in Wisconsin, Louisiana, Florida, and South Carolina.

So of course, because I wasn’t sure what that meant, I looked for a basic primer on the ACA on-line and found the Henry J. Kaiser Family Foundation Health Reform Source (no connection with Kaiser Permanente) where I found the link to “A Guide to the Supreme Court Affordable Care Act Decision”. The link is A Guide to the Supreme Court’s Affordable Care Act Decision – Kaiser Family Foundation. There I found the pdf file ( with a few pages worth of admittedly dense text, but an overall non-partisan, fairly clear summary of the background on the ACA itself, the Individual Mandate, the Medicaid Expansion and more. It helped me put the implications of Governor Branstad’s action into context.

The section in the pdf entitled “The Medicaid Expansion” explains one of the ways the ACA increases access to affordable health care insurance is by expanding eligibility for Medicaid benefits. Even President Obama says this is politically ugly. Medicaid is funded jointly by the Federal and state governments and it’s voluntary for states. All states participating in the Medicaid program have to follow certain federal rules. Funding the expansion will cost money and the federal government would cover 100% of the states’ costs of the coverage expansion in 2014-2016, tapering to 905 in 2020 and thereafter. The Congressional Budget Office estimates this would cover about 17 million uninsured, low-income Americans.

If I understand it correctly, the Supreme Court decision identifies the ACA as a tax, and it probably is one of the biggest in American history. And the ACA’s Individual Mandate is constitutional (though there was dissent among the justices). However, the court ruled the Medicaid expansion “is unconstitutionally coercive of states because states did not have adequate notice to voluntarily consent, and the Secretary could withhold all existing Medicaid funds for state non-compliance.” States could stand to lose over 10% of their overall budget which can be an economic disaster. So what the Court did to remedy that was to limit the Secretary’s enforcement authority, leading to the acceptable “opt-out” choice for states.

However, the Medicaid expansion of the ACA is otherwise intact and other changes to the Medicaid program contained in the ACA are preserved, including:

  • Increases in primary care provider payments
  • New options to expand home and community-based services
  • Gradual reductions in disproportionate share hospital payments
  • The requirement that states maintain the eligibility standards in place as of March 23, 2010

So now that I have this context, I can better understand how the ACA gets politicized and the Medicaid expansion would be vulnerable to that. However, Iowa has another response to the ACA and I’m pretty sure Governor Branstad would applaud it. That would be the newly created University of Iowa Health Alliance (UIHA), a regional alliance of four large health systems including over 50 hospitals and over 160 clinics. According to Jean Robillard, MD, Vice President for Medical Affairs, who announced the UIHA on the same day as the Supreme Court’s ruling on the ACA, the alliance will add value by enhancing care to patients while improving the health of Iowans, and at the same time reducing costs. “UIHA will create a platform for sharing expertise, selected support services, and information technologies needed to succeed in the emerging ‘accountable care’ environment.” You can read more about Iowa’s innovation at link, Four Health Systems Launch Regional Alliance.

And another issue regarding ACA pertinent for patients with mental illness as far as gaining access to insurance coverage are the state insurance exchanges. Many patients with chronic mental illness don’t have insurance. A recently published paper examined a couple of mechanisms in the ACA, namely risk adjustment and reinsurance, which might help ensure financial solvency of health plans that have a disproportionate share of enrollees with mental illness. Risk adjustment involves a federal or state exchange moving funds from insurance plans with healthier patients to plans with sicker patients–often those with complex, comorbid medical and mental illness. Reinsurance involves all plans in a state contributing to a pot of money used to reimburse costs to individual market plans for costs of patients who exceed a high predetermined level [1]. I’m hoping Iowa takes advantage of these mechanisms within ACA.

1. Barry, C. L., J. P. Weiner, et al. (2012). “Risk Adjustment in Health Insurance Exchanges for Individuals With Mental Illness.” Am J Psychiatry.

OBJECTIVE: In 2014, an estimated 15 million individuals who currently do not have health insurance, including many with chronic mental illness, are expected to obtain coverage through state insurance exchanges. The authors examined how two mechanisms in the Affordable Care Act (ACA), namely, risk adjustment and reinsurance, might perform to ensure the financial solvency of health plans that have a disproportionate share of enrollees with mental health conditions. Risk adjustment is an ACA provision requiring that a federal or state exchange move funds from insurance plans with healthier enrollees to plans with sicker enrollees. Reinsurance is a provision in which all plans in the state contribute to an overall pool of money that is used to reimburse costs to individual market plans for expenditures of any individual enrollee that exceed a high predetermined level. METHOD: Using 2006-2007 claims data from a sample of private and public health plans, the authors compared expected health plan compensation under diagnosis-based risk adjustment with actual health care expenditures, under different assumptions for chronic mental health and medical conditions. Analyses were conducted with and without the addition of $100,000 reinsurance. RESULTS: Risk adjustment performed well for most plans. For some plans with a high share of enrollees with mental health conditions, underpayment was substantial enough to raise concern. Reinsurance appeared to be helpful in addressing the most serious underpayment problems remaining after risk adjustment. Risk adjustment performed similarly for health plan cohorts that had a disproportionate share of enrollees with chronic mental health and medical conditions. CONCLUSIONS: Cost models indicate that the regulatory provisions in the ACA requiring risk adjustment and reinsurance can help protect health plans covering treatment for mentally ill individuals against risk selection. This model analysis may be useful for advocates for individuals with mental illness in considering their own state’s insurance exchange.

Psychiatry Research at Iowa: Way Ahead of the Curve

I’m a clinically oriented psychiatric hospitalist at The University of Iowa Hospitals and Clinics, and I’m interested in the research going on here, which is always way ahead of the curve. One protocol that immediately caught my eye is Dr. Laurie McCormick’s “Ketamine Augmentation of Electroconvulsive Therapy (ECT) for Patients with Depression.” The description follows:

“This is a randomized controlled trial of ketamine versus anesthesia as usual during ECT procedures in unipolar or bipolar depressed patients (male or female, ages 26-60) being treated with ECT. This study involves neuropsychological testing before and after the 6th (or final) ECT treatment along with clinical assessments of depressive symptoms before, after the 6th ECT and within a week of completing a series of ECT.”

OK, so I’ve posted about this before and I’ll admit I was a little less than enthusiastic about Ketamine by itself as an instant cure for depression, see link Momma Said There’d Be Days Like This « The Practical Psychosomaticist: James Amos, M.D. But hang on, Dr. McCormick’s study takes a much safer and elegant approach, which is to add it to ECT, an already well-studied and extremely effective treatment for depression. It’s intuitive appealing to augment ECT with Ketamine, for which there is a great deal of research evidence supporting its potential usefulness for depression as well.

Some remarks from Dr. McCormick, MD and Dr. James Beeghly, MD were intriguing:

“Previous studies have found that ketamine may enhance the antidepressant response to ECT, possibly be neuroprotective against memory problems during ECT, and is actually quite safe. Our study here will continue for the next year before we have a large enough sample to determine whether all of these 3 factors are true. I did get several e-mails inquiring about the use of ketamine alone for the treatment of depression a few weeks ago. We’d prefer to see the results of studies comparing ketamine injections alone for depression as well as the result of our study using ketamine with ECT before considering routine use of ketamine outside of the FDA indication as an anesthetic.”

Another exciting protocol by Daniel O’Leary, PhD, is “Marijuana Use and Schizophrenia.” The protocol:

“The primary goal of this study is to learn more about the manner in which smoking marijuana changes mental activities and blood flow in the brain.  We are seeking individuals between the ages of 19 and 55 who have a diagnosis of schizophrenia or schizoaffective disorder.  Participants must use marijuana regularly (at least 4 times a month for at least 1 year).  Volunteers also must be willing to undergo a P.E.T.  Imaging and MRI scan.  Study will last approximately 3 visits totalling 7-8 hours. Compensation is available.”

I guess some of you can remember my posts about marijuana as well:

Let Somebody Else Bogart That Joint, My Friend « The Practical Psychosomaticist: James Amos, M.D.

Watch Out, Here’s a Caveat about Medical Marijuana–Cannabinoid Hyperemesis Syndrome! « The Practical Psychosomaticist: James Amos, M.D.

It makes sense to me to gather more information about what marijuana is doing to the brain in those who have schizophrenia and schizoaffective disorders because there is high comorbidity of substance use in patients who have these mental illnesses. If state legislatures are going to consider legalizing marijuana, then lawmakers need as much information as they can get their hands on about all the issues including the medical issues.

Music for The Wandering Iowa Geriatric Education Center Website

Looks like the Iowa Geriatric Education Center (IGEC) website came back to me. Lately I’ve been able to connect only intermittently. I swear if you go again, I’m going to post John Hiatt’s “Gone” on the Home Page. Hey, catch the great educational content before it’s…gone, gone away again.

Iowa Geriatric Education Center…Until You Come Back to Me

Well, until the Iowa Geriatric Education Center (IGEC) website comes back to me to stay, I’ll be unable to see the cool and educational video presentations about delirium. Maybe I’m the only one who can’t see them? No kidding, the IGEC has been difficult to connect with lately and I hope it’s just me and the rest of you can access the outstanding talents of Weckmann, Ness, Rosenbaum and others teaching the world at large about how to recognize, manage, and prevent delirium, and how to give bad news to patients.

I’m gonna rap on your door until you come back to me…to stay.