MARK TRAHANT

DENVER – Dr. Donald Berwick is one of the nation’s leading authorities on health care quality and improvement. He’s president and CEO of the Institute for Healthcare Improvement. He’s also a clinical professor of pediatrics and health policy at the Harvard Medical School and a professor in the Department of Health Policy and Management at the Harvard School of Public Health. Berwick has been on boards ranging from the American Hospital Association to an elected member of the Institute of Medicine. ABC’s Medical Editor, Dr. Timothy Johnson, calls him a “beloved” voice.

Berwick uses that voice to say look at the Indian Health Service as a model for what the U.S. system could be. “The Indian Health Service can, and will be, one of the leading prototypes for health care in America,” he said at a National Indian Health Summit in Denver on July 8.

First, think about the money. Health care costs are double what the amount spent in other developed countries. And for that money, Berwick says, the “American health care is not the best in the world. It’s not even close.” Indeed he calls the current health care system a “low-value” enterprise, one that strips money from both family and government budgets.

Then there is the IHS. “The Indian Health is trying to deliver the same or better care with half the funding of other systems in the United States,” he said. Spending by IHS is even less than other developed countries. Berwick said he didn’t want to underestimate the resource challenge – and he’d be the first to say IHS needs more money – but at the same time the IHS’ ability to execute is “stunning.” The very nature of the agency’s under-funding has resulted in a discipline that’s “an example for us all.”

There’s a paradox: The Indian Health Service isn’t broken, it’s significantly under-funded while the national health care system is both over-funded and broken.

“We cannot afford in the longer run universal coverage for the health care system we have today,” he said. The care system is “too broken, too fragmented, too wasteful … and it’s not up to the task.”

Real health care reform is “beyond almost anything this country has faced,” Berwick said. He defined reform as a triple aim: Improving people’s health; improving the experience of care; and, controlling costs.

These three aims have different constituencies – and in many ways are competing ideas. How many drug companies want to sell fewer prescriptions? What incentives are there for hospitals to have fewer beds or be empty? And what will it cost to improve the population’s health over the near and long term? To address better health, money will need to be spent on the causes of illness, rather than symptoms.

But if you start over and design a health care system it would look very much like the IHS, built around the need of the patients, or a community-focused population. Berwick calls this “population-based thinking.”

And that’s one of the strengths of the Indian Health Service is the constant collaboration between the agency, tribal governments, regional health boards, families, patients and on and on. Think about what this means: A regular, ongoing system for determining community, familial health priorities. This is a patient telling doctors what’s important, not the other way around. This is built into the very ethic of IHS.

Another strength of IHS is its culture of learning. “I’m stunned by the honesty of measurements,” Berwick said. “IHS data shows data that doesn’t work as well as what does. It raises the idea of a learning organization.”

At the very least I think IHS has to be the model for a national rural delivery care system. There is nothing like it dollar for dollar anywhere in the world. But to bring up an old theme, if Congress fully funded the Indian Health Service would the redesigning the national health care system even require a debate?

            Mark Trahant is the former editor of the editorial page for the Seattle Post-Intelligencer. He was recently named a Kaiser Media Fellow and will spend the next year examining the Indian Health Service and its relevance to the national health reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes.