TrahantReports: Indian Country & health care reform

Why the Indian Health Service should embrace Facebook

Mon, 8 Mar 2010 09:08:14 -0800

How does a health care agency listen to patient complaints in the era of social media? Well, the easiest thing to do is to ignore complaints or to explain them away. The best practice: Treat complaints as critical nuggets of information.

Let’s start with a bit of context. The U.S. Department of Health and Human Services and the Indian Health Service have an extensive process for tribal consultation. There is a formula for listening to tribal leaders about its operation, priorities and budgets. There’s also an open line for internal IHS reform. The IHS collects data about best practices, ranging from treatments for cardiovascular disease to partnerships with traditional healers. This is a simple, but important, way to share ideas about programs or treatments that work.

So the context is that the Indian Health Service has an extensive practice collecting information – complaints – from tribal and community leaders. In general the Indian Health Service does a better job of listening to its constituents than most health care agencies. But that system was designed for another time.

So back to the question: How does a health agency listen to patient complaints in the era of social media? Each unit, clinic or hospital has a formal process, but most complaints aren’t filed, they are spoken between family members or said in the waiting room? How does a modern health care agency learn from those?

This is where the new world of social media kicks in. Patients are contributing thousands of bits of information on Facebook in a group called, “I just spent 6 hours at IHS just for them to give me Tylenol.”

Angel White Eyes writes from Pine Ridge that she got the idea after getting sick a couple of months ago. “I was throwing up and coughing up blood. Plus had flu symptoms. I contemplated on going to IHS all weekend because I knew they'd only give me Tylenol.”

Her Facebook friends convinced her to go into the clinic anyway. “After sitting at IHS for 4 hours, I told them all my symptoms, and they said I had a virus and gave me some Tylenol and cough syrup and told me to stay home,” White Eyes said.

Then she posted a rant to her Facebook page. “At first I had joked about creating the group but one of my friends convinced me that it should actually be done. And I knew there were a lot of people who had their IHS stories too. I did expect to see their complaints and what had happened to them at IHS. I didn't know what to categorize the group so I put it as just for fun because IHS is a joke in a way.”

More than 1,600 people have joined the group and are telling their own stories. Long waits and Tylenol are common themes. And not all of the information is critical. Some report good experiences with IHS.

This may sound odd but the Indian Health Service is lucky to have such a page already created on Facebook. The agency ought to embrace it, monitor it, react when it can and learn. It’s golden intelligence because it’s a real time reaction from patients. (This is why federal agencies ought to have a social media policy that allows open access to Twitter, Facebook and other public communication tools).

To me the most damning complaints on Facebook and other comment boards is from the people who’ve completely given up on the Indian health system. Some say it’s better to make a co-payment at an off-reservation clinic because service is better. Or they suggest using insurance at IHS until their insurance deductible is met and then fly free from the system. That is a narrative thread that limits what can be done to improve Indian health for every patient. If you’ve already given up, why bother?

But those who complain openly want a health care system that works. Every time they write about what happened to them, it’s an open invitation for improvement. The IHS is lucky to have so many volunteers posting helpful information. In fact, I would put a terminal in every waiting room, perhaps with someone who could help patients who don’t use computers to get even more direct response. Embrace Facebook.

As a friend wrote on Facebook: “Angel White Eyes … Bless your Heart!! haha! This is too TRUE!!”

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment at www.marktrahant.com

The best health care in the world (if you’re a Canadian premier)

Mon, 1 Mar 2010 07:48:27 -0800

I didn’t figure the Indian health system would be a huge agenda item at the Blair House bipartisan meeting last week. On paper, at least, the Indian Health Care Improvement Act is one of ten titles in the president’s proposal. So ideally Title 10 would have rated a mention.

It would have been even better to hear a debate about the merits of reauthorizing the 1976 law at the summit with the Democratic and Republican leaders in Congress. Some of the Republicans at the Blair House have complained many times that the Indian Health Service represents the worst of government-run care. So, we ought to ask, “why not fully fund the IHS and give it the resources to be successful?”

No such question was asked. Then no tribal leaders were in the room and the only American Indian representative in Congress wasn’t there … so it was easy for the subject to never come up.

I watched the meeting on the Internet and updated short items on Twitter (a “live tweet” with my 140-word commentary about the meeting). I wrote: Can we agree US health care system finest in the world? No. Another point of diff. WHO ranks France first (we're not top 10, 20 or 30) #hcr

The context for this tweet was when Wyoming Sen. John Barrasso said: “I do believe we have the best health care system in the world. That’s why the premier of one of the Canadian provinces came here just last week to have his heart operated on. He said, ‘It’s my heart, it’s my life. I want to go where it’s the best.’ And he came to the United States. It’s where a member of parliament – a Canadian member of parliament with cancer came to the United States for her care. They all have coverage there, but what they want is care.”

If you believe the U.S. health care system is the best in the world, why change a thing?

As I wrote in my Tweet, the World Health Organization has a different take on our “best” health care. We rank 37th overall. If you compare the United States to other industrial nations, we’re last. We’re 39th in infant mortality; 3rd for adult female mortality; 42nd for adult male mortality; and 36th for life expectancy. But we do have a number one spot: We spend more per person than any other country in the world.

The president responded to Dr. Barrasso by saying most Americans are “not premiers of any place. They’re not sultans from wherever. They don’t fly in to Mayo and suddenly, you know, decide they’re going to spend a couple million on the absolute best health care. They’re folks who are left out.”

And I thought the Indian health system wasn’t on the agenda?

We need more conversation about health care, wealth, poverty and how we define what makes the “best” health care system in the world.

No system is at its best when a Canadian premier can fly in for advanced surgery while a patient at a federally-run Indian Health Service facility is told too bad that procedure will have to wait because there’s just not enough money in the pot called “contract health.” Or what does it say about the “best” when the government’s own auditors describe the Indian Health system as too poorly funded to qualify as basic insurance?

But at least the Indian health system affords basic coverage for its patients. Across the country the situation for those without insurance is even bleaker. In Idaho, for example, the state next door to Barrasso’s Wyoming, the number of people on employer-based plans fell to 56 percent last year from 82 percent in 2002.

This is the moral divide. We can pretend our system is best in the world. Or we can try to make that ideal so. Everyone one of us should be able to say, “It’s my heart, it’s my life, too.”

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment at www.marktrahant.com

Finding Blair House consensus with the Indian Health Care Improvement Act

Mon, 22 Feb 2010 07:42:27 -0800

President Barack Obama is hosting a health care summit Thursday at the Blair House. It will be televised live. We can all watch and judge the proposals for ourselves. That transparency is an ideal opportunity for the president, Democrats and Republicans to put their best ideas forward and debate different approaches to solving the health care crisis.

“I am inviting members of both parties to take part in a bipartisan health care meeting, and I hope they come in a spirit of good faith. I don’t want to see this meeting turn into political theater, with each side simply reciting talking points and trying to score political points,” the president said in his weekly radio address. “Instead, I ask members of both parties to seek common ground in an effort to solve a problem that’s been with us for generations.

But after months of rancor about health care reform is there any common ground left? Absolutely. And I hope our elected leaders think so too.

First there is common ground on the fundamental nature of the U.S. system, employer-based health care. Neither Democrats nor Republicans dare attack what should be at the heart of the debate.

I’ll throw out my wishful thought for the day: We made a mistake with employer-based health care and should be looking for a national exit strategy.

But Democrats are attached to the current system in part because labor unions, a key constituent group, have fought hard battles to win health care benefits for workers. This notion would be fine except the nature of work is changing (if you are lucky enough to have a job). If you work for yourself (or even want to work for yourself) the prospect of buying insurance on the open market these days is daunting. For example I am relying on my former employer’s health care plan via COBRA. This plan is subsidized by a generous 66 percent subsidy from taxpayers (a back door approach to health care reform?) but when that ends in a few months I am not sure what I’ll do next.

On the other hand, the problem for Republicans is that once you say that employment-based health care is a mistake, the assumption is that the only alternative is a government-based single player plan. There are, of course, other options but how do you make the practical transition away from employer-based plans? Yet a shift of the health care responsibility away from jobs to individuals actually represents conservative ideas about individual responsibility.

But that’s enough trashing of the employer-based system. At least for now. There is a political consensus that employer-based health care stays. (Again, for now.) So the debate will be a back and forth about what goofy mechanisms are required to keep in place an illogical, impossible to design health care insurance system.

There is another issue of common ground that probably won’t get the attention it deserves on Thursday: Improving the Indian health system. This is clearly a government obligation and one where conservatives and liberals alike say the government has failed to live up to its promises. In an ideal world, that would mean full funding of the Indian Health Service.

But this week perhaps the best that can be done is an agreement to reauthorize the Indian Health Care Improvement Act. The president’s proposal includes this provision – as does both the Senate and the House bills. It should be an easy sell.

Will Republicans agree? A generation ago the original Indian Health Care Improvement Act had bipartisan support in Congress and was signed into law by President Gerald Ford.

Today one of the best cases for the conservative side of this debate comes from J.D. Hayworth. Hayworth is running against Arizona Sen. John McCain for the Republican nomination because, as Hayworth put it, McCain “campaigns like a conservative and … legislates like a liberal.” Hayworth’s credentials are solid in settings ranging from right-wing talk radio to any Tea Party assembly.

So what does Hayworth say about the Indian Health Care Improvement Act? As a member of the U.S. House of Representatives he testified in support for the reauthorization in 2004. “Unfortunately, today’s health care delivery to Native American communities remains disproportionately less than what the general population receives here in the United States,” Hayworth said.

Part of the problem, Hayworth said, is the that “year-by-year appropriation is not the optimal way to fund Indian health services. The tribes do not like it. Fiscal conservatives do not like it.”

Nothing has changed. Tribes still don’t like year-by-year approach. Fiscal conservatives ought not either. There is a lot of common ground here that could help produce a Blair House agreement.

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment at www.marktrahant.com

Customer/owners are key to the Nuka Model of health care in Anchorage

Mon, 15 Feb 2010 10:38:36 -0800

ANCHORAGE, ALASKA
It takes about 30 seconds of walking around the campus of the Alaska Native Medical Center to appreciate that you are in a special place. There are values communicated in every hallway.
• Colorful banners remind visitors that the entire campus is tobacco free;
• There are many gathering places scattered about for family and community with the finest in traditional art showcased;
• And, in waiting areas, there are open computer terminals for people to research their own health information. Signs remind patients that if you’ve been waiting more than 15 minutes, talk to someone.

This is what the Indian Health system should look like across the country. “No,” a friend corrected me, “this is what the U.S. health care system should look like.”

The Alaska Native Medical Center is two facilities in one. Essentially, there is an in-patient hospital and some statewide services managed by the Alaska Native Tribal Health Consortium. And outpatient services are administered by the Southcentral Foundation. The two management teams work closely together.

The Indian Self-Determination and Education Assistance Act of 1975 opened up contracting for tribal and native management of Indian Health Service programs. Southcentral (a non-profit affiliate of the Cook Inlet Region, Inc.) assumed some programs in 1987 and by 1999 ran the whole show. Today Southcentral serves some 55,000 people with 1,400 employees (including 10,000 in 55 remote villages).

“I believe that Alaska is the only state that has enacted Indian self-determination to the fullest extent of the law in assuming health care,” says Katherine Gottlieb, president and chief executive officer of the Southcentral Foundation. “We have taken what we had from the government and transformed it.”

Self-determination in Alaska means just that. It’s not just federal programs managed by a native organization; instead the federal money is redesigned to build a system based on Alaska Native ownership.

So much so that Southcentral Foundation continually refers to its “customer/owners” as its foundation and inspiration.

Southcentral’s “Nuka” model of health care boils down to some basic ideas: That relationships are the key to health care; that patient care should be integrated, there should be same-day access to primary care; customer-owners are partners in their own health care and there should be given ample opportunity to offer advice and feedback. And to make all of this happen, there should be a culture where training and retraining is valued.

Some two decades ago the Indian Health Service asked Gottlieb to conduct a survey of its Anchorage hospital. “Are you sure you want to do that?” she asked. “I was like, delighted, because I knew what the answers were going to be. I was not surprised at all when the answers came back. Long waits. Everybody hated waiting.”

Most of the primary care back then was in the hospital’s emergency room where they were handling everything from “heart attacks, broken arms, strep throat, to you name it, and here we were coming in with our baby for just an appointment,” Gottlieb said. “I personally waited up to 7 hours, waiting for an appointment, just to get in the door.”

After contracting from the IHS, Southcentral Foundation made surveys and listening to customer/owners a key ingredient in its culture. “I think transparency is a key to success,” said Gottlieb. “Transparency in your self and in everybody.”

Most health care organizations take complaints and file them away. “We don’t file the complaints,” Gottlieb said. “We use them for improvement. Constant. Instant. Fast improvement.” Complaints are logged in and referred to a Customer Satisfaction Committee. Each department receives the complaints and asked for a response and a resolution. These complaints are reviewed quarterly at the vice presidential level.

“We are literally customer-owners, Alaska Natives. Our board of directors are all Alaska Natives,” she said. So when people are hired they are told this system is customer-owned. That’s part of the deal: Every patient is one of those owners.

And patient owners aren’t keen on waiting. That explains the 15-minute signs in the waiting room – and the philosophy behind the service. Patients can communicate by email or fax – and expect answers on the same day.

The primary care facility has four identical wings. Each entry area is smaller, more like a neighborhood clinic than a large facility’s overcrowded “waiting” room. But what is really striking is the attention to detail: The reception area is inviting; interview rooms are designed so patients and their medical team partners can have conversations sitting at the same level in rooms absent of examination tables (unless absolutely necessary). Customer-owners are treated with respect.

The medical team approach is different too. The team sits together without hierarchy. Members include doctors, medical assistants, nurses, care coordinators and often a behaviorist. Customer-owners can choose their own team – and make changes if unhappy. The ideal is integrated care, so patients don’t have to make as many return visits.

Consider how most health care dollars are spent: Expenses increase at the end of a person’s life. What if that was reversed? What if dollars instead were invested early on prevention? That means treating the root causes of diseases before they surface as heart diseases, diabetes, depression or domestic violence.

When root causes are treated there will be a reduction in the health disparities that are so much a part of the Native American experience. Gottlieb describes this model as even more imperative because as the baby boom generation ages, those costs will be unaffordable.

The data backs up the Nuka model. There has been a 40 percent reduction in emergency room, urgent care. A fifty percent decrease in specialty care visits; a 20 percent decrease in primary care visits and a 35-plus percent decrease in admissions. “We have statistics that show a generational change,” Gottlieb said.

The Nuka model is not about money. “We still have a poorly-funded IHS system. We are not fully funded,” says Gottlieb. In fact she says the government has not fulfilled its treaty-trust obligations to American Indians and Alaska Natives. “Not yet.”

Southcentral’s system is about 45 percent funded by the Indian Health Service, 50 percent from “aggressive” billing of third party insurers or Medicaid and the remaining 5 percent from foundation or other government grants.

“You won’t find anything in Indian Country like this campus,” said Douglas Eby, the Alaska Native Medical Center’s vice president for medical services. There is less direct funding from IHS and this is by far the biggest, most sophisticated campus in the Indian health system that’s far better off than most for a variety of reasons ranging from leadership to the structure and resources of Alaska Native corporations.

“We were smart enough to say, we need to optimize revenue, and we’ve done very well at doing that,” Eby said. But the growth in population, people moving in from the villages, and flat funding from IHS, and health care being such a “wasteful” business drove a rethinking of business model. “Our real hope lies in controlling costs, doing things smarter, better and avoiding high care cost as much as possible.”

The same could be said about the entire U.S. health care system. And, it turns out, controlling costs also results in better health care outcomes.

Yes, this is exactly what America’s health care system should look like.

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment at www.marktrahant.com

Growing the budget during tough times

Mon, 8 Feb 2010 08:52:30 -0800

President Barack Obama answered an important philosophical question last week: How will the federal government fully fund a starved Indian health system?

The answer is budget by budget: The administration boosted spending by 13 percent in fiscal year 2010 and is proposing another 9 percent increase for 2011. But this budget does not resolve the contradiction between “historic underfunding” and the larger reality about federal spending. The proposed budget calls for $5.4 billion in spending for Indian health care, ranging from clinical services to facility maintenance and construction. (The bulk of that money, $4.4 billion would be from appropriations, the rest comes from health insurance collections and special grants.)

HHS Secretary Kathleen Sebelius said: “Our budget also contains a significant increase in funds for the Indian Health Service as we continue to work to eliminate health disparities. It is the principle that we are trying to establish in our healthcare system – that regardless of race, ethnicity, gender or geography every American deserves high quality and affordable care.”

But while spending on Indian health is increasing – is it growing fast enough to catch up? There remains a significant gap between what is spent on an American Indian/Alaska Native patient than a federal prisoner, $2,130 per person versus $3,985. One measure used by the federal government is a benchmark based on spending for federal employees. The Indian Health Service is currently appropriated about 55 percent of that standard on per person basis.

Indeed, last April a tribal task force recommended a $2.1 billion increase in the budget authority for IHS in fy 2011. The tribal leaders called for a ten-year phase in of $21.2 billion to reach spending parity.

The National Indian Health Board describes the budget this way: “The Budget demonstrates the Administration’s continuing commitment to honoring the Federal government’s trust responsibilities and treaty obligations. Exempting IHS from the same “freeze” that other programs and agencies are under is a significant sign. However, with IHS deeply and chronically underfunded, IHS services remain woefully short of need.”

Perhaps the area that most highlights that shortage of need comes in the area of contract health care, services that must be purchased for IHS patients. There is a $46 million boost, or more than 11 percent, from $398 million in fy 2010 to $444 million in fy 2011. That’s important because it’s increasing faster than medical inflation (about 5.7 percent) and the patient population growth of about 2 percent.

Contract care is often the primary narrative for the Indian Health Service in news accounts. This is the source of “don’t get sick after June.”

A few weeks ago, before the budget was announced, I talked to IHS Director Yvette Roubideaux about contract health. “It’s a program where we know people are not satisfied because in general American Indian and Alaska Native people believe health care is something owed to them. Unfortunately with the contract health service program we’re struggling to meet the need with existing resources,” she said. “That unfortunately results in some denials and deferments of services. We know that the patients don’t like this; we know the tribes don’t like that, but it’s the reality of providing health care with a limited budget.”

Dr. Roubideaux said the fair way is to stick with medically based decisions. She would also like increasing the alternative sources of funding, such as employee insurance, Medicaid or Medicare.

That’s the other side of the contract health story. When clients of the Indian health system bring their own insurance – employer-based, purchased directly or because of other public programs – adds resources. The fy 2011 revenue budget only shows a slight growth in this area, revenue from private and public health insurance is estimated at $829 million up from $814 million.

The president’s budget is only a proposal, one that will be refined by the Congress. That might even mean more money. But it’s important to put this in perspective. Federal domestic spending is under pressure because it’s an easy symbol of excess. The federal spending that’s growing the fastest is off the table, namely Medicare, Medicaid and interest on the debt.
And that brings us back to the need for general health care reform: There won’t be spending parity in the Indian health system until that’s accomplished.
Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment at www.marktrahant.com