December 14, 2009

Challenging the master narratives about government health care

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Op-ed by Mark Trahant

ORLANDO, Fla. – There are two master narratives about the Indian Health Service. First, everyone knows the Indian health system needs more money. Everyone, it seems, except the collective members of Congress who, when they write budgets, can’t seem to appropriate at least as much money as they do for the U.S. Bureau of Prisons.

And, second, critics say the Indian Health Service represents the failure of government-run care with complaints ranging from rationing to mismanagement of government funds. Just last week Sen. Tom Coburn, R-Oklahoma, repeated this narrative in his attack against the Senate’s health care reform bill. He again called the IHS “a failure.”

These two narratives stick because the truth is far more complicated. It’s hard to communicate a “yes, but” message in a political context. Yes, the IHS does ration care – but that’s because it has only so much money in its budget.  Yes, the IHS isn’t perfect with its spending (or insurance billing operations), but is that also a reflection of its limited budget? We really won’t know the answers unless the agency gets adequate funding.

There is another story that deserves at least the same attention as the first two themes: The really remarkable efforts underway to improve quality for American Indian and Alaskan Native patients.

A partnership began three years ago with the IHS and the Institute for Healthcare Improvement focused on chronic diseases. The project is now called Improving Patient Care, or IPC, and is designed to show measurable improvements in preventive care, experience of care, managing chronic conditions, while maintaining financial viability.

In plain language the goal of IPC is to make it easier for patients to see a doctor or nurse and then to spend less time in the waiting room (without spending too much money in the process). This is the ultimate initiative for doing more with less.

Dr. Charles “Ty” Reidhead, currently a fellow with the Institute for Healthcare Improvement in Boston as well as National Chief Clinical Consultant in Internal Medicine and chair of the Chronic Care Initiative for the IHS, says the exciting thing about the IPC is that it is a tool to help “people who are already wanting to do better.”

“We learned pretty early on from the teams that it wasn’t just about chronic conditions,” Reidhead said. There was a solid track record of success from the IHS diabetes program, “so the idea was to do better at all the other conditions.”

The problem was if you pick any one condition, whether it’s cardiovascular or depression, a single focus might not be enough.

“We were worried that we wouldn’t change the system enough, we’d get better diabetes or depression care,” said Reidhead. “Instead what we tried to do to look at patient care to meet their needs, no matter what they came in with.”

One innovation to improve care was a standard bundle of patient tests, flagging early warning for alcohol misuse, depression, domestic violence, tobacco use, blood pressure and obesity.

Nearly 40 units in the Indian health system are part of the IPC pilot. A key element of the initiative is transparency. Results are measured and become learning tools that are shared across units in the program.

One of the reasons why the Indian health system is ahead of the rest or the country is the word “system.” If nothing else this is what needs to be part of the larger discourse about health care. When a patient is discharged from a hospital, that system ends its service. There is no more. But that’s not true for health providers run by the IHS, tribes or urban organizations. They provide care for a “population.” The patient remains in the system even after being released from a hospital.

Why does a systemic approach matter? Because treating chronic diseases represents three-out-of four health care dollars. The goal of a low cost, high quality system is the only sustainable model going forward. And that is a story that must be told.

Mark Trahant is an advisory board member of InvestigateWest 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.

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