Reznet

Challenging the master narratives about government health care

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 writebudgets, can’t seem to appropriate at least as much money as theydo for the U.S. Bureauof Prisons.

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

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

Thereis another story that deserves at least the same attention as the firsttwo themes: The really remarkable efforts underway to improve qualityfor American Indian and Alaskan Native patients.

Apartnership began three years ago with the IHSand the Institute for Healthcare Improvement focused on chronic diseases. The project is now called Improving PatientCare, or IPC, and is designed to show measurable improvements in preventivecare, experience of care, managing chronic conditions, while maintainingfinancial viability.

Inplain language the goal of IPC is to make it easier for patients tosee 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 ultimateinitiative for doing more with less.

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

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

Theproblem was if you pick any one condition, whether it’s cardiovascularor depression, a single focus might not be enough.

“We were worried that we wouldn’tchange the system enough, we’d get better diabetes or depression care,”said Reidhead. “Instead what we tried to do to look at patient careto meet their needs, no matter what they came in with.”

Oneinnovation to improve care was a standard bundle of patient tests, flaggingearly warning for alcohol misuse, depression, domestic violence, tobaccouse, blood pressure and obesity.

Nearly40 units in the Indian health system are part of the IPC pilot. A keyelement of the initiative is transparency. Results are measured andbecome learning tools that are shared across units in the program.

Oneof the reasons why the Indian health system is ahead of the rest orthe country is the word “system.” If nothing else this is what needsto be part of the larger discourse about health care. When a patientis discharged from a hospital, that system ends its service. There isno 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.

Whydoes a systemic approach matter? Because treating chronic diseases representsthree-out-of four health care dollars. The goal of a low cost, highquality system is the only sustainable model going forward. And thatis a story that must be told.

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.

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