Challenging the master narratives about government health care

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.