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

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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 the entire campus is tobacco free;
  • There are numerous gathering places scattered about for family and community with traditional art showcased;

  • And, in waiting areas, there are open computer terminals for people to research health information. Signs remind patients to speak to someone if they have been waiting more than 15 minutes.

This is what the IHS 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 inpatient 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 nonprofit 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,” said Katherine Gottlieb, Southcentral Foundation’s president and CEO. “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 the 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 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, IHS 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; transparency in yourself 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.

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“We are literally customer-owners, Alaska Natives. Our board of directors is 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 e-mail 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 50 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.” In fact, she said 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 IHS, 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, ANMC’s vice president of 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