Our view: Health care reform: wrong target?

TOO MUCH MONEY

"There's too damn much money in our health care system" and it's spent in a wasteful way, Eby said. State Sen. Hollis French's plan for universal coverage through mandatory (and, if necessary, subsidized) private insurance "just moves money around."

Ensuring people can afford health coverage or medical services is only one-third of the problem, Eby said during his conference presentation the next day.

Two-thirds of the problem is the way we deliver health care. It's "completely ineffective," he said.

INEFFECTIVE SYSTEM

"We give out a pill or they have a procedure and then we're pretty much done until the next visit. We take no responsibility for the person in the meantime."

The health care system doesn't pay for keeping people healthy, Eby noted. On the contrary, in most cases, the more visits, tests and procedures, the more money providers take in. That's great for the bottom line but not for producing healthy people.

Doctors, he says, do little or no follow-up to help change the behavior that causes or worsens so many health problems. (Ask yourself: When was the last time your doctor's office called to see if you were taking medicine as prescribed, or were exercising as recommended, or had quit smoking?)

PATRONIZING ATTITUDE

Instead, Eby noted, doctors condescend to patients, labeling them as "compliant" if they do what doctors tell them to do. This patronizing approach -- essentially using shame as a technique for changing people's behavior -- is "ridiculous," Eby said.

He mocked the finding of a recent obesity study, which said people are more likely to be fat if they hang around with fat people. Somehow it was "a stunning revelation" that a person's social environment makes a difference to health.

The medical system ignores that critical influence, Eby said. It uses a mechanical, scientific approach: You have a health problem, so doctors supply you a pill or a procedure and you go away to get better -- or not --- on your own.

This mechanical-repair model of medicine is great if you are in an accident and need trauma care, Eby said. But the vast majority of health care deals with chronic conditions and the fallout from behavioral choices people make.

Eby said he and his fellow doctors are selected wrong and trained wrong for helping people change their habits and behavior. Doctors are experts in diagnosis and treatment.

A DIFFERENT APPROACH

Eby works in a medical system that uses a much different model. Southcentral Foundation serves the medical and other needs of Alaska Natives throughout this region. Its network includes a primary care clinic and some specialty services and it jointly runs the Alaska Native Medical Center with the Alaska Native Tribal Health Consortium.

Under the leadership of CEO Katherine Gottlieb, the Native-run organization has transformed the way medical care is delivered.

When the federal government ran the Native health system here, care was fragmented and at times chaotic. The same patient would see a different doctor on each visit. The old hospital, since torn down, was cramped and badly organized. There was no follow-up between visits. Patients were on their own.

When Southcentral took over part of Native medical services nearly a decade ago, things changed. As a Native-run organization serving Natives, Southcentral listened to those it served and focused on building relationships with patients and supporting them in maintaining or returning to health. That focus on building relationships is especially important in Native cultures.

HUMAN DIMENSION IS IMPORTANT

In this Native-run model, Eby said, "messy human stuff is important." It's not just a matter of picking the right pill or medical procedure. People who come there are called "customer-owners," not patients. They are treated as peers having conversations, instead of being judged whether they are "compliant" with what experts tell them to do.

Customer-owners can select their own care team, which includes a doctor, nurse, and case manager, as well as access to a nutritionist, traditional healers and a behavioral counselor. Same-day access to the team is guaranteed, either in person or by phone or e-mail, depending on the level of attention needed.

The entire family is welcome when one member comes in for a medical visit. Follow-up services -- pharmacy for drugs, labs for testing -- are right on the same campus, making access easy.

IMPRESSIVE RESULTS

With this comprehensive approach, Southcentral reports major changes for the better. Writing in the January 2008 issue of Family Practice Management, CEO Gottlieb reported that emergency room and urgent care visits have dropped by more than 40 percent, while use of specialists fell 50 percent and the number of hospital days shrank by 30 percent.

This impressive record hasn't required buckets full of money. The number of Southcentral's "customer-owners" goes up by about 7 percent a year, but Indian Health Service funding goes up by about 2 percent. Only 40 percent of the budget comes from the Indian Health Service. The rest is from private insurance, Medicaid, Medicare and grants.

Smart management helps keep costs under control. Southcentral's Karen McIntire told the public health conference that 70 percent of primary care does not require a doctor. "In our system, who you see depends on what you need."

'MEDICAL HOME'

Southcentral's approach is one version of the "medical home" model that is getting a lot of discussion nationwide. In the simple version, the doctor in your medial "home" would be paid extra to keep in regular touch with you about your medical needs, coordinate care in complicated cases and encourage you toward healthier lifestyle choices.

President-elect Obama is reportedly looking into the medical home concept, according to a Reuters report.

But "most medical home models are a simplified piece of crap," says Dr. Eby. "You can't just put a veneer of behavioral health on a broken system."

A robust medical home, Eby says, would "give me (the patient) what I and my team determined I need. They know me, care about me. They answer questions and coordinate care. My values and goals drive the care." It's designed as a system; it's not an isolated series of piecemeal improvements.

STILL A WORK IN PROGRESS

Eby says Southcentral is only 30 percent to 40 percent of the way to a full transformation of its medical care system, even after 10 years of working at it.

Nonetheless, it looks like this medical center in Anchorage is way ahead in the effort to produce better health at lower cost. Gov. Palin's health commission should take a long look at this example and brainstorm ways the state can encourage similar changes throughout Alaska's health care system.

BOTTOM LINE: This could be a cost-effective way to produce better health for Alaskans.