Health care is a $5 billion industry in Alaska. Change faces resistance. There are vested interests in maintaining the current system. Part of the resistance is the feeling that the uninsured could switch to a job that offered insurance if they wanted. While this appeals to traditional Alaska self-reliance, there simply are not enough employers offering health benefits in Alaska.
At the Alaska Public Health Association forum in Anchorage on Dec. 2, attendees agreed that reform must address the following measures: 1. access, 2. affordability, 3. high-quality care, 4. efficient care and 5. financing. Because the five measures are interrelated, transformation requires efforts in each area. Affordability affects access. Quality and efficiency affect cost and affordability.
On Dec. 4, Gov. Palin established the Alaska Health Care Commission "to provide recommendations and to foster the development of a statewide plan to address the quality, accessibility and availability of health care for all citizens of the state." Forum attendees expressed support for a commission and urged that it evaluate the following measures and solutions:
1. Access: Alaska ranks in the bottom 15 percent of states, with close to 17 percent of Alaskans uninsured.
Solutions: expand Denali Kid Care to cover kids and their parents to at least 200 percent of the Federal Poverty Level. Assure benefits cover preventive care. Strengthen community health centers. Fund homegrown Alaska health work force training.
2. Affordability: Alaska ranks 47th of the 50 states, with average health-care premiums of $11,542 for employee family coverage. Much health-care spending is for hospital treatment of episodic high-cost complications of preventable chronic illness. Alaska has high smoking and obesity rates. Retiree health benefit costs are a major factor in the crisis in unfunded pension liabilities.
Solutions: Other states have established the definition of health care affordability as the total cost of premiums.Co-pays and deductibles should not exceed 5 percent to 10 percent of family income. Health care must be reorganized around primary care that provides a "medical home" to all patients. Care must focus on behavioral change to prevent the rising epidemic of chronic disease related to smoking and obesity. New primary care payment models must exempt preventive and primary care from deductibles.
3. Quality: Alaska ranks 49th. Nationally less than 50 percent of patients receive recommended care for common chronic conditions. Twenty eight percent of U.S. primary care doctors use electronic medical records (EMRs) compared to 92 percent in New Zealand and 89 percent in the UK.
Solutions: Redesign the office visit around the provision of quality care. Southcentral Foundation has been an innovator in this effort as have community health centers. EMR's are an essential part of quality health care delivery. Leverage Alaska's health care purchasing power to provide incentives for the use of EMRs for meeting quality indicators and the interconnection of health information systems. Medicaid must implement a chronic disease management program. Educational and cultural barriers to patient's health care "literacy" must be systematically assessed and care must be responsive to it.
4. Efficiency: The U.S. spends more than twice per capita for health care as Canada and the other developed nations. The United States has the highest percent of national health expenditures on insurance administration and overhead at 7.3 percent.
Solutions: Encourage public-private purchasing alliances to achieve administrative simplification. Reduce unnecessary care by implementing performance incentives for meeting cost efficiency and quality indicators. Increase transparency in reporting on quality and costs.
5. Financing: Solutions must include collaboration between the separate payers and providers of health care in Alaska, employers, individuals, the state, federal systems, Native health, military and VA.
The Alaska Health Care Commission provides Alaska the opportunity to develop a high-performing health system. Strategies must focus on each of the five interrelated measures. The future health and productivity of Alaskans depend on it.
John Riley is coordinator of the physician assistant program in the Department of Health Sciences at the University of Alaska Anchorage.
By JOHN RILEY