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    A fast year: Lessons from the Indian Health system

    Native American health workers can teach others about rural health care, electronic patient records, and the management of chronic diseases such as diabetes.
    There's much to learn from the Indian Health system's approach to managing diabetes.

    There's much to learn from the Indian Health system's approach to managing diabetes. Association of American Indian Physicians

    A year goes by fast. Way too fast. Thirteen months ago I plunged into my “year-long” exploration of the Indian health system. It’s been fascinating because there has been so much activity: Congress enacted the Patient Protection and Affordable Care Act and included with that bill the permanent authorization of the Indian Health Care Improvement Act.

    My idea was to explore two basic questions. First, what lessons from the Indian Health Service ought to be a part of the national health-care reform debate? And second, what is the impact of health-care reform on the Indian Health system? (I’ll write about that next week.)

    In some ways the first question is the most difficult because of its complexity. The “story” of the Indian Health Service told in Congress and by news organizations is primarily the story of how the government runs a health-care delivery system.

    Sometimes that even reflects a positive message.

    “It may come as a shock to many that when I compare the private insurance industry to the Indian Health Service, VA, Medicare and Medicaid, it is the private insurance industry that is the worst,” wrote Dr. Richard Anderson in the Cody Enterprise, a twice-weekly newspaper in Cody, Wyo. “The reason for this is that when compared to government agencies, insurance companies are not in the business of providing health care benefits as much as the denial of such benefits to make a profit for shareholders. That's why government agencies have much lower overhead and are more efficient in delivering services.”

    Far more often, however, the story is about how government fails as a provider. A recent post on KevinMd.com is an example of that narrative: “So, if you’re in the camp that supports a Medicare-for-all-type solution to our health care woes, consider how that same government, whom you’re entrusting to be the single-payer, has neglected the Indian Health Service.”

    What’s interesting to me about both these posts is that they were written after Congress enacted health-care reform legislation. We’re still fighting over a law that already passed (and, as I have written before, one that will be impossible to repeal until at least 2012).

    But this narrative — Indian Health as a single-payer success/failure — misses the complexity. It’s hard to find many news stories at all that describe the role of Indian Health Service as a partner and funder of tribal, non-profit, and urban health-care organizations, even though that activity represents more than half the IHS budget.

    That’s why I would change the name of the Indian Health Service. It’s no longer a “service,” it’s a system. And in the coming decades I believe the IHS will provide even fewer direct health-care services, while continuing to grow in areas associated with funding or the support of medical innovation and practices.

    So what lessons from the Indian Health system can be applied to the national health-care reform debate? Three quick ones:

    • A demonstration of what it takes to support and operate a rural health network, even in remote locations, using practices such as telemedicine;
    • Experiences with an early implementation of an electronic record system for patients, information that will be valuable as other providers move away from paper records;
    • The search for a financial model that is frugal, yet fully funded. Neither the IHS nor any private or government provider has discovered the right balance.

    But perhaps the most important lesson is the Indian Health system’s history with the care and management of chronic diseases, especially diabetes.

    Diabetes is the most expensive disease in America. It’s the fifth leading cause of death, surpassing AIDS and breast cancer combined. It represents nearly a quarter of all hospital spending, and as much as one out of five health-care dollars are spent on people with diabetes.

    Unfortunately this epidemic is not news in Indian Country. American Indian and Alaska Natives are three times more likely to have diabetes than the white population, and four times more likely to die as a result.

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    Posted Thu, Aug 26, 2:45 p.m. Inappropriate

    Have followed your IHS articles with interest--it's been a year well-spent for you, and readers have gotten some exposure to this system.

    I'd like to take issue with your quotation from Dr. Anderson, but can do so only partially. To tar the entire health insurance industry is unfair and demonstrably inaccurate. For every Rick Scott (the former HCA slimeball and Medicare cheat who's now buying his way to high public office in Florida), there is a well-intentioned and principled executive who seeks to provide value for those who enroll and pay premiums.

    The problems with "making a market" in personal health services are severe, and often subvert the efforts of even the best companies and executives.

    The first of these, let it be admitted, is the need of for-profits to set aside and pass along to investors some positive margin on their investment. This does indeed mean that, ceteris paribus, a for-profit would charge somewhat higher premiums than would a similarly-situated nonprofit (however, since there are so many other inefficiencies in the industry, this really isn't a fatal flaw; it's definitely possible to deliver value to the consumer while still generating a positive margin).

    The second of these is that the essential "unit of production"--the physician--is not answerable to, or at least not completely responsive to, the financing organization.

    The third of these is that beneficiaries very often have a more expansive (and more expensive) view of what should be covered, and on what terms, than does the insurer or its other customer, the sponsoring employer. This is related to the difficulty of writing benefit language that is specific enough for all parties (primary payer, insurer/administrator, provider, and recipient) to agree on.

    Fourth, factors such as varying risk and health status, age, price increases, and advancing technology can operate to destroy the predictions of the best actuaries. This breeds a tendency to build in higher-than-needed risk factors in calculation premiums (an unnecessarily timid, but benign, reaction on the part of some carriers, and a frank exploitation of the 'spread' by others).

    Finally, the nation's insurance commissioners and legislatures don't set and enforce reasonable limits on medical loss ratios (the percentage of premium that is actually paid in benefits), so insurers aren't required to manage to a sensible minimum standard. This is so deeply American and capitalist a dereliction that it almost doesn't need to be mentioned.

    Dr. Anderson's assertion that government agencies have much lower overhead, and are more efficient in administering claims, isn't one that I would accept on face value. That's because of the complexity of the system, some of which is described above, and because one shouldn't readily equate prompt and full payment of claims with efficiency. There are also efficiencies of scale that operate: give the average health insurer the volume that Medicaid or Medicare have, and the other advantages that come with that role, and it wouldn't be surprising if many could equal or better what government does. The unfortunate fact is that you can't run an experiment to actually determine who would be more efficient--so no one can either prove or disprove statements of this sort.

    As for the IHS, I'm not expert on that system--and have learned some things from your series of articles. I will point out, though, that some statements you made could benefit from a bit of probing--for example, the claim that there has been a 13% decrement in the blood sugar levels of IHS patients, that levels of LDL and proteinuria declined, and that there's a reduction in ESRD (end-state renal disease, which precedes dialysis and, often, renal transplant). With respect to blood sugar reduction, you'd have to ask what the baseline levels were, and whether the 13% reduction achieved is commensurate with what is normally achievable in similar populations elsewhere. Similarly, the cholesterol and proteinuria reductions may or may not be consonant with what would be expected of standard therapies in similarly-compromised populations. Finally, it would be worth knowing the details of claimed reductions in severe renal impairment (chiefly, were these findings based on sound clinical and epidemiologic methods).

    This may all sound like an apology for the for-profit insurance industry and a questioning of the value of the IHS and similar government programs. That's not the intent; rather, I point out these complexities and pose these questions to underscore the complexity of the health care industry in its entirety--from conferring eligibility and describing the benefits available to defined groups of people, to empowering and paying those who provide services (corporate or individual), to paying the claims or incurred service costs of we who may be described as consumers, customers, 'end users' or patients.

    The IHS certainly does have something to offer on the basis of its experience; identifying and propogating its "best practices" should be a part of our fumbling efforts to rationalize our systems of care.


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