IN THE STATES: Doing Primary Care Right -- In Alaska (Part 1)

I've met Dr. Doug Eby twice, exchanged emails, spoken on the phone, read articles by and about him, and I'm still not quite sure how he ended up practicing medicine in Anchorage, Alaska. But I do know that the innovations and quality he and his colleagues have achieved in a challenging setting is attracting notice in the lower 48.

Eby is a family physician and the medical director of a nonprofit health care system that serves Alaska Native people in Anchorage and far flung remote communities, some accessible only by air.

He has learned that a diagnosis and a pill don't necessarily make a patient well. And he has helped organize Southcentral Foundation (SCF), the tribal-owned system that has attracted notice nationally for its innovation and ability to find a better way to deliver quality health care

Before the makeover, he wrote:

The system misunderstood the core product as being tests, diagnosis, pills and procedures. When individuals sought health care services, providers would take their signs and symptoms, perform a physical examination, and produce a differential diagnosis. Then providers would do what health care does really well: order a bunch of tests. That would lead to a definitive diagnosis, which would then result in pills being prescribed, procedures and tests being ordered, and perhaps some advice being delivered. When the visit was done, the provider thought the work was done.  

 

 

 

 

 But really, that isn't the model that works best for chronic illness, long-term conditions, prevention and wellness. 

The customer decides whether to pick up the medicine the provider prescribes, whether to take it as prescribed, whether to share it with a neighbor, whether to split it in half so it lasts longer, whether to stop taking it in a few days, whether to exercise, what to eat, whether to drink too much, whether to smoke... All of these things are determined by the customer and not always in the provider's presence.

 

 

 

 

SCF, which runs outpatient centers focusing on primary care and jointly operates a 150-bed hospital with the Alaska Native Tribal Health Consortium, regards patients as both its owners and its customers. SCF focuses on community and primary care (broadly defined). The consortium is responsible for more specialized inpatient care.

The clinics provide about 400,00 outpatient visits a year, integrating primary care, behavioral health, and, when appropriate, traditional healing and complementary medicine such as acupuncture. For complex historical and economic reasons, they have to do it efficiently. As Eby explained, they have no choice.

SCF isn't a purely safety net hospital, but it has a safety-net component. Many customers are educated, health-literate and insured. They could seek care outside the tribal system, and, before the SCF makeover about a decade ago, they did. But now they choose to get their care there.

But Eby and the other providers also see poverty, unemployment, and a fair amount of dislocation and family disruption as people transition from a rural subsistence lifestyle to an urban, cash-based environment. "It's fair to say that our population has higher than the general community's averages of risk factors," Eby said. Health care, therefore, must include getting a handle on stresses, smoking, alcoholism, nutrition.

The patient mix means there is also a payment mix -- Medicare, Medicaid, private insurers, and a payment from the federal government based on the tribal status. The federal money gives SCF some flexibilty and room to innovate -- but it also never keeps up with the rising cost of care, Eby said. "We have to become smarter about how we design and deliver services every year," said Eby, who has been there nearly 20 years.

"In our system, every bit of outpatient care is delivered through an integrated primary care team," he said. The team has access to "immediately available advice and support" from cardiologists or other specialists but they are "truly consultants, and not primary care givers." Specialists do see the patients, of course, when needed, but at about one-fourth the rate elsewhere. And when a patient (or customer) does need to see, for instance, the cardiologist, he or she is seen that day or soon after. No weeks of waiting. It's fast and convenient -- the specialists are right across the street, and next spring they will move into the primary care building.

When patients need something, they call their care team -- not via a clerk at a front desk.The team assesses whether they need to come in, and can usually arrange an appointment that day. The team includes primary care provider, a case manager, two medical assistants, and there's one behavioralist for every three teams. 

Because the team works so closely, they pack as much of the routine annual care into a visit. For instance, if a child comes in with an ear infection, the team will make sure they do the appropriate preventive care, immunization, screening and wellness services at the same time. That way there's no need for a special "well-child visit" (unless the child never gets sick enough to need the doctor in between scheduled checkups). A woman who comes in with a sprained ankle may also get caught up on her routine OB/GYN care. If a 45-year-old man comes in for the first time in five years, and he's happy and healthy other than, say, an ingrown toenail, he'll get the relevant routine checks and maybe a tetanus shot. But if he's not so happy and healthy, he may get some help with diet and exercise, smoking cessation, lowering his risk for things like diabetes and heart disease.

It is all holistic -- and scientific. They measure outcomes -- both through standard HEDIS measures and patient satisfaction surveys. Eby lists successes:

• Hospital days per 1,000 people have dropped by more than half
• They have 40 percent fewer inpatient admissions
• Emergency room visits have plummeted
• Specialty visits dropped by 60 percent
• Diabetes is being better controlled
• They have high immunization rates
• They have high rates of screening for colorectal cancer and depression

In part two of this post, Eby shares his "to do" list -- What problems have not yet been solved, what they are doing about it -- and how health reform can help.

Photo copyright Southcentral Foundation