Yesterday we posted about innovations in primary care and quality improvement in a medical center that serves Alaska Native people. Today Dr. Doug Eby, a family physician and medical director of the nonprofit Southcentral Foundation nonprofit health system, talks about items on his care quality "to-do" list and what dimensions of health reform can help him achieve them.

Dr. Eby spends a lot of time thinking about end-of-life care -- specifically how to "improve the conversation." Many experts in the field of palliative medicine have found that better communication, earlier in the course of disease, can both improve care and save money. Those conversations give patients a clearer idea of the likely course of their disease, and physicians have a greater understanding of patients' values, choices, and wishes.

"We can do a much better job, at less cost," Eby said, adding his goal would be to "help people transition out of life in a wonderfully celebratory way," with their pain controlled, their wishes respected, their stories heard.

Second, he and his colleagues want to address the "high utilizers," the people who are coming in 15 or more times a year. "How do we learn more about them? How do we better meet their needs?"

"We need to understand the social complexity of their lives much better," Eby said. That will require more than managing physical symptoms. They will also have to examine homelessness, social supports, and mental health.  "We need to bring in behavioralists to understand their story," and find ways of addressing their needs in the community.

Third, they want to build on the healthy habits of pregnant women to create a continuum of childhood health from preconception through the first few years of life.

"We know that a large number of pregnant women, and their families, will make very positive lifestyle changes. They'll stop smoking and drinking, they'll get enough sleep, they make a bunch of healthy changes. We've convinced people as a society that that's important to do, and they are a lot healthier. Then, on day one after their pregnancy -- it's over. That's a lost opportunity -- for the mother and the child." Some lifelong patterns, including eating habits and other factors contributing to obesity "are pretty much in place by the time you start school."

Eby's team is exploring how to change patterns of care to create more continuity, instead of repeated broken relationships. For instance a woman may switch from primary care to obstetrics or a midwife, back to primary care, while the child goes off to a pediatrician. "We engineer three or four or five breaks by design"  instead of leveraging that magic moment of a baby's birth into a health opportunity for the child, parents, "aunts, uncles and grandparents."  

Speaking by telephone recently from Anchorage, Eby sounded ready for health reform -- if it gives him the tools he needs to improve care not only of individuals but of a complex community. "The U.S. health care structure is the dumbest thing created by human beings in the history of mankind," he said. "There are good things in it, of course, but the system is insane."

What he's looking for -- besides of course, help for the uninsured -- is change in the underlying way the system works.

He wants to be paid for "doing the right stuff" for improving the health of the population over the long term. He wants to be rewarded for good outcomes, now and over time. He wants a system that will reimburse him for things he knows work -- like care coordination, complex case management, and a robust medical home -- that aren't highly valued, if they are valued at all, in the current payment system. 

"Build in the incentives. If I can improve the health status and drop the total cost -- if I'm on the hook to do that -- hold me accountable. And incentivize me."

And he wants a system that takes into account the social complexity of the clientele for whom we provide services and partner with. "If you pay only for the services, the incentive is for health care providers or organizations to skim the relatively healthy, and avoid or underserve the high-need, high-complexity cases. "It's got to be calibrated... if that isn't built in, you're screwed."

In short, he wants a world which enables him to deliver culturally-sensitive, economically-efficient, integrated health care that addresses the physical, emotional and spiritual needs of individuals, families and communities. Tall order, but he's already started.