Talking Health: Taking on the big issues

A conversation with Kevin Howlett

Taking an in-depth look at health care on the Flathead Reservation, Tribal Health Department Head, Kevin Howlett recently spoke about past, present, and future strategies for health care delivery. With the threat of recession facing the United States, concerns surrounding access to competent, quality health care has become a political hot point for many, especially in Indian Country.

“I think if we’re to do an honest assessment of where we are in health care, I think first of all we need to recognize and appreciate the fact we have access to health care. There are many people in this country who do not. It is for this reason I try to remain optimistic about where we, as a tribe, are. The reality however is we only receive about 50 percent of the funding needed. There haven’t been any budgetary increases over the past several years, so our capacity to respond has been significantly diminished by inflation. If someone asks where we are, I like to think of it in this way: we still have our head above water but we’re fighting the current and being carried downstream.”

Getting to this point
“A lot of people really don’t understand how we got ourselves into this situation. The health care on this reservation is different than it is on virtually every other reservation. The differences are a result of a number of actions. First and foremost was the opening of the reservation in 1910 to homesteading. The immigration of settlers created an atmosphere and opportunity for the federal government to look at how to accommodate these settlers with the provision of health care in this new land. It also opened the door for review with regard to the federal government’s treaty obligation of health care to the tribe. Congress enacted legislation for what was probably one of the first faith-based efforts of the United States government. This legislation partnered the government and the Catholic Church to begin providing publicly funded services to Native American people. It was through the Hill-Burton legislation that public funds were allocated toward health care in rural communities. As a result the hospitals in St. Ignatius, Ronan, and Polson were constructed. The intent of this partnership worked for a while, however during this time most of the Indians on the reservation were Salish or Kootenai people. Times have changed significantly and the same cannot be said today.”

The challenge today
“The number of people Tribal Health serves today is 11,000. When you look at the numbers there are only 3,800 members from this tribe included. We are serving roughly three times as many people who are members of other tribes than we are of our own membership. Looking back at the Hill-Burton legislation, it provided for access to care in the private sector. The private sector health care services promotion was the rationale used by the government to stave off building a tribal medical facility on the Flathead Reservation. On most other reservations tribal clinics and/or hospitals were being constructed. The lack of tribal facilities here created a complete reliance on the private sector for health care services. In today’s language this is referred to as Contract Health Services (CHS). Primarily those functions are bought on the outside, meaning outside the scope of what a tribal health facility can offer. In our particular case, the Confederated Salish and Kootenai Tribes do not have a facility. Subsequently contract health care is the access to care and there are 11,000 people eligible to access care from the private sector. So, where in most places people go through the tribal clinic and referrals to specialty care, here people go to the private sector direct. Access to the private sector cannot be controlled and along with that comes a lack of control over expenditures for medical costs. Additionally there is no control over the health care service utilization by 11,000 people. Prior to 2005, bills incurred for health care were paid for mainly by the Tribe. Today the bills are submitted to the Indian Health Service who issues payment. With present funding levels at 50 percent of what is needed, we are forced into a position of assessing (1) how we can control access to primary care and place ceiling levels on related costs; (2) how do we increase our base funding for services; and (3) how do we gain full implementation of the tribes’ right to make local decisions.”

Working toward solutions
“The ability to control and confine health care costs is nothing new. It’s part of health care as a business. If you have unlimited access and absolutely no controls the health care industry will eat every dollar you have. If you are eligible for Indian Health Services on this reservation, you have access to physicians inclusive of Missoula and Kalispell. This access approaches approximately 150 physicians and becomes a nightmare to try to manage.

The solutions would all address, how we as a tribe take forward our case to increase the base amount of money each year, knowing we only have 50 percent of what’s needed available. There are two methods which are congressionally approved. The methods are not considered funding earmarks, but rather processes Congress has approved to allocate resources to Indian Country. One of those is to do a program justification with all the accompanying paperwork, get placed into the system, present our request, and wait 25 to 30 years for it to come up as a priority. The second method, which we are proposing, involves what is known as a joint venture. The tribe agrees to construct the facility per the Indian Health Service established guidelines and formulas, and in turn, the federal government agrees to fund the staffing and operations of the facility. It is important that people understand these are not the Tribes’ formulas; not the Tribes’ wish list. They’re formulas the Indian Health Service has adopted and Congress has approved. If the Indian Health Service were to build a facility for the provision of health care to Indian people, the construction would be based on these formulas. My management staff and I have spent the past year developing a strategic plan which would support this joint venture. Included in the planning meetings were our tribal leadership and administration. Once the plan was finalized it was formally presented to and adopted by our Tribal Council. So we are looking at, and moving forward with the development of a joint venture process. The development can take up to approximately six years. We’re not talking inpatient or hospitalization services. It is our hope to be in a new, modern, fully staffed and equipped outpatient primary care facility six years from now. Our goal is once the facilities are in place those who are Indian Health Service eligible will use them.”

Health care traditions changing
“With the construction of a new facility, we will have the ability to control the costs because we will know how many physicians and other necessary personnel will be on staff. We will also have a greater ability to coordinate care and collect revenue for services provided in the clinics to individuals having third party insurance coverage. From these efforts, we will have met our statutory obligation to provide care for Indian Health Service primary care eligible people.”

Controlling change

So where are we?
So where are we as a tribe in the joint venture process? During 2007, an extensive and time involved assessment of Tribal Health was conducted. The Innova Group, a consulting firm out of Tucson, Arizona was contracted to guide Kevin, his management team, Tribal Administration, and leadership through the arduous process. It was made clear to the consultants, this was not to be a pre-determined course handed to the group for implementation, but rather a concerted effort to develop a plan tailored to fit the unique needs of the Confederated Salish and Kootenai Tribes. Together the consultants and the team walked through the realities facing not only Indian Country, but the nation in health care, crunched numbers, and devised several scenarios applicable to this tribe.

The Innova Group essentially wrote the Congressionally approved process for developing the joint venture proposal and has assisted other tribes in securing joint venture agreements. Kevin stated his goal in this process was not to re-invent the wheel but to adapt what was available to suit our Tribes’ health care needs.

“We have tapped the best possible consultants to assist us with this endeavor,” says Howlett.

Hard work ahead
“We have to work with the Indian Health Service area office. We have to begin to work with our Congressional offices. This will be a six year process. Right now the first thing is to begin framing what we’re calling a white paper. It is a planning paper we would use to educate our congressmen on the status of our health care and the need for this joint venture.”

Another important point is that this project is not something that would take resources away from an existing Indian Health Service operation elsewhere in the nation. Again, it is a congressionally approved process wherein Congress would add to the Indian Health Service budget the necessary funding to take care of the specific needs addressed in the approved proposal. It is an addition to the Indian Health Service budget for a specific reason through an approved process.”

Challenges?
“The biggest obstacle in this case will be opposition from the private sector; specifically out-patient primary care physicians. This is because it will mean people come to our clinic and not theirs. What a lot of people don’t understand is we only have a limited amount of money. Approximately half the money available now to pay for care is paid to primary care doctors. When you only have half of what you need, and half of what you’ve got is being spent so an individual can go to a primary care doctor of their choice, you’re not going to be able to go beyond that point. There is no money to do surgeries, procedures, or MRI’s. The money you do have must be monitored closely to cover the costs for in-patient care, emergency surgeries, heart attacks, strokes, and catastrophic accidents. So you see there are not very many resources available to spread around. What we are coming to understand is if you cap the amount you’re going to spend on primary care, you don’t have a financial unknown out there. The unknown about how many people are going to any doctor on any given day.”

“Why would Indian Health Service eligible people oppose this? I would venture to say it is probably because they’re going to view this as diminishing their ability to have open choice. The thing we have to keep in mind is what our responsibilities are. It is my responsibility to ensure people have access to a broad spectrum of health care; primary, secondary, and tertiary or care at a specialist institution. This care must be done in a competent, fiscally responsible manner. If we choose to do nothing, we will reach a point where the current I spoke of earlier, will take us down. We’ll reach a point where we’ll only be able to be seen by a physician in an emergency situation. This description may seem dramatic to some, but it is accurate. We are going downstream but our head is still above water. We need to get to the bank, literally. It is important to understand, we are only talking about primary care here. We need to be able to increase our base, which this joint venture would allow. In doing so, we are going to have more resources to do things that aren’t currently available because the resources are being spent in the primary care sector. Additionally, we will be able to generate more revenue from third party collections such as Medicare, Medicaid and people who have insurance.”

Breaking ground
“What we are proposing has never been done here. Over the years there have been in and out discussions; but I don’t think it has really become a crisis until probably the last 10 years. We’ve just had an explosion in terms of the number of people who have come into our system. This is a result of numerous things, not the least of which is students and their families who have moved to go to school here. Understand it’s not the 1,200 students at SKC. It’s the five or six immediate family members and extended family members who travel with them, all of the sudden coming into our system. The student remains the responsibility of the place they have come from, as long as they are a full-time student. The families however, access our system and because we don’t have a clinic for them to be seen in, they go to the private sector. Our proposition is not going to take away choice. Those people having third party insurance coverage and wanting to use it certainly can where they want to. Tribal Health will not pay co-pays and deductibles. In other words, if you have insurance that has a $500 deductible and you chose the private sector that is going to be your bill.”

Doing your part to help
“If you have an appointment you need to keep it. Staff time and resources have been allocated to that appointment. We have a terrible no show rate for people who have broken their appointments. Along with encouraging our beneficiaries to keep their appointments, we continue to encourage them to make the necessary lifestyle changes that would improve their health and quality of life. People need to think smarter, eat better, and they need to exercise. We encourage people to engage in activities that promote a healthy community. Our beneficiaries need to learn how to understand and manage the diseases and conditions that afflict them. More importantly, they need to understand they are the first person in the treatment line of defense. It isn’t Tribal Health’s disease. It’s their disease. If they have diabetes, it is a disease they have to make some personal choices about regarding management. Neither the Tribal Health department nor a physician can do what they need to do for themselves. Lifestyle changes include the promotion of preventative programs. We need to get into the schools to discuss nutrition, physical fitness, and the detriment of substance abuse. We need to encourage people to follow the advice of their providers; to be compliant. Our beneficiary population needs to be patient while we continue to work under the present systems in place. For example, in each pharmacy, we fill over 300 prescriptions a day. People can’t treat medical services like fast food restaurants. It’s a lot more complicated and intensive then the current perception of placing an order and expecting an immediate response.”

Thinking ahead
“It is not too early to begin thinking about change. I encourage people to dream of what they want, dream of what they need in terms of healthcare. Dream of how young people can enter the health care, as well as other professions. Dream of our own people holding medical professional jobs which are treating our families. Dream of being able to get the services you need that are currently unavailable because we’re locked into a system that will never be responsive.”

“We have to make changes. We cannot continue with what we are doing. We haven’t been sitting on our hands in the Tribal Health organization wondering. I certainly didn’t leave a council seat to come back here and not try to find solutions. The cause is too great, and the work is too hard to not try and find solutions here. We have to keep our eye on the ball. We have to understand health care is a business and it is a huge business. It is not just a service. It has to be treated as a business, but it also has to be flexible enough to endure the changes we need to make. This is an exercise not only in self-determination; this is an exercise in our definition of what we want for our community as a tribe. It is not just a governmental exercise; it is what we will leave to generations behind us in terms of access to health care.”

“We’ve planned this joint venture concept out to the year 2020. We cannot keep operating year to year losing ground. Unfortunately, that is what we have been doing. Congress is not going to put any more money into the present health care system. We must seek out and go through an alternative process they have approved. My knees are sore from crawling to Washington D.C.; as are many other councilmen’s knees. Five hundred tribes make an annual pilgrimage to Washington asking for more money. Indian Health Service is inadequately funded. Subsequently it cannot give what it does not have.”

If not now, then when?
“This is in your backyard. If you can’t get the care you need or your kids can’t get the service they need, or elders can’t get the care they need, it’s because we haven’t been smart enough. It’s because we haven’t asked, “How do we get around this wall, rather than continue ramming into it?” I am very optimistic that in six years we’re going to be in new facilities. I’m very optimistic that in six years we’re going to have people in training programs and we can begin to think of some of our own people holding some of these professional positions. I am not however, so naïve as to think we’re going to fill every position with tribal members. We need competency. There is no substitute for it in the medical field. It is enough to know these jobs will be there for our tribal members who choose to pursue careers in medicine or allied health. There is absolutely no reason why we as a tribe cannot manage this as a tribal service and business venture. We know what has not worked and we simply know if we do not do something we will be swept away by the current and will go over the falls.”

Photos courtesy of THHS.