Sunday, July 22, 2012

A Formula for Cutting Health Costs -

No matter what happens to President Obama’s health care reforms after the November elections, the disjointed, costly American health care system must find ways to slow the rate of spending while delivering quality care. There is widespread pessimism that anything much can be achieved quickly, but innovative solutions are emerging in unexpected places. A health care system owned and managed by Alaska’s native people has achieved astonishing results in improving the health of its enrollees while cutting the costs of treating them.

At a recent conference for health leaders from the United States and abroad at the native-owned Southcentral Foundation in Anchorage, the Alaskans described techniques that could be adopted by almost any health care organization willing to transform its culture. Such a transformation would require upfront financing for training, data processing and the like, but the investment should rapidly pay off in reduced costs.

The foundation, established in 1982, provides primary outpatient care to Alaska natives and American Indians who had previously been the responsibility of the federal government’s Indian Health Service. It serves 45,000 enrollees in the Anchorage area and 10,000 more scattered in remote villages, most reachable only by air, on an annual budget of $200 million. It also jointly owns and manages (with a consortium of native tribes) a small hospital, and has built a modern campus of outpatient clinics with the help of loans, grants, bonds and retained earnings.

About 45 percent of its revenue comes in what amounts to an annual block grant from the Indian Health Service, a source unavailable to most health systems; another 45 percent comes from Medicaid, Medicare and private insurers, and the rest from philanthropy and grants.

As the Commerce Department noted when it gave Southcentral a national quality award in 2011, known as the Malcolm Baldrige award, the foundation has achieved startling efficiencies: emergency room use has been reduced by 50 percent, hospital admissions by 53 percent, specialty care visits by 65 percent and visits to primary care doctors by 36 percent. These efficiencies, in turn, have clearly saved money. Between 2004 and 2009, Southcentral’s annual per-capita spending on hospital services grew by a tiny 7 percent and its spending on primary care, which picked up the slack, by 30 percent, still well below the 40 percent increase posted in a national index issued by the Medical Group Management Association.

Patients have not been shortchanged; in fact, care and access to services have improved greatly. Patients are virtually guaranteed a doctor’s appointment on the day they request it, and their calls are answered quickly, usually within 30 seconds. The percentage of children receiving high-quality care for asthma has soared from 35 percent to 85 percent, the percentage of infants receiving needed immunizations by age 2 has risen above 90 percent, the percentage of diabetics with blood sugar under control ranks in the top 10 percentile of a standard national benchmark, and customer and employee satisfaction rates top 90 percent.

The staff is trained to treat patients courteously, not with the disdain often reserved for the poor or ethnic minorities. The atmosphere is so welcoming that natives routinely congregate in waiting areas to swap stories and meet old friends even when they do not need medical care.

Although Southcentral has unique attributes (it even refers cases to traditional tribal healers if doctors agree), here are some of its techniques that almost any health care system can adopt:

¶Assigning small teams — consisting of a doctor, a nurse, and various medical, behavioral and administrative assistants — to be responsible for groups of 1,400 or so patients. The team members sit in the same small work area and communicate easily. When a patient calls, the nurse decides whether a face-to-face visit with a doctor or other health care provider is required or whether counseling by phone is sufficient. The doctors are left free to deal with only the most complicated cases. They have no private offices and the nurses have no nursing stations to which they can retreat.

¶Integrating a wide range of data to measure medical and financial performance. Southcentral’s “data mall” coughs up easily understood graphics showing how well doctors and the teams they lead are doing to improve health outcomes and cut costs compared with their colleagues, their past performance and national benchmarks, and it provides them with action lists of what they can do to improve and mentors to guide them. That almost always spurs the laggards. One doctor whose team ranked well behind 10 others in scheduling annual eye exams for diabetics jumped to first place within two months once she became aware of how poorly her team was performing.

¶Focusing on the needs and convenience of the patients rather than of the institution or the providers. The facilities feature rooms where providers and families can chat as equals on comfortable chairs, in sharp contrast to examination rooms where a doctor looms over a patient. Every patient visit is carefully planned so the patient can get in and out quickly without being delayed because, say, a needed lab test result is not available.

¶Building trust and long-term relationships between the patients and providers.

¶Changing from a reactive system in which a sick patient seeks medical care to a proactive system that reaches out to patients through special events, written and broadcast communications, and telephone calls to keep them healthy or at least out of the hospital and clinics.

Visionary health care systems elsewhere are already adopting Southcentral’s techniques, usually after visits to Anchorage to observe them in action.

CareOregon, a small Medicaid managed-care plan in Portland, sent not only its own people but also delegations from the clinics that serve its patients. It then paid the clinics a subsidy to get started and found that, within two years, Southcentral’s tactics greatly reduced the use of costly emergency departments and hospital admissions while improving health outcomes. Dr. David Labby, CareOregon’s medical director, said in an e-mail that the example set by Southcentral was “hugely inspirational” and “remains the model that guides us.”

Similarly, Maxine Jones, the service manager of a primary care practice in the county of Fife, Scotland, is supervising a pilot study for the National Health Service using techniques adapted from Southcentral that almost immediately produced a sharp decline in visits to the practice because many problems could be handled by an integrated team of doctors and nurses by phone. “I can see that this model has the potential to transform the face of primary care in Scotland,” she said in an interview at the conference.

Many other health care organizations in the United States and elsewhere have consulted with Southcentral on how to make their delivery of care more efficient and less costly while maintaining or improving quality. If enough of them summon the energy to transform their operations, their combined impact could help slow the rising curve of health care costs, or even bend it downward.

Wednesday, July 11, 2012

Earliest Americans Arrived in 3 Waves, Not 1, DNA Study Finds -

Published: July 11, 2012

North and South America were first populated by three waves of migrants from Siberia rather than just a single migration, say researchers who have studied the whole genomes of Native Americans in South America and Canada.

Some scientists assert that the Americas were peopled in one large migration from Siberia that happened about 15,000 years ago, but the new genetic research shows that this central episode was followed by at least two smaller migrations from Siberia, one by people who became the ancestors of today’s Eskimos and Aleutians and another by people speaking Na-Dene, whose descendants are confined to North America. The research was published online Wednesday in the journal Nature.

The finding vindicates a proposal first made on linguistic grounds by Joseph Greenberg, the great classifier of the world’s languages. He asserted in 1987 that most languages spoken in North and South America were derived from the single mother tongue of the first settlers from Siberia, which he called Amerind. Two later waves, he surmised, brought speakers of Eskimo-Aleut and of Na-Dene, the language family spoken by the Apache and Navajo.

But many linguists who specialize in American languages derided Dr. Greenberg’s proposal, saying they saw no evidence for any single ancestral language like Amerind. “American linguists made up their minds 25 year ago that they wouldn’t support Greenberg, and they haven’t changed their mind one whit,” said Merritt Ruhlen, a colleague of Dr. Greenberg, who died in 2001.

The new DNA study is based on gene chips that sample the entire genome and presents a fuller picture than earlier studies, which were based on small regions of the genome like the Y chromosome or mitochondrial DNA. Several of the mitochondrial DNA studies had pointed to a single migration.

A team headed by David Reich of the Harvard Medical School and Dr. Andres Ruiz-Linares of University College London report that there was a main migration that populated the entire Americas. They cannot date the migration from their genomic data but accept the estimate by others that the migration occurred around 15,000 years ago. This was in the window of time that occurred after the melting of great glaciers that blocked passage from Siberia to Alaska, and before the rising waters at the end of the last ice age submerged Beringia, the land bridge between them.

They also find evidence for two further waves of migration, one among Na-Dene speakers and the other among Eskimo-Aleut, again as Dr. Greenberg predicted. But whereas Dr. Greenberg’s proposal suggested that three discrete groups of people were packed into the Americas, the new genome study finds that the second and third waves mixed in with the first. Eskimos inherit about half of their DNA from the people of the first migration and half from a second migration. The Chipewyans of Canada, who speak a Na-Dene language, have 90 percent of their genes from the first migration and some 10 percent from a third.

It is not clear why the Chipewyans and others speak a Na-Dene language if most of their DNA is from Amerind speakers. Dr. Ruiz-Linares said a minority language can often dominate others in the case of conquest; an example of this is the ubiquity of Spanish in Latin America.

If the genetics of the early migrations to the Americas can be defined well enough, it should in principle be possible to match them with their source populations in Asia. Dr. Greenberg had argued on linguistic grounds that the Na-Dene language family was derived from Ket, spoken by the Ket people in the Yenisei valley of Siberia. But Dr. Reich said there was not yet enough genomic data from Asia or the Americas to make these links. His samples of Na-Dene and Ket DNA did not match, but the few Ket samples he had may have become mixed with DNA from people of other ethnicities, so the test, in his view, was inconclusive.

The team’s samples of Native American genomes were drawn mostly from South America, with a handful from Canada. Samples from tribes in the United States could not be used because the existing ones had been collected for medical reasons and the donors had not given consent for population genetics studies, Dr. Ruiz-Linares said. Native Americans in the United States have been reluctant to participate in inquiries into their origins. The Genographic Project of the National Geographic Society wrote recently to all federally recognized tribes in the United States asking for samples, but only two agreed to give them, said Spencer Wells, the project director.

Interracial marriage — or admixture, as geneticists call it — may have distorted earlier efforts to trace ancestry because subjects assumed to be American may have had European or other DNA admixed in their genomes. Dr. Reich and his colleagues have developed a method to define the racial origin of each segment of DNA and have found that on average 8.5 percent of Native American DNA belongs to other races. They then screened these admixed sections out of their analysis.

Archaeologists who study Native American history are glad to have the genetic data but also have reservations, given that several of the geneticists’ conclusions have changed over time. “This is a really important step forward but not the last word,” said David Meltzer of Southern Methodist University, noting that many migrations may not yet have shown up in the genetic samples. Michael H. Crawford, an anthropologist at the University of Kansas, said the paucity of samples from North America and from coastal regions made it hard to claim a complete picture of early migrations has been attained.

“Sometimes the statisticians make wonderful interpretations, but you have to be very guarded,” he said.

The geneticists’ finding of a single main migration of people who presumably spoke a single language at the time confirms Dr. Greenberg’s central idea that most American languages are descended from a single root, even though the genetic data cannot confirm the specific language relationships he described.

“Many linguists put down Greenberg as rubbish and don’t believe his publications,” Dr. Ruiz-Linares said. But he considers his study a substantial vindication of Dr. Greenberg. “It’s striking that we have this correspondence between the genetics and the linguistics,” he said.

Saturday, July 07, 2012

Child Welfare Dangers Seen on Spirit Lake Reservation -

Published: July 7, 2012

Federal and state officials say they have documented glaring flaws in the child welfare system at the Spirit Lake Indian Reservation in North Dakota, contending that while child abuse there is at epidemic levels, the tribe has sought to conceal it.

The problems uncovered by medical and social services administrators include foster children on the reservation who have been sent to homes where registered sex offenders live and a teenage female sexual-abuse victim who was placed in a tribal home and subsequently raped.

The tribe, according to federal officials, also hired a children’s case worker who had been convicted of felony child abuse and employed another social worker who discovered a 1-year-old child covered with 100 wood ticks but did not take the child to a hospital.

The conditions led the State of North Dakota to take the unusual step this year of suspending financing for 31 tribal children in foster care.

Concerns about the children of Spirit Lake, which is in a remote area of northeastern North Dakota, extend to minors outside the social services system as well. In May 2011, a 9-year-old girl and her 6-year-old brother were found dead, raped and sodomized, inside their father’s home on the reservation, a federal official said. By the time their bodies were discovered beneath a mattress, the children may have been dead for as long as three days.

The tribe, according to federal and state administrators, has not conducted required background checks before placing foster children, failed to make mandated monthly visits to children in foster care and illegally removed foster children from homes and placed them elsewhere without determining that the new homes would be safe.

Unease about the tribe’s ability to adequately safeguard children has escalated in the past several weeks after two scathing, detailed e-mails were sent by federal officials to their superiors at the Department of Health and Human Services, alleging misconduct by reservation officials.

In a June 14 e-mail sent to his managers in Washington, Thomas F. Sullivan, the regional administrator for the Administration for Children and Families for six states, called on the government to declare a state of emergency at Spirit Lake, cut off the reservation’s federal financing and charge the tribe’s leader with child endangerment to combat what he described as “daunting” child abuse being covered up by the tribe.

The Spirit Lake reservation, like many Indian reservations across the country, has for years suffered from disproportionately high rates of child abuse and neglect, paired with accusations that abuse is underreported and minimized by tribes and infrequently prosecuted by federal authorities.

American Indians make up 9 percent of North Dakota’s population, but Indian children constitute nearly 30 percent of the state’s child abuse victims, a 2009 study by the Department of Health and Human Services found.

While statistics related to abuse at Spirit Lake are not public information, federal officials believe that the reservation has an even more significant child abuse problem than others in Indian Country. As one indication, the reservation is home to 38 registered sex offenders out of a population of 4,500, according to Justice Department figures — a far higher proportion than in most cities and towns in the United States.

The recent e-mails from two highly respected government officials to the health department’s Washington headquarters present a picture of a reservation hierarchy more intent on masking rampant child abuse than on ensuring the safety of children.

“The leadership of the Spirit Lake Nation as well as those who are responsible for delivering services on that reservation, by their actions as well as their inactions, have failed in their most basic responsibility to protect children,” Mr. Sullivan wrote. “They have hung signs at the borders of the Spirit Lake Nation, ‘Pedophiles Welcome.’ They have made these signs operational by firing professionally qualified staff, directing their replacements to ignore reports of abuse and neglect, refusing to prosecute the most egregious cases of abuse.”

While the tribe’s leaders have not actually placed such signs on Spirit Lake, a clearly exasperated Mr. Sullivan also called for Roger Yankton Sr., the tribe’s president, to be charged with a federal crime, saying Mr. Yankton has allowed children to continue to be harmed without addressing the problem.

The second e-mail, written in April by Michael R. Tilus, the director of behavioral health at the federally financed Spirit Lake Health Center, came below a subject line that read “Letter of Grave Concern.” Dr. Tilus said that child abuse on the reservation was “epidemic” and that he had “no confidence” in tribal leadership “to provide safe, responsible, legal, ethical and moral services to the abused and neglected children of the Spirit Lake Tribe.”

Tribal officials did not return phone calls seeking comment.

Mark Weber, a Health and Human Services Department spokesman, said the agency was working with the tribe and other agencies “to address concerns regarding the Spirit Lake Tribe’s Social Service Department.”

Nedra Darling, a spokeswoman with the federal Bureau of Indian Affairs, said the agency, which oversees some of the tribal programs, “has made it a top priority to address deficiencies with the Spirit Lake Sioux Tribal social services program” and plans to “take immediate actions to meet the needs of children on the reservation.”

The agency, Ms. Darling said, is “conducting a comprehensive review” of tribal social services and plans to send a social worker to provide oversight and technical assistance.

Scott Davis, executive director of the North Dakota Indian Affairs Commission, said he had recently met with tribal leaders and believed that many of the tribe’s problems were related to the departure of an employee who had been responsible for filing cases.

“I assume things are on track now,” Mr. Davis said.

Timothy Q. Purdon, the United States attorney for North Dakota and one of the recipients of the e-mails, said he had insisted on holding a meeting with Bureau of Indian Affairs officials within the next few weeks.

Mr. Purdon said his office had prosecuted only a handful of child abuse cases from the reservation in the past year, but acknowledged that others might not have reached the attention of law enforcement if the tribe did not report the crimes.

“This certainly raises concerns for us about the social service function on Spirit Lake,” he said. “I want to meet with B.I.A., agency to agency, and say, ‘What are you doing to make sure we’re responding to this appropriately?’ ”