Judson Howe Sonda, tell me you've largely become known for building a culture of deep trust and collaboration. If I was sitting in one of your clinics for maybe an hour, what is something that I would see that would really encapsulate that Nuka philosophy?
Sonda Tetpon I would say that the teamwork that can happen and what is possible when you have all team members firing on the same cylinders. When you can get a high functioning team operating, their ability to meet the needs of customer-owners as they come through the door really just skyrockets. So the ability to provide a quality customer-owner experience is really demonstrated by how well the team is working together. So that team could be a dentist and a hygienist, a couple DAs, but it also includes managers and supervisors to make sure everything in the background is running smoothly.
Judson Howe Zoom out for me, or actually go backwards. You've used the term “customer-owner” a few times in your explanation. That's not a term that many of us know much about, so why don't you explain what that customer-owner is to you.
Sonda Tetpon Sure. So customer-owners in the Nuka system of care really talks about patients but takes it to another level. Really what we're trying to highlight is that the people really in control of their health aren't the doctors, aren't the dentist, aren't the hygienist. It really is the person living their life and what choices they make on a daily basis. So really talking about healthcare from the customer-owner, personal perspective. Not necessarily the doctor told me I need to do this because of x, but more about it's important to me to live a lifestyle that is conducive to good health, whether that's good blood pressure, good mental health, good oral care, oral health, all of those things are really in the control of the person themselves. You really only interact with the medical or the healthcare system periodically, and the choices you make on a daily basis is really going to determine your health, not how you interact with the health system. So we just really want to highlight that. For both customer-owners themselves, but also for the staff that are working with us. Most staff come to us being trained in what is probably the typical American model of healthcare. I'm going to do this to you, to create health for you. And we have to sort of change that mindset and really talk a lot about with staff, really the people who are going to make an impact on someone's health in the long term for themselves and their family, are the individuals coming to see you, not necessarily the doctor or the dentist.
Judson Howe Why do you think that this philosophy or way of treating people coming to you seeking care is not universally true or used across the American delivery system?
Sonda Tetpon It's a lot harder. I mean, I think philosophically, when you recognize that you're not the one in control, that can really have impact on someone's health, it's that individual person — that's a mind shift for everyone involved. I think it shifts some responsibility to the customer-owner. But it also sort of disrupts the hierarchy that American medicine likes to create, where the person at the top is the doctor who gets to make all the decisions, tell you what to do, and they're right. It sort of evens those levels out, and some people really struggle with that.
Judson Howe Why don't you take us back to where this started for you? Go back to the beginning. Did you grow up here in this community?
Sonda Tetpon Yes, born and raised in Anchorage, Alaska. My father is from Shaktoolik, which is an Inupiaq village up north, next to Unalakleet, which is a bigger community that people might know. And then on my mother's side, we're from the Kenai Peninsula. My great grandma was raised in Jesse Lee home, which was an orphanage on the Aleutian chain. And everybody ended up in Anchorage, mostly for opportunities, mostly so that they could get a career and have some stability with a job. And so that's how my family has ended up in Anchorage, Alaska.
Judson Howe What was your childhood experience with healthcare?
Sonda Tetpon It's a great question. I have a very vivid memory of being incredibly ill. I must have been five or six and it was like the flu. It was a stomach bug. And I remember my mom saying, you know, you've been sick for a couple of days. We need to go in. I need you to see a doctor, and I begged her not to take me to the hospital, because I knew that every time we went, we entered through the emergency room. It wasn't a primary care visit, and every time we went to the ER, it was hours and hours of waiting, 4, 5, 6, 7, 8 hours. And I remember in this one encounter, we went to the ER, we sat out in the waiting room again, and I felt terrible, right? I was really sick, and my mom, we got roomed into a room. I think maybe someone saw how bad I was feeling. And we got into the room, and we knew we were going to wait. And I remember my mom putting me on the exam bed and then turning the light off and coming and laying down with me so that we could sleep until the ER doc came into the room. And it was after that and that experience that at that point, my mom was a schoolteacher, and so she had insurance. And after that, where I really was just like, I don't want to go, please don't take me there. She decided to use private insurance, and we actually left the tribal health system until I was in my early 20s. And it was when I left for college and then came home was my first time I went to the Anchorage Native Primary Care Center. It was old Family Medicine, and I was seen there. But it wasn't until we had moved from the old location, which was downtown and moved into the new location off of Tudor, that I actually engaged back with the tribal health system.
Judson Howe If I was going to ask one of your peers or childhood friends, would they have had a similar experience? Was it a common experience?
Sonda Tetpon Very common. Most of the times what you hear about the old hospital is the smell. There is a very distinct smell. Three things: the smell, the line you had to wait in to get your charts, because you actually were responsible to bring your health record with you to the appointments, and the waits.
Judson Howe Why was that? Why did you have to bring your own medical record?
Sonda Tetpon I can only assume that it's because there was not a better system in place. I'm not sure why, but I'm sure it's because it was not enough staff, not enough people, and an effort to try to get to care as best they could, would be my guess.
Judson Howe You mentioned both your father and your mother were living in different parts of Alaska and found themselves in Anchorage. Talk me through from your experience as an Alaska Native, is that a common transition? Obviously, there's a lot of urbanization happening around the world, but maybe share with me the Alaska Native perspective of that transition to the big city?
Sonda Tetpon Sure, I will say that this would be my perspective. And so there is a lot of diversity in people's experience. So I would hesitate to say that I speak for all Alaska Native people. So again, I was born and raised in Anchorage. My dad moved to Anchorage in his early 20s, mostly for opportunities. He is an artist, so for a long time a soapstone carver but transitioned to ivory, mostly later in his life. My mom was born and raised in Seward, Alaska. There was a lot of travel on my mom's side of the family between Kenai, Seward and Anchorage, and also Seldovia. A lot of that was tied to work in canneries. There were canneries that were in those communities that my great-grandmas had worked in, and so that's how they ended up in some of those places. I think a lot of the time, what ends up happening for people, living in a cash-based economy and there just aren't a lot of opportunities to generate a lot of cash for your own families, that people start to look elsewhere to be able to support themselves. And that really was the story for my father. That really was the story for my grandma, actually, because my mom, again, was born in Seward, and they had moved off of the Aleutian chain and out of Kenai by that point. But really it was for job opportunities.
Judson Howe Dr Doug Eby, Executive Vice President for Specialty Services at the Southcentral Foundation. How long have you been up here in Anchorage, Alaska?
Doug Eby I arrived in 1990 which is about 35 years ago, and I came as a physician just out of training, and I came in the Indian Health Service, at the time when Sonda is referencing, the old hospital downtown that was operated by the federal government, by the Indian Health Service. The regions around the state of Alaska in the ‘90s were moving to local tribal control, but the Alaska Native Medical Center, which is the name for the medical center in Anchorage, moved to tribal ownership in ‘98 and ’99.
Judson Howe You're a family medicine physician. Did you train up here in Alaska? Or did you train elsewhere and then transfer up here to Alaska?
Doug Eby In Alaska, there's no professional training, really. I mean, there is today a small family medicine residency training program, but there's no dental school, there's no medical school, there's no radiology tech school. Almost all clinical professionals have to get their training outside of Alaska. I'm not from Alaska, I grew up elsewhere, and then just moved here after training was completed. But even if you're from here, you have to leave and then come back.
Judson Howe Tell me your story. Where did you come in from?
Doug Eby My family of origin lived a lot of different places, mostly outside of the US, but when it came time for college and medical school, I was in the Midwest. I was in Indiana and Ohio, and did my college, medical school and residency training in the Midwest, and longed for mountains and ocean, which had been my experience other places in the world. And Anchorage had a lot of mountains and ocean and a very interesting cultural environment. And so by then, I was married, had a young child, and we thought this sounded like an interesting place. Just to tell you how smart we were, we came to interview the first week in January, so the sun barely cleared the horizon. There was new snow everywhere. It was stunningly beautiful. But a few hours after we landed, a volcano erupted and shut down the airport for four days. So we thought this was suitably exotic and interesting and unusual and we could give it a try.
Judson Howe You mentioned mountains and ocean. I was thinking, Hawaii also has mountains and ocean, and volcanos, for that matter.
Doug Eby Both my wife and I grew up in tropical environments, and frankly, living and working in heat and humidity has no appeal for us.
Judson Howe So you've been here 35 years approximately. Walk us through that journey and that story for us.
Doug Eby When I arrived, the Anchorage-based Alaska Native Medical Center was pretty much oriented towards supporting the small regional hospitals in the state, so it acted almost entirely as a secondary, tertiary referral center. And as Sonda described, if you needed services and you lived locally, there really wasn't a developed system. You went to the emergency room and you waited and waited and waited, because the system was built around being a secondary, tertiary care referral center, almost entirely. My training was in primary care, and I was pretty fired up to try to help build an actual primary care system in Anchorage, because lots and lots of Alaska Native people had migrated to the city by then and needed a decent primary care system. Luckily for me, there was some ambitious leadership at the small Southcentral Foundation. They had maybe 25 staff at that time but had ambitions to create a very sophisticated, local and regional, capable health system. And so I went and talked to the leadership at the time and found a lot of similar vision, and I was very fortunate to be the first medical physician hired into Southcentral, and I got to help then manage and oversee the transition, bringing in federal employees and building a system for the local population.
Judson Howe I just want to make sure I'm understanding. So this is a small clinic of Alaska Native services here in Anchorage. They had 25 employees, but no doctors?
Doug Eby Yeah. So it had started out of passion of a few people. There was a small dental practice, optometry, and some non-physician mental health, but with ambition to take over what the federal government was running as laws allowed that to happen. So federal laws changed and allowed tribal owners to take over federally run services for tribal people. And the big question in Anchorage was how much of that ownership would be statewide versus local. I got hired by the local entity, which is Southcentral Foundation. There were about 900 people working at the Alaska Native Medical Center. It ended up split, kind of two thirds to a statewide consortium which remained focused on secondary and tertiary care, and about one third of the assets went locally to Southcentral Foundation, which focused then on behavioral health, optometry, dental, primary care, maternal/child health, and other kinds of ancillary and support services for those areas.
Judson Howe So the transition, again this is early 1990s, and there's a transition from the federal government directly delivering services to allowing for Alaska Natives to take control and ownership of their delivery system. And that's the opportunity that the leaders of the Southcentral Foundation in that time saw. Is that correct?
Doug Eby Yeah, it already been happening other places in the country, and it had happened in the smaller regions in the state. In Anchorage, it was delayed for two reasons. One is the government was building a new medical campus. Sonda referenced the old hospital downtown. That's where I started working. But in 1997 the government opened a brand new hospital and medical campus in kind of the middle of the town, and the Alaska Native leadership were waiting for the government to finish building that building and opening it, and then at that point, taking over ownership and management of the Alaska Native Medical Center.
Judson Howe So how big is Southcentral Foundation today?
Doug Eby Yeah, so at the time of transition in the late 90s, there were about 900 total staff that got split then between the new Alaska Native consortium and the Southcentral Foundation. Today, those same two companies employ about 6500 people, just under 3000 at SCF and just over 3000 at the consortium. And then we provide a whole range of services, from engineers helping with water and sanitation, through primary care and community health services, all the way up through a tertiary care hospital, NICU, PICU, ICU, CCU, level two Trauma Center. Kind of the full range. It's a full vertically integrated system but two owners, and we, SCF, are focused on more community, local, regional, primary care, maternal child health, behavioral health, dental, optometry, that sort of thing.
Judson Howe So we go from some 25 employees to —
Doug Eby At first it was about six or seven hundred but we've grown it to just under 3000 since that time.
Judson Howe I want to better understand. I mean, that's a rapid growth cycle for any organization. I'm trying to do the math in my head, that's a 10, 20x multiplier.
Doug Eby It's a big increase.
Judson Howe Was that taxing on the culture of the organization?
Doug Eby Sure, I mean, under the government, under the federal government, there was more limitation on how you could pursue revenues and what funding sources you could pursue and so forth. Today, we and the consortium are both privately held companies, so they're nonprofit health corporations, but privately held, tribal governance and ownership, and that's allowed us to diversify funding sources. So we can draw money from the VA, from FQHC. We run about 15 federally qualified health centers and get some funding through HRSA for that. With Medicaid expansion under the Affordable Care Act, the amount of money brought in from secondary payers like Medicaid, Medicare, private insurance, has exponentially increased, and we can keep all of that. So we have a very multi-faceted funding source, from Indian Health Service to VA to FQHCs to third party, fee-for-service billing. The total still adds up to less per capita total than the average spend in the US. So even today, we're not wealthy, but we're way better off than we were 25 years ago financially. We still run the place on about two thirds of the per capita spend national average in the US, so we're still on the poor side, but definitely much more financially healthy than 25 years ago.
Judson Howe That sounds like a paradox or a contrast to me. So unpack that for me. You said you're two thirds of the national, and yet maybe some would say you're more financially vibrant than others. So can you unpack that for me?
Doug Eby We think and act at a whole system level. So on the medical campus of the Alaska Native Medical Center, all the money is pooled and then shared by a formula between the two owners. And within Southcentral Foundation, part of our revenue comes from the shared Alaska Native Medical Center, and part from things we directly run that are not part of that campus. But we think and act and fund at a global planning level, so the governance and senior executives of SCF listen very extensively to the community. We are truly community-owned and community-driven. What Alaska Native people say they want and need is what we set about doing. I would say we listen at kind of 10 times the rate of listening of most health care organizations. We have tons of tribal advisory councils. We have tons of ways we listen to individuals. We have tons of ways in which you get feedback from the users of the system all the time. Our surveys that we do, we do tens of thousands per year. And all that information goes into informing us what Alaska Native people want and need, and then it's our job to respond and figure out how to create that, financially, program development-wise. So we strategically think and plan and act at a whole system level. Each operational unit, like, say, Dental, where Sonda works, is not financially independent of the whole. There's a small incentive for keeping some revenue you generate, but the vast majority is pooled centrally and then deployed strategically in a planful way to build a system that helps support health and wellbeing of Alaska Native people.
Judson Howe Just going back to the question, and I just want to connect it to the answer. So we're spending two thirds of the national average, and the reason that we're creating some financial success around that is because of you're saying the pooling of those resources. How does pooling the entire resource, how does pooling all the resources lead to better financial performance?
Doug Eby Our vision and mission state that we are in the business of supporting multi-dimensional health and wellness for Alaska Native people. So medical, behavioral, emotional and spiritual. And our governance, our owners are very serious about all those dimensions. So we spend several times the usual per capita spend in behavioral health services, and then we spend considerably less in classic medical services, because we believe that if you can unpack things like generational trauma, family dynamics, parenting difficulties, you can actually decrease the demand for acute medical services, hospitalizations and so forth. And we've actually proven that to be true. By running the system how we run the system, compared to before we took it over, we refer less than half as often to specialists. People are admitted to the hospital less than half as often. We order considerably fewer labs and X-rays, considerably fewer medications than the national average, because we're not trying to just churn, churn, and make people happy in the moment. We're trying to partner in meaningful relationship across decades with people, and they allow for non-pharmaceutical answers to things, and they know that we've also guaranteed same-day access for over 20 years. So if you have guaranteed same-day access, in trusting relationship, where every conversation the story builds on the previous one, you're willing to do less intense testing and less intense treatment, which then saves a lot of money in terms of total cost, but allows you to focus where you spend your money then on things that are actually more directly impactful. An awful lot less indirect costs and overhead as well, if you think and act in a whole system, instead of all these artificial ways in which you have all these intermediaries who skim off a bit of money at every step of the way.
Judson Howe What do you think prevents this from being the model elsewhere in the American healthcare delivery system?
Doug Eby Everything. If you really took our system and scaled it to the entire United States population, we would need less hospitals, we would need less specialists, we would need less pharmaceuticals. There would be less profit made off of procedures and medications and tests. You would need a lot more people in conversation, like behavioral health therapy and primary care relationships. And you'd have to retrain, as we do, you have to retrain all your staff to think differently. We don't teach our people how to churn, churn, churn. We teach our people how to be responsive in story across a long period of time and immediately available anytime anybody needs anything. Even before COVID, we were at 70 to 80% of our encounters in primary care being virtual. So text, email, phone. The smartphone is actually the center of how we communicate and connect with people, not the exam room, and that's dramatically different. Your doctors have to quit being the do everything people. They have to be the facilitator of extensive teams. If you go sit in our primary care clinics, it's like a ballet. The doctor has to sign off on lots of things because of legal requirements, but 80, 90% of the work is being done by other people, by behaviorists, by pharmacists, by dietitians, by physical therapists. The doctor becomes advisory and consulting and supportive but is no longer doing everything, and the exam room is no longer the center of healthcare. It's just another piece, and the center is actually the smartphone through which we text, email, phone, and connect with each other whenever and however people need support on their health journey.
Judson Howe Sonda, this is a unique model, and you're in a market where there's other providers of healthcare. So when you're hiring into the dental programs, do you find that it's a challenge? Do you have to retrain providers from other delivery systems into this model? Or what's that experience like?
Sonda Tetpon It's a great question, and I think that what's unique to dental’s story is we're actually going through a transformation right now, where previously we had a pretty heavy focus on our residency programs, and now we're trying to focus more on clinical outcomes for customer-owners. So where is the oral health for the overall population, that's really what we want to impact. So usually when we hire somebody into our system, it's a pretty complex system. There are a lot of pieces and players. We actually travel out. There's like 55 villages that are within our service unit that we provide dental care to, either through them coming to here in Anchorage or us going out to their clinics and doing a couple clinics a year. So generally speaking, it's more about how we approach the care. It's less about how much productivity do you bring to the table, although that's a piece of the puzzle. We can't ignore that that's important for us. It really is about how do we create a system that surrounds the customer-owner to help get them to the best oral health possible for them. That tends to be a different approach than how many people can you see in an hour? What's your total bottom line of people you see every day? While those things are important, because without access, you don't have care, so we have to pay attention to those things. The way that we look at data, the way that we center ourselves is from the customer-owner experience. People who come to us tend to be more about this is what I can do, this is what I can provide, this is who I can work with, these are the things that I like to do. And at Southcentral Foundation, being a community-based organization, we really are looking at what is the community saying that they want and need, and how do we respond to that? And so that can be a little discombobulating for dentists sometimes, because generally speaking they come and they say this is my scope, this is what I'm really good at, this I don't really want to do, I'm not good at doing that, so I'm just going to focus over here on Endo. And what we need is each general dentist to be very good generalists so that we can provide the most care to the most people with that general team. That is a little counter to modern dentistry, where people tend to be highly specialized, and so we're asking people to be more general and provide more services.
Judson Howe You mentioned a moment ago the way you orient yourself around the data. Explain to me, how do you orient yourself around data differently than others?
Sonda Tetpon So one of the things that we're working on right now are our referrals. So as I mentioned, I think earlier, we have a handful of specialists for orthodontics, endodontics, prosthodontics and oral surgery. We are trying to understand better what our referral patterns are looking like, not only from internal dentists from Southcentral Foundation, but from our outlying regions that we also support. We are not looking at that data based on the experience of the providers. We are setting up all of our data to be through the lens of the customer-owner. So the things that we're tracking are point of referral through when can that person actually get seen. That tends to be slightly different than what I've seen in other organizations, where it's more about we have all of these referrals, we're nine months out, take it or leave it, right? We really want to organize ourselves in a way that we can meet the need. And so if we have really long waits, we really are looking at, why is that happening? What is the experience for customer owners? How can we make that better? And driving work that way.
Judson Howe I'm realizing that in this conversation, I've used Southcentral Foundation, I've also used Nuka. Could you explain to me what’s Southcentral Foundation and what's Nuka? How should I use those terms in this conversation?
Sonda Tetpon Sure. I would welcome Doug to plug any holes I may have, but I would really say SCF is Nuka. Because what I'm describing is really kind of the basis of the Nuka model of care, which is, how do we make sure that everything we're doing from a systems perspective meets the need of the individual and community. So I don't know that you can really pull them apart necessarily.
Doug Eby You mentioned when you first heard our name, you thought we were in Los Angeles or Southcentral LA. That's the core problem is Southcentral Foundation could be in Georgia, could be in Louisiana, could be in California. We're an Alaska Native tribal organization, and so the Alaska Native term Nuka was easy to say, easy to spell, brand identification effort on our part to make ourselves Alaska Native.
Judson Howe What does that mean?
Doug Eby Well, it's sort of a slang term, and you'll find a lot of different people telling you different ways that they use but it's a term of endearment. It's also sometimes used for, like, there's a mountain, there's a Nuka Peak, and there's a Nuka Bay. So it's used for a place name, and then it's used in a slang sort of way as a sort of familiar term of endearment.
Judson Howe Let's dive deeper then now we've established this and we've danced around this in this conversation, but Dr Eby, what does it mean to be Nuka?
Doug Eby So modern medicine, prior to 30 years ago, kind of just trusted all its professionals to do the right thing. I'm a doctor. I'm trained, trust me to do the right thing. Modern medicine discovered, and the community discovered, that a lot of harm was being done. So the whole patient safety movement arose, starting about 30 years ago, and in the course of a few years, modern medicine went from sort of each person craft in their own individual way how to do things, to things like checklists and Six Sigma and Toyota production system theory. So it went from very personalized to very impersonal, mechanical manufacturing-style excellence. And there was some good to that, but only maybe a third or less of what we do in healthcare is actually really manufacturing. Whenever the patient or the customer-owner is passive that applies. But it turns out that more than two thirds of the time what's happening is being driven by people living with chronic conditions, and what happens is then driven by choices that the person makes. Do they pick up their medications? Do they not? Do they take medications as prescribed? Do they exercise? What do they eat? How do they handle frustrations? What's their relationship to alcohol and tobacco? Choices they're making all day, every day, are driving 85-90% of the variables to determine how well they live with their chronic conditions and whether they end up in an emergency room or admitted to a hospital. So what we did was acknowledge that as just fact, and embrace it as reality, and say we live not in a Six Sigma protocol reality. We do that in an operating room and a trauma situation. When you're doing procedures, there are places where that's the right methodology, but most of the time we live in the environment where what the person decides to do or not do and what their goals are, are what drives what happens. And that's actually called complex adaptive system theory. And so we are deep, deep into complex adaptive system theory, which basically says we do know what best practices are, we do know what excellence looks like, but we continually modify that based on the person in front of us, their goals, their values, their ambitions, their plans, what they're willing to do. That's what drives what we do. We're actually a guest at their table and in their lives, rather than the instructors that create a plan and then call them non-compliant when they don't do what we say.
Judson Howe This is really fascinating. I had another guest bring up complex adaptive systems as well. And before that, I had never heard of this before. My personal story is I had been in a system where, as an administrator, I was asked to enforce what we called the sepsis bundle, which I'm not clinical but my understanding is it was when a patient shows up in your ER to be septic, there was a standardized protocol that they expected all ER physicians, whether they were board-certified or homegrown ER-trained, they expected all physicians to behave the certain way under the certain guidelines. And in my personal story, there was quite a bit of pushback from the physicians because they felt that the ability to make decisions in the moment had been compromised by someone non-clinical, e.g. myself. So, you know, just talk me through whether it's a sepsis protocol or something you've had in your experience where you've actually rolled out, you've decided that something can be used Lean, Six Sigma around and where something is that you need more agency too.
Doug Eby The differentiating point is generally when the patient or the customer-owner is passive versus when they're active. So if we are doing things to people, that means we can actually eliminate variation. It's possible to eliminate variation, and it's possible to have certainty as to the one best way to do things, if those two conditions exist, you can eliminate variation, and there's one best way to do it, then you should apply Six Sigma, and you should standardize and protocolize, and you should make everyone do it the same way. This happens almost entirely when the patient is passive, so in procedures and operating rooms and trauma situations, that's when it applies, which is about 1/3 or less of modern medicine. But it is the high acuity, high intensity areas. As soon as the individual or family start to have choice and start to become involved in the process, then rigidity no longer works, because, by definition, there is variation. So people are not all exactly the same, and the best way to approach a person when they have choice about what they're going to do or not do is not going to be the same for every person. So the example of good application of Lean and Six Sigma is like central line placement and management in an intensive care unit. So we place a big catheter under the clavicle into a large vessel and pour medications into their body. Placing that, when I was trained as a physician, it was expected that 15 or 20% of those would be infected within three days. That was like best practice. But it turns out, if you force conformity, protocols every single time exactly the same way, you can lower that infection rate to none across multiple years. And this has happened in many hospitals, so central lines can, if they're placed exactly the same way every single time and maintained by the nurses in intensive care exactly the same way every single time, you can pretty much eliminate infections. And that is life-transforming for those people who are keeping infectious bacteria and stuff out of their blood vessels and their circulation. But if we're talking about a 55 year old Alaska Native man living with diabetes, there are better and worse ways to approach this diabetes, but there's not a single way for every single 55 year old man with diabetes. Things about the person are somewhat variable, not infinitely variable, moderately variable. There are best practices I need to know, but I need to adapt my approach to the person in front of me. Which medication, what dose, whether to start that or push lifestyle issues. That all depends on the person in front of me and what they're willing to do. Because if I'm like, you must take a medication. They're like, well, no, I need to do lifestyle and in a year I'll think about medication. I need to conform to him if we're going to be successful. “Do whatever you want” is chaos. So the doctors who like “leave me alone, I'll just do whatever I want”, that's chaos. And 30 years ago, we discovered that was incredibly unsafe, and the whole patient safety movement happened. So it's never okay for medical professionals to just do whatever they want, but it's also not effective to demand rigid standardization when the individual involved has choice and when there is some variation from person to person to person.
Judson Howe When I first met you, I told you about a video I had seen of you, that you referenced throwing a bird at a dartboard, and I replayed to you the story, and you told me I was wrong. So here's how I told you. I said I was impressed and the way I was impacted by this story was you were saying that, that a lot of this is like throwing a bird, a live bird, at a dartboard, versus throwing —
Doug Eby Yeah, so this comes out of complexity science, and complexity science has this analogy, if you're standing somewhere and there's a target on the wall at some distance, and you have a pile of rocks, you can learn how to throw those rocks and make them hit the target every single time. The rocks are passive. I can study best practices and experts. I can learn about trajectory, about wind speed, and I can eventually make the rock hit the target every single time. The rock is passive, I am active. I can learn how to do it perfectly. But if I have in my hand a live bird instead of a rock, I can push the bird towards the target with some force, and it will move a little bit that way, but where the bird goes is ultimately up to the bird and where it wants to go. So does it want to sit on a wire? Does it want to sit on a fence? Does it want to go to bird food? Does it want to go to its bird babies? So if I need the bird at the target, I have to figure out either how to make my target appealing to the bird so it wants to go there. Or if I'm even smarter, I'm going to figure out how to move my target to where the bird already wants to go. And that's the real secret is for me to turn my target into something that's already of value to the bird. So if we go back to our 55 year old Alaska Native man living with diabetes. In Anchorage, almost every 55 year old Alaska Native man is first or second generation from a village. They almost all go back to the village every summer to do hunting and fishing, and most of the time, by the time you're 55, you have a grandchild or two who are young, maybe one, two or three years old, and you desperately want to take those grandchildren back to the village you came from and do some hunting and fishing and berry picking in that setting. And you especially want to do that once they are teenagers. So if I talked to him about maintaining his eyesight so that he can hunt, and he can see through the rifle to shoot the animal. He can see the bottom of the creek where the fish are. He can see the color of the berries. Maintaining his eyesight, maintaining his fingertips, so he can handle the fishing pole and the rifle and also pick the berries. And maintaining his toe tip sensation so he can walk on the tundra or stand in the stream. So what happens in diabetes? You lose sensation in your toe tips, your fingertips, and you lose vision in your eyes if you don't maintain a really good hemoglobin A1C. If I tell him, we need a hemoglobin A1C of less than seven, he doesn't know what that is. He doesn't feel what it means. But if I tell him, we want to maintain your eyesight, your fingertips and toe tips for 10 years until your young grandchildren become teenagers, so you can take them hunting and fishing and berry picking in the village, I've connected my goal of a low hemoglobin A1C, good diabetes control, to things that are the most important values in his entire life. And if I add that the three year old is going to take grandpa on a walk around the block every day, and during that walking time, there'll be no technology, and the three year old has to listen to the stories from the grandpa while they walk, but then he can have a cell phone back when they get home, now they've had together time. The grandpa gets to tell his stories. The child is helping keep grandpa alive. And we've doubled down on things that are important to the grandpa, and we've got some immediate fitness stuff going on.
Judson Howe Sonda, how does this play out operationally in the clinics?
Sonda Tetpon It's pretty hard to do well at a systems level. I would say that you have to make sure that the staff really are good at connecting with customer-owners on an individual basis, but at a large scale. So we serve 65,000 people, and then the amount of people that the clinical staff are supporting, it is unrealistic to expect them to know every story on a deep level for every person they help. So EHRs, of course, are enormously helpful with that, being able to know the story, what was the last conversation I had with this person? But over time, you end up being able to keep track of some of those things. So highlighting the importance of relationship, setting up your space so that you remove any physical barriers and really set a welcoming space that people can come be themselves and really share what's really happening with them in a healing environment. It's about creating the right environment with the right physical space. It's about taking staff through the journey of it's not just the numbers, it's not just the revenue that you're generating. We really want you to have a connection with the people that you are serving, and how to do that well. Because I think in most training that happens in healthcare, there isn't a lot of time spent on the how do you know me as a person? I tend to be, what are my lab results? What are the diagnoses I have? Where are the areas in my life where I'm deficient, quite frankly? And so helping people understand why relationships are important, what it can do for your clinical practice, and then giving them the tools to be able to do that is, is what I'd say, is kind of the magic mix.
Judson Howe Give me a sense, maybe not in dental, but you were in primary care before. How many unique patients does one of the providers at Nuka have, and how are they able to build a relationship with those folks?
Sonda Tetpon Each panel in general is 1100 customer-owners, is my recollection, 1100-1200 people, give or take. And really, it's important to say that there is this relationship to the institution. There is this in the community, in the Alaska Native community, ANMC, or what it was called ANS, Alaska Native Services, I'm guessing, in the old hospital. I had an auntie who passed from cancer a couple years ago, and she never made it to ANMC. She always referred to the Alaska Native Medical Center as ANS. So there is this, it's where everyone goes, right? So there's this relationship in the community, from Alaska Native people to our healthcare system. So there's that, that's in place. And then there's also the individual interactions you have with the system. So it's more about you don't need to form this deep, deep relationship with somebody in a 45 minute encounter. That is impossible to do. It's more about how does the customer-owner experience their team at an individual level over time? So the comment about same-day access — being available to people when they have a need for the system is really important. We've got to set ourselves up in a way that people can reliably get the care, get an appointment if they feel they need it, either that same day or relatively close to that.
Judson Howe Can you give me a story of a time that a customer-owner has recognized the value of this Nuka philosophy on their lives and their family.
Sonda Tetpon Yes, I can. But before I start, I would also like to say that there is a lot of value placed on Alaska Native hire within our organization. We prioritize Alaska Native applicants, and that's important because of the story I'd like to tell, and it's really about my mom. So my mom was born like I said in Seward. She had me at 25 and so probably until her early 30s, ANS or the old native hospital, really was the health care that she got in her lifetime. She left it very easily once I had spoken up as a young child saying, I don't want to go here anymore. Can we go somewhere else? And she left the system for a long time, and actually only recently returned, I would say, within the last five years. So there are parts of my family who have maintained their relationship with ANMC, but my mom was not one of them. And every time she goes to a medical appointment — any appointment, dental, medical, behavioral health, whatever it may be — she always comments about how much she loves seeing Alaska Native people in the clinics, but not just as janitorial staff or administrative staff, but also checking her in. You know, people in the actual exam room are there to help support her, and that, to her, has been a very fulfilling experience. She also says that there's a complete 180 around how she is treated as an individual.
Judson Howe Compared to ANS?
Sonda Tetpon Yes, yes. So at ANS, depersonalized, very much a hospital setting. Here, she's greeted at every door when she walks in. There's a warm face at the front desk when she's checking into her appointment. The CMA, the person checking her in, often remembers what's going on. She's got some pretty complex health stuff going on right now, so she's in appointments a lot, and she sees the same people over and over again. And so she's had this ability to build a relationship with the primary care provider and their support staff. The person she calls to schedule the appointment is the same person, who happens to be a Native person. You know, the case manager is the same nurse that she talks to every time she has a question, unless she's engaged in specialty services. And the ability to trust that when she expresses a need, that that need is met to the best of our ability as a system has gone really really far with her experience. She now can call her case manager and knows and trusts that that person is going to do what they said they were going to do, whether it's find out about that mammogram she needs or she needs to reach out to a dietitian, and get an appointment, all of those things. When somebody says they're going to do something, something happens, and it happens in a pretty quick turnaround time. That has built so much trust that she now is fully engaged in services on campus, where five years ago, she wasn't coming at all.
Doug Eby When we started all of this, our HEDIS comparable performance was in the bottom fifth percentile in pretty much every HEDIS measure that existed. And over the last 25 years, that has moved to now, with only two exceptions, we're at the 75th or better percentile on every single HEDIS measure. So the ability to identify and manage chronic conditions has exponentially increased for all the reasons Sonda just described. Because the person's engaged. They're owning their own journey. They're connecting with people they know. They're entering a social environment where they feel familiar, where they feel a sense of ownership, but also obligation to do their part. These are all parts of the success so the individual ability to receive story and remember and connect in story over time is, of course, very important. But as Sonda was just describing, there's all kinds of elements of the system that can contribute to that. How we build physical spaces, how we do art decor, the fact that we've raised pride and self-esteem among Alaska Native people about their facilities, about their programs, about their participation, about their ownership of this completely remarkable thing. We now have a national/international reputation, and the pride that that brings, and the want to be part of it in the way Sonda just described, are powerful, powerful things that also help achieve health outcomes. It's all connected. It's all important. The one other thing I want to add to this particular point is we've had, in the last few years, we've had two clinical teams that have gotten to the 90th percentile on every HEDIS measure for their panel, 90th percentile on everything. And so I went and spent time with both of those teams. And the common element they had to get from like the 75th, 80th percentile to the 90th percentile, was their Alaska Native case management support person. These are high-end admin support people who handle all the phone traffic. And what I was told by the doctor and the nurse, by both of these teams, was when they were having trouble getting enough trust from someone to do some hard work to achieve better chronic condition management, they'd hand the phone to their 55 year old Alaska Native case management support person who knew the right way to talk to the person on the other end to get them to do something difficult. And it was transformative. So this idea of community helping community in a way that's known and where each other is helping each other to achieve, that's not just some theoretical, nice to have thing. That actually moves from the 75th percentile to the 90th percentile in clinical outcomes, that actually drives health status, cost and satisfaction.
Judson Howe I guess I'm just trying to wrap my head around what I'm hearing sounds like good human interaction. And recently, I read someone opine that Nuka might be the best healthcare delivery system in the world. Why isn't this being adopted more places? Because I have heard, Doug, people say what Southcentral Foundation is doing is unique because they're in Anchorage, Alaska, and because of their unique funding sources. How does that make you feel, Doug, when you hear that?
Doug Eby When we first started getting a little recognition, and I first would show up at conferences and do some presenting, people would come up to me pretty regularly and say, Doug, you seem to have some talent. Why are you wasting it in the most hopeless place in the country? It's Alaska. People want to visit but they don't want to live there. There's no professional schools. You have to import all these people from outside. You're poorly funded. You have crappy old facilities. Alaska Native people have big socioeconomic challenges. The community and the state and the government have done terrible things over decades. It's like the most complicated, difficult, hard to succeed place in the country. Why waste your time there? Now that we are two national Baldrige awards, 75th or higher clinical outcomes, lots of people all around the world literally saying that we are an example for people to look to, all of a sudden, the message is, well, Doug, that's because you have all these unfair advantages. Who wouldn't want to live and work in Alaska? It's beautiful and wonderful. Alaska Native people love their elders and love their children and have community ethic that's incredible. And look at your buildings. Obviously you've got lots of money, because you have beautiful buildings and you do amazing things, and your panel sizes are half the national average. You must just be wallowing in money. The reality is that we spend about two thirds the national average per capita spend per year -- average, and this is in a higher risk population, socioeconomic, geographic. I mean, there's lots of reasons why our costs should be at the high end, not the low end, and we do this on two thirds of the national average because we don't waste, we meet people where they are, we walk with them. It means we order way less labs, way less X-rays, way less pharmaceuticals, less ER use, less hospitalizations, less specialty referrals. So our primary care cost is very high because we spend a ton on having lots and lots of people in primary care to do all of this work. But all the costs that are generated -- ordering, labs, X rays, pharmaceuticals, referrals, hospitalizations -- are way lower than national average, so our total cost is well below. It's because we've created an intelligent, well-designed system that's built around what works for people on the receiving side, and then just double down and double down and double down on that over and over and over and over, across 25 years of time.
Judson Howe I recently saw a sobering statistic that men of European descent in the United States without high school degrees have seen like a 20-30% erosion in their mortality. And other demographics continue to improve across the United States. So I'm hearing us say that we have challenging populations elsewhere in the United States, and I'm trying to figure out, how do we take these best practices — you know, in healthcare, we're known for taking standards that are working and doing them elsewhere. Let’s get specific. Let's say that you are talking to a health executive in Louisiana, and they're looking at Nuka and saying —
Doug Eby Oh, Louisiana is a great example. The immediate past health director for the state of Louisiana, Dr Rebekah Gee, has discovered us and spent a lot of time with us and gone back to Louisiana and created something called Nest Health. And she is reaching the hardest to reach people in Louisiana. And over the last 18 months, she has produced startlingly amazing, impressive statistics. The changes in the health outcomes of the people that she's reaching now through her organization called Nest Health is blowing the socks off of everybody else, because it's very human. It's very relational. It's meeting people where they are. She and her teams actually go into homes. They don't have offices, they don't have exam rooms. They're doing phone, text, email and going into homes, and providing continual support to the most fragile, difficult families with newborn babies in early childhood. And they're not running a fee-for-service environment. They have a comprehensive, relational, support people where they are, meet them on their terms, and support their goals and ambitions. And it's blowing the socks off outcomes in Louisiana today. And she gives us an incredible amount of credit. She's very generous with her credit of sort of the philosophy inspiring what she's doing. And it's not identical to what we do. In fact, it's a little bit different, but it's exactly the same philosophy.
Judson Howe Doug, I don't know if Robert F. Kennedy has ever called you –
Doug Eby We actually know him, because Robert F. Kennedy actually loves Alaska Native, American Indian people. He has spent more time in Alaska Native villages than probably any other elected official in the history of the United States of America. And he's focused on holistic health, which is a very Alaska Native, American Indian concept. And he's interested in helping people lead healthier lives and deal with chronic conditions. That happens to be our forte. We actually have pretty direct connection to him. And he loves what we're doing. And he loves what he's learned from Alaska Native, American Indian people about what health and wellness and comprehensive approaches to health and wellness are.
Judson Howe So let's say he's looking at the healthcare spend in this country, 18% I think of GDP, and he's seeing some erosion in mortality, or life expectancy, rather, in the United States. And he says, Doug, what's the one thing that I need to do to improve this? What are you telling him?
Doug Eby So I hate the question –
Judson Howe Fix my question then.
Doug Eby Well, what I hate is the what's the one thing. Because what we've done is take an entire system. Not so much the hospital, the ICU, the NICU, PICU, not that. But we've taken the entire community, primary care, mental health, maternal child health, part of this system, and changed literally everything about it. The core element is to refocus everything around the wants, needs, wishes and goals of the people for whom we exist. So that's the one philosophical change. But that doesn't lead to one change. That leads to 100 changes that we've been describing for the last couple of hours. So it’s to be consumer-driven, it's the rock and the bird. How do we move what we do to what it is people already value and want to do and then support them? We teach everyone in our company something called Core Concepts for three days. We learn a common language, common values, common approaches, every single person employed in the company. The next most subscribed classes we offer — we have an entire development center where we spend about 10 times the usual amount on employee development as a priority for us. We're very inspired by the Baldrige framework, which says you have to spend as much time and energy and money on leadership, voice, community, workforce development as you do on system design, quality and measurement. Healthcare understands system design, quality measurement, Six Sigma. They don't understand workforce development, leadership development, and obsessing about what works for the consumer. And Baldridge says, in any industry, that's what you have to do. We believe that, and we invest in that. The second most subscribed course — so Core Concepts for all 3000 of our staff. But the other thing is coaching. We put hundreds of people through every few months coaching classes, and we still have wait lists, because in our system, the ability to connect in story, motivate, influence, comes down to coaching, which, it turns out is basic human relational influencing skills. When we first started getting serious about coaching, it was about 15 years ago, and we started with a bunch of doctors. We put like 10 doctors through a formal coaching class, and at the end of it, like six months later, we went back and checked with them, and they said, oh my god, Doug, my whole professional life is transformed. I now know how to be a better teammate with my team. I know how to better encourage people in the exam room and on the phone. Turns out primary care is like 90% about coaching and coaching skills. And they said, I'm such a better leader as a medical director, because I actually listen to connect, to know how to influence and interact with everybody else in my work environment. And then here's my favorite part. Three of our doctors claim that learning these skills saved their marriages — they were headed towards divorces and separation — saved their marriages and to crown it all several of them said I actually know what to do with my teenagers now. I actually know how to relate to a teenager. I mean, this is life. This is human life. How do we influence each other? How do we partner? How do we coach? How do we be coached? And it's back to the 55 year old man with diabetes and my ability to connect to him around things he already values that are tied to his grandchildren and his traditional way of life.
Judson Howe Where do you think the biggest resistance will be for you and Secretary Kennedy, when you decide to roll out some of these philosophies in the nation. Where is that resistance?
Doug Eby Resistance everywhere. We need less hospitals, less emergency rooms, less specialists. We need less insurance companies. In fact, we don't need any insurance companies if we actually fund things intelligently. Less medical supply people, less pharmaceutical manufacturing. I mean this, this is bad for everybody who has a financial stake in making a ton of money off of healthcare, which seems to be one of the current favorite things to do in the United States of America. The only people who really love this are communities and payers and philosophy people and family members and people who are dying who need support. They all love it, but those aren't the people that control modern medicine.
Judson Howe Sonda, what is the biggest weakness of Nuka in your experience at Southcentral?
Sonda Tetpon I need a second to think of that. It's not without its issues, right? And of course, when you're in management, that's what you see a lot of. You know, what is maybe not working as well as you need it to be, and what do you need to do to fine tune it?
Doug Eby How easy is it to get all the staff to buy into this all day, every day?
Sonda Tetpon It is a philosophy shift for most people. I would say that you and I were talking a little bit about how dentistry and pharmacy tend to attract certain personality types to that work, right? I think you could expand on that and say in healthcare, the things that people are usually good at, what gets them into healthcare is more the academic stuff. They're good at science. They're good at math. They want complex problems to try to figure out, you know, what can they do to help? And maybe that human side isn't necessarily well developed or their strength. And so what we're asking people to do is really lean on that human side. How do you become a really good listener? How do you recognize where your influence stops and where their ownership and responsibility begins? Those things can be really difficult for classically trained healthcare professionals. I also think that compassion fatigue would be another thing that can be hard on folks. When you are in deep relationship with people, you see all of the trauma, the hardships and being able to process all of that, know all of that, and still show up to work every day and do the hard work can be really difficult. And quite frankly, some people can't do it. Some people don't want to sign up for that.
Doug Eby I want to piggyback on that point if I could. So about eight or nine years ago, I noticed that the satisfaction scores among our primary care physicians were among the lowest in the company. They weren't terribly unhappy, but they were less happy than everybody else, so we went and spent a whole lot of time with them, and it's exactly what Sonda is talking about. They said, well, gee, in this Nuka system, we go deep, and we end up spending two thirds of our day on depression, anxiety, violence in families, generational trauma, and people living with pain and addiction. It's just difficult, difficult, difficult most of our day. So at that time, this is almost 10 years ago now, we hired addiction specialists and put them in primary care. We hired pain specialists, fellowship trained chronic pain physician, 30 year experienced chronic pain psychologist — put them in primary care. Hired pain oriented physical therapists, put them in primary care. Hired four psychiatrists, put them in primary care. So now you had 15 additional professionals who are really good at addiction, psychiatric issues, living with pain, mobility, depression, anxiety. And it wasn't magic-magic, but the scores changed, and the ability of the primary care people to deal with this deep dive stuff all day, every day, went dramatically up, because now they had support to help them feel more comfortable and feel supported, and to hand off to sometimes when dealing with this, as Sonda called it, compassion fatigue, that can happen when you do deep dives. Because back to your earlier question about how big the panels are and all that. Not everybody comes in a lot, all the time. The people who come to healthcare, it's an 80/20 rule: 20% of the people on your panel drive 80% of your work. And they're not the 20% happiest, fittest, most healthy people. So you end up in primary care dealing with a lot of hard stuff all the time. Sonda is just exactly right on. I just wanted to double down on the example.
Judson Howe You were a practicing physician for many years. How did you recharge from that, what we now call compassion fatigue?
Doug Eby It's what Sonda started to say and then I added to, which is you build structural support in. You can't do it alone. If you try to carry the load by yourself, you'll do it a few years, you'll burn out, and you'll start to do histories and physicals for Department of Motor Vehicles, because that pays well, and you don't have to deal with depression, anxiety and difficult stuff. You have to add teammates. You have to add breathing space. Primary care is a high volume business, and you're never going to get away from that. So you can't just all of a sudden turn it into low volume, and you can't all of a sudden turn it into happy, healthy people. Those are unrealistic expectations. What you can do is build a more robust system of supports and skilled people to help you carry the load.
Judson Howe What would you say to some family medicine or internal medicine physicians that have just walked away from the system and said, I'm going to go start a direct primary care and have a panel of 400 or 500 or 600 people, and build deep, deep, intimate relationships and they can call me 24/7?
Doug Eby Direct primary care is a marvelous thing in concept. It's exactly what we're doing. You're spending deep amount of time with people who have lots of challenges, and you're not worrying about churn, churn, churn, crank, crank, crank. Direct primary care tends to be a doctor by themselves, with no team for the most part. We're the opposite. We added a whole lot of team members, but it's kind of the same goal. The problem with direct primary care is it's not scalable to all of society. We'd have to produce five times the doctors and 10 times primary care people that we're currently producing. So at present, it is not scalable and sustainable as an answer to society in the United States. It's a boutique, little nice thing to do for the doctor and the people who can afford to sign up for it. You don't see these kind of practices in poor neighborhoods either. So it's a bougie privileged thing. But I understand doing it, why people are motivated to do it. But it's because the system has failed them. And what we've done is create, at full scale for an entire population, a system that actually works and gets you a decent life. One of my favorite indicators is actually the guy you were going to meet with yesterday, Dr Verlyn Corbett is one of our primary care medical directors for over 20 years. And before we did this system, he would end the day at 5-5:30, and he'd still have a pocket full of yellow sticky notes that he had put in -- follow up on this, connect this, you know, things he had to do when seeing people finished. And he'd be there another hour and a half, two hours, finishing his notes and working down his yellow stickies. My favorite outcome measure of the Nuka system is Dr Verlyn Corbett telling me that he now finishes his day at 4:30 or 5 and goes home and has zero yellow sticky notes in his pocket.
Judson Howe I didn't catch why he doesn't have sticky notes?
Doug Eby He’s got 10 team members. He's got a case manager, case management support, a behaviorist, a dietitian, a pharmacist. They're all taking care of all these things in real time during the day.
Judson Howe If I had asked for those resources as a leader in a large health system, I would have been told that I'd be over investing into a non-money-generating —
Doug Eby You have to think total system. You have to think total cost. What amazes me is when I deal with healthcare executives and talk to them — everybody knows that margin is the game, right? Not revenue, but margin, the difference between revenue and cost. They intellectually know it, but they don't act like they know it. Every executive I talk to talks about increased revenue, more throughput, larger market share, better efficiency, Six Sigma, productivity quotas, RVUs, paying for performance. You hit this number, I'll give you more money. Revenue your way out of everything. By practicing how we practice, we have lost like 30% in revenue we could make. Not 3% -- 30% more or less, this is my rough calculation. But we don't crank, crank, crank. We don't see people back for trivial things. We do a ton on text and email and phone that we don't get paid for. We could make a lot more revenue than we make, but by practicing how we practice, we, I think, eliminate about 40% of cost. If you give up 30% of revenue, but you cut costs by 40%, your margin improved. Healthcare doesn't seem to — I mean, everybody's like, duh, Doug, but they don't act like they really understand that. Everyone says there's up to 50% waste in modern healthcare, but they don't do anything about it. We did something about it.
Judson Howe Really impressive, Doug and Sonda, what you've been doing here. But Doug, I want to ask you, what's your biggest failure in the last 35 years that you've been working on this project?
Doug Eby I got old and fat.
Sonda Tetpon Fat's the only thing you can do anything about. You can't fix old.
Judson Howe I can't help you. I don't think there's a medication for that yet.
Doug Eby Sorry, ask the question again.
Judson Howe What's your biggest failure in the last 35 years?
Doug Eby I don't know if it's a failure, but the biggest challenge is maintaining this thing. To run a guaranteed same-day access system for absolutely everything, for absolutely everyone, is nonstop hard work. And the minute you start to compromise a little bit, and you know, just a little compromise here and there, pretty soon, today's work is being done tomorrow, and as soon as you do any of today's work tomorrow, you're dead. You have to do all of today's work today, always without any exception. And COVID did us a lot of harm. We have intensely packed teams and intensely packed spaces, because it turns out, the closer you are to each other, the more you support each other and work with each other. The more you're spread out, the less you do. COVID made us spread everybody out to six feet, which meant half of our staff in primary care got moved out of our integrated care team space into other spaces, meaning they weren't together. They couldn't see each other, they couldn't touch each other, they couldn't hand work off. They couldn't connect with each other by just turning and talking. And the system degraded significantly, and we've been in a hard fight to get all the way back to where we were before COVID. We're most of the way there now, but we're not all the way there now. So my biggest failing is, after 30 years of effort, the system's not performing as well as it was 10 years ago, and I don't know if it will ever perform as perform as well as it was 10 years ago, for a lot, a lot of reasons. Supply and demand of staff is an issue. This compassion fatigue stuff is an issue. Maintaining same-day access for literally anything for everybody is a difficult issue. The threat right now to Medicaid and other funding sources is potentially catastrophic for us. It's very difficult to attain what we've attained, and it's very difficult to maintain what we've created. And it will never be easy. It's messy, human, difficult stuff. By the way, one thing that kind of ties to this is we think that the actual ideal panel size is probably 700-800 and the closest we've got is 1000-1100. So our panels are still too big, meaning all our people struggle all day, every day, to keep up with same-day access, while still doing deep dives on super difficult issues. But I don't know how else we should do it. This is why we exist, is to do this work in support of people and their difficult situations they find themselves in. Cheerleading, supporting, coaching, meeting their goals and expectations, tying our goals to their ambitions and their values and what they're willing to do. It's the only way this ever makes any sense.
Judson Howe What happens after your generation of leadership is gone? Where does this organization go?
Doug Eby Sonda carries it. So it's a little difficult. And Sonda can add to this, because she experiences it a lot too. There's way higher value on flexible work schedules, working less of full-time hours, having pet projects that feed your heart and soul, and that's hard to do in our environment. So we're wrestling with being way more accommodating, flexible work schedules, shorter work weeks, and the balance between what the community needs the people to do, versus what inspires them individually and gives them passion. And that's a tough challenge. The other challenge is that primary care, the way we do it, is somewhat attractive, but for the most part, primary care in the United States of America is terrible and unattractive, and almost no one wants to go into it, or very few people want to go into it, because it's such a drag with so many disincentives and run so poorly.
Judson Howe Wouldn’t that make you a magnet for primary care? For providers across the nation, being marginally better?
Doug Eby We're in Alaska, it's still hard to recruit. We have a ton. We have like 60 primary care provider slots, and we keep them all full, or mostly full, almost all the time. Our ability to recruit and retain -- Sonda has been here forever, I've been here forever, half of our primary care providers have been here forever. We do, compared to almost anywhere else in primary care in the United States of America, we do exceedingly well. Part of the problem though is the training programs. I have a daughter who just came through a family medicine residency, finished 18 months ago. Most of her colleagues are becoming hospitalists, or they're not becoming core primary care people. They're doing other interesting things. They're doing some addictions work, or they're doing sports medicine, or they're becoming hospitalists and not doing the core primary care function. So the training, like our daughter just went through, the training, is still almost entirely inpatient, trauma, high acuity. They come out of training not liking office practice for the most part, not feeling particularly competent in office practice. The MGMA sets the requirements for family medicine residencies and all the rest of the residencies, and their requirements are counter to the skills and abilities that we need to run Nuka.
Judson Howe Why don't we train them at Nuka?
Doug Eby They can't be board certified physicians if ACGME doesn't approve. The actual technical requirements to become a family physician are counter to what we're trying to do.
Judson Howe Have you ever talked to them?
Doug Eby We and other — I mean, this is a national debate conversation. There's all kinds of lobbying going on all the time. Part of this is, what is primary care? What is primary care's role in the system? What do we need primary care people to do? And our model is not the dominant model.
Judson Howe Sonda, where do you want to take this organization?
Sonda Tetpon Well, continue to build on what we've done. I think there is still a ton of unmet need across our community and so getting better at really listening to what people need and want and tailoring our operations to meet that need. It really is about — in my mind, I see our behavioral services division getting much bigger. I see a ton of growth opportunity, even within dental, with the five clinics and 110 chairs, we're not meeting need. We still have some capacity issues, and so I don't think that we have completely realized everything we can be yet, and there's still some areas for us to get better.
Doug Eby I'll just piggyback again. Totally agree with everything Sonda said. But if you look at the whole package of what Alaska Native people need, we're not in the assisted living business. We're not in the skilled nursing business, we're not in the subsidized housing business. We're not as good at end of life and palliative care as we should be. I mean, those are all things that the Indian Health Service just didn't do at all and never funded. And there is no identified funding stream for Alaska Native people for those areas. It's up to us to figure out how to make money off of other things and divert it to those purposes, which is a hard thing to do. I'm just giving specific examples in support of what Sonda said.
Judson Howe Isn’t that what we're proposing the rest of the country do, is go ahead and use other resources just to do the right thing?
Doug Eby Yeah, can you make that happen?
Judson Howe But if we're not willing to do that here —
Doug Eby Oh, we are. We're getting there. This is a decades journey. This is a marathon, not a sprint. Our CEO has great vision around assisted living, subsidized housing, skilled nursing facilities, and desperately wants to lead us there over the next five to 10 years. So hopefully we will. Work to be done. This is a side light, but 15 years ago, IHI and Don Berwick, Institute for Healthcare Improvement, were trying to attract more academic medical centers to become more involved with IHI, and so they asked 15 of us faculty to each write a white paper on the future of medical education, and they thought they would then get these brilliant white papers that they could take to academic medical centers and say, don't you want to join these brilliant faculty who are thinking creatively about medical education? Mine was titled “The current system must be destroyed and completely rebuilt” —
Judson Howe And that wasn't widely adopted?
Doug Eby It wasn't accepted. But I actually explained it all and proposed an alternative. And I think my alternative proposal is completely brilliant, but it's radically different than the current way.
Judson Howe What is that proposal?
Doug Eby Well, first of all, I almost said this in follow up to Sonda, but I decided to just let her statement stand. I was just going to make a smart alec comment that the main way I got into medical school was by sitting alone in a room memorizing crap to regurgitate on the test while the people that were good at interacting with other humans were down at the bar having a good time. And that really you want them, and not me, to be your doctor in primary care. Now you want me to be your orthopedic surgeon, but you don't want me to be your primary care provider. And the fact that we make everybody who's a doctor go through the same four years of training, and some of them are going to do nothing but ACL replacements on knees when they're done is a complete waste of their youth, their time, their money, and society's money. That's insane. You're going to replace ACLs in knees, and that's all you're going to do for your professional life, you don't need to go to medical school. So I proposed six streams, and you would enter each stream, and you could not cross-transfer between streams. And you would progress from like medical assistant to LPN to nurse to nurse practitioner to doctor. And you would learn and then work, and then learn, and then work, and then learn and then work. And you'd have to be convincing that you were worth the investment to progress. So right now, you can go all the way through to practicing physician almost entirely on academia, without ever proving you know how to actually do anything, and that's just wrong. But if you had to be a CMA and succeed, and then a nurse and succeed, and then a nurse practitioner and succeed before you were allowed to become a doctor. And if you progressed up through a certain stream, so you want your surgical people in a stream. You want your rehab people in a stream. You want your primary care, mental/behavioral health people in a stream. And you want your ICU, CCU, intensivist people in a stream, and the fact that they all have to go to this thing called medical school and have that as a common base is completely insane. And most are coming out with $100-300,000 in debt, which also corrupts everything about them financially for the rest of their lives.
Judson Howe It's like, was it Deming said –
Doug Eby That every system is perfectly designed to produce exactly what it's producing. We've produced a bunch of people who love Six Sigma, love protocols, and need to make a shit ton of money and feel entitled because we put them through hell to get where they are. Insane. Don't publish that. Actually, I don't care. I'm retiring and I have no future in academia.
Sonda Tetpon Some freedom in that, really.
Judson Howe Sonda, for our listeners, all five of them --
Sonda Tetpon That's actually brought my anxiety down.
Judson Howe There might be six. What do you want them to take away from this conversation?
Sonda Tetpon Really, I think what really stands out to me are two things. One is the importance of active listening. Are you really listening and hearing what people and communities really need from healthcare? And the second thing I would say is that it's not the census data, it's not the HEDIS measures, it's not all of the statistics that you can get that tell you about a community, that really get you to your end point, which is good health outcomes, and to make sure that you're not over-relying on the objective facts without talking to people directly and collecting information about what people really want and need from their healthcare.
Judson Howe Doug, if it was 1990 again, what would you do differently this time around?
Doug Eby I don't know that I do much differently, because you can move faster to the right answer. But part of what's happening in the journey is the journey and the learning through the journey. And this is part of people that come and visit us want to go from where they are to where we are, like all at once. And if you do that, you do it because of us, and not because you actually learned anything along the way that makes you deeply believe in what you're doing. And so I think that the journey matters. Now, because we weren't following anybody, and we were creating a new reality -- and not that no one, I mean, there are other people that have similar philosophies and elements, but I'm not aware of anyone who's done the whole package like we've done it. So I think you could go faster. But actually I'm not sure that's all that valuable. Something else we haven't mentioned. The other thing that we did right, that I would encourage other people to do, is we visited, visited, visited, observed, observed, learned, learned. You know, almost all the ideas we've had have come from either the community or from other places. What we've done is put them all together and execute at scale. It's not that we've done something that no one else has ever thought of. What we've done is execute at full population scale, sustained for 25 years, and that's actually what we've pulled off that pretty much no one else has pulled off. So every step of the way you have to think about sustainability, scalability, succession planning, which is also why, I think I mentioned to you earlier, we have almost no rules, but we have a lot of philosophies, principles and frameworks. And that is sustainable, because if you have a bunch of rules, you have to then have enforcers of the rules. And that isn't as sustainable as building a philosophy and a culture.
Judson Howe If you're talking to another medical leader or pure administrator, what would you tell them was the scariest moment, or the most fragile moment of this highly successful journey? Was there a moment this almost fell apart?
Doug Eby COVID about did us in. I mean, it did kind of fall apart during COVID, and we have not fully recovered. We're not all the way back to where we were. Getting here is very hard, and sustaining it is very hard. None of this is easy because probably more than anything else you're expecting humans to deal with super difficult human problems — depression, anxiety, abuse, violence, developmental delays. If you just quit saying, here's a symptom, here's a pill, here's a symptom, here's a pill, you're in deep water. And dealing with that and maintaining that is just really difficult stuff, but it is what we are called to do if we are in healthcare.
Judson Howe Dr Doug Eby, Sonda Tetpon, thank you so much for your time today and what you're doing for the conversation across the country.