Re-Release: The Nuka Blueprint (feat. April Kyle & Dr. Doug Eby)

Speaker A: What does it look like to question how healthcare operates, who its drivers are, who's in charge? And if you flip that and decide that families know what families need and we're gonna give families the keys to the car and let them be the drivers, what do you end up with?

Speaker B: We're walking with, we're partnering with, we're supporting. We're not doing things to people, we're not doing things for people. That puts us in power and them on the dependent side of the equation.

Speaker A: So the control sits with community. And we're asking for our health institution and the people who work in it to rebalance to a role of, uh, shared responsibility and partnership.

Speaker B: What we've done is take the best known practices from literally all over the country and the world, pull them all into a single system that align with our principles and execute them at full scale with obsession for 25 years.

Speaker C: Thanks for joining us for another episode of Moving to Value Unscripted. My name is Dr. John Rodas and I'm a recovering ex hospital president and the president of Moving to Value Alliance. Our mission is to advocate for a value based health care ecosystem with the highest quality outcomes at a reasonable cost for our communities. I want to thank our members who make this presentation possible. We'd like to give special recognition today to our trade member, CT Joint Replacement Surgeons. We're joined today by my fellow board members Lisa Trumbull and Dr. Steve Schutzer. Lisa is the CEO of Southern New England Healthcare Organization, a physician led clinically integrated delivery system in Connecticut and Massachusetts. Steve, a nationally renowned arthroplasty surgeon, is one of the founders of MTVA and is co founder of Upswing Health. We are thrilled to be joined today by two very special guests who have an amazing story we're eager to share with you. Welcome to Moving to value unscripted. Dr. Doug Eby and April Kyle.

Speaker A: Hi John, happy to be here.

Speaker C: Thank you.

Speaker B: April, good to see you.

Speaker C: Thank you, Doug. Thank you so much. And uh, I can't tell you how excited we are to have you here, Daryl. Uh, Moon has been talking about you guys and of course I've been hearing about it. And as we all have Nuka Health System and the South Central foundation, which is Alaska and everyone says it's one of the best health systems in the world. And I know people from all over the world come to visit, so I need to say our listeners are dying to hear the story and uh, we keep hearing all about the story. So maybe Doug, if you want to just start and just give us A little bit of. Maybe a little bit of your journey of how you got from finishing, uh, residency and family medicine and somehow ended up in Alaska in the first place, and then just maybe transition into a little bit at Nuka and how it got started and, you know, what it was like before and what it's like now.

Speaker B: So I had the usual medical training of a physician in the US and came, uh, to Alaska in 1990, so 35 years ago now. And at the time, the Alaska Medical center was run by the Indian Health Service, by the government. I was a family practice doctor, but I was put to work in what was called the emergency room, which is essentially where everyone went. It was a big, huge walk in clinic. Everything from heart attacks to, you know, earaches. Not really much of a system design and pretty much no acknowledgement of the fact that there were tens of thousands of people living locally, in addition to being a hub for the whole state. So within a few years, we had done a lot of work to redesign the whole outpatient area, create actual primary care, redo the emergency services and so forth. Uh, a lot of good work using something called TQM and CQI. But then in the mid-90s, it became apparent that the whole system was going to move from federal management to tribal ownership and management, as is permitted under federal legislation. And that started the journey of transitioning from looking internally for answers to instead following the lead of the people for whom, um, the system exists, what we call customer owners. The Alaska Native people who took actual formal ownership, but also, in our case, became actually the teachers and leaders of how we designed and recreated things from there. And I'll turn it to you, April.

Speaker A: Uh, my name is April, and I'm, uh, serving as our president and CEO. I've been here for 22 years. I, um, am Alaska Native. My family's from the Native village of Ninilchik. Uh, while Doug was working in that, er, um, my family was using that old health system, the hospital that was run by the federal government. And it wasn't the best place in Anchorage to go. It was underfunded. There weren't ways to access care other than through the emergency department. It was very responsive. And we had this great opportunity to, um, decide as a community that we wanted to own and operate our own health care system that came from the Indian Self Determination act, which had passed in the 70s. And, um, all across the nation, really, Alaska Native people, American Indian people, were thinking, you know, maybe we want to do this differently. What would it look like if we operated our Own services, and we're a product of that. It's sort of a grand experiment. What does it look like for a community to lead, operate, run, design, Imagine what they would want their healthcare to be. We're just a part of that in Alaska. So there's a whole tribal health system. It's a regionalized system. We are one of the regions in the Alaska tribal health system. We happen to be the region that's based in Anchorage. So we're the region with the, uh, biggest population and we provide the local and regional services and we cooperate with our tribal partners, the hospital that's here in Alaska. And what people come to learn from us about is just whole system transformation. What does it look like to be willing to, you know, really question how healthcare operates, what it's based on, who its drivers are, who's in charge. And if you flip that and decide that families know what families need and we're gonna families the keys to the car and let them be the drivers, what do you end up with? And that's the journey we've been on for decades.

Speaker D: What a unique opportunity, right, to be able to take a, uh, community and work with the community to design a health system. Can you talk a little bit about what that experience was like for you all and how'd you go about that? What kind of ideas came out and a little bit more on the journey to get to where you are today?

Speaker B: I've been hired by the, uh, CEO at the time, Catherine, uh, by 94, 95, so several years ahead of the actual training transfer, which happened then mostly in the later 90s. So by the time the transfer of ownership happened, I was chomping at the bit to get going. Kathryn and I and the community, lots of conversations, we pretty well knew, you know, what sorts of things we were going to do. But Katherine was very wise and said, Doug, the first thing we're going to do is a very extensive listening process. And for six months we didn't change anything. We did tens of thousands of surveys, we did thousands of people in focus groups. We did 1001 on one interviews with anyone who wanted an interview or thought they were partner, had a title, and spent, well, four months in a very showy listening process and in two months collating the millions of data points and information that we got. And out of that came something called operational principles, which we created in the late 90s from, um, all of that input. And that's still how we run the company today. The operational principles are central. If things people want to do, align with the principles, we're likely to do them. If they don't align with the principles, we're not likely to do them. They're detailed enough that you can actually take an idea and score it. So it's like 13, 14 points. It describes in quite a bit of detail exactly what the people said would work and wouldn't work for a system. So relationship based, immediate access, continuity based in story building on strengths, easily accessible, measured and accountable, coordinated, no duplication, and built around what works best for the people using the system rather than the people staffing the system. So powerful, powerful process and powerful product that has pretty much driven everything we've done now for the last 25 years. People ask us, what should we do first? We often quote that story and say, first, listen longly and deeply and thoroughly to the people for whom you exist. That's not your staff, that's people receiving services. Now, uh, it's important to listen also to your staff. We listened very extensively to our staff because the people other than the community who know best are the people directly interacting with the community all day, every day generally not the executives in the executive suite. So a lot of staff input as well. But at the end of the day, primarily voice of the community.

Speaker E: Just a follow up question. Was that fortuitous that the government just said, hey, let's transform from federally managed. What was the incentive for them to do that?

Speaker A: Yes, Steve, the history is that, you know, it's hard in a podcast to really talk about the harms that came to Alaska, Native and Native American people on this continent at the hands of our government. You know, there was an opportunity historically for tribes to um, interact with the US Government through treaties. And one of those treaties said that Alaska, uh, Native and Native American people would receive health care. So the government has a treaty obligation to provide health care to Native people. And so they created this branch of the government called the Indian Health Service. The reality is the government's never fully met that treaty obligation or fully funded the ihs. And there was a lot of criticism about how do these services look, what's happening? And Congress looked at that and the congressional findings in the 70s acknowledged that the underfunded IHS system was causing harm rather than creating wellness for Native people. It opine that perhaps if the community who's receiving those services had a voice or even better could lead those services, they could create systems that would really improve the well being of their own people. So it was a really cool opportunity in the 70s, but it came from a, uh, really never meeting what the federal government's responsibility is to the indigenous people.

Speaker E: And this was a national transition from federal. Right.

Speaker A: So what happened was the Indian Health Service was operating sort of across the US and in places where Alaska Native American people are. And the Indian Self Determination act gave tribes tribal organizations the opportunity if they wanted to contract or compact in order to receive those federal dollars and design their own health care system. So it was an option that played out differently in different places. In Alaska, Alaskan people said, uh, we want to do that, let's figure out how to do that. And we decided to do it collaboratively as a community. And in the beginning that base funding that ihs, that IHS money that came to us sort of was how you operated healthcare. It was the majority of what we did over time that's been sort of flat funded and we' and we are funded more like everybody else. So Medicare, Medicaid, third party payers really interested in what's happening at a federal level with Medicaid and changes to how people are paid. So we operate more and more like anybody else in the healthcare market. Our difference is that we really consider our driver, our voice, our leader to be community. And that everything we do or change or try is based on what people and families need. And the question is, so how has that worked? Right, so you've been doing that and what's the result then? And when, uh, you look at this primary care system that we've developed and the outcomes we've created, that's why people like you reach out to us and say, hey, let's talk to you. What have you done?

Speaker B: There's a number of people in the US that have the idea that if we could just move to a single payer system or to community driven healthcare, that magically all the problems will be solved and all will be good. And that's just not true. I mean in our case we are vertically integrated and all our money is under our control for all of the different pieces. And we are community owned and community driven. But the real secret sauce is what you do with that. It creates possibilities that don't otherwise exist. But it's not matching magic in and of itself. In fact, most tribally operated places and most community health centers, FQHCs are in control of their own destiny and are locally governed. And they don't all just magically produce the results that we have produced because the, um, culture and ethic of modern medicine is also very dominant. Pretty much everyone who works in healthcare has been trained in the modern medical model and the modern medical model is in incredibly institution centric, professional centric, negativistic and judgmental. And we have pretty much moved away from all of those things. So even if you get community ownership and uh, vertical integration and single payer, if the medical model remains dominant, you still have huge problems. I'm a doctor, I was trained. You know, I sometimes joke that from the beginning of my training, the end of my training, basically it was how to take a two and a half hour history and physical and put it into 10 minutes. And that's only half joking because that is essentially what you're taught is how to take the human out and put the technical in. So a process in an exam room looks like, first of all, I can't talk to you if I'm not in an exam room, which is ridiculous. Second of all, you come in, we don't know each other, in a few minutes I get what I need to know. I tell you this is your label, your diagnosis or multiple diagnoses. And then I tell you what you're going to do. You're going to take these pills, you're going to change your life in these ways, and then you'll come back in a little while and we'll see how you're doing. And then when you show back up and you haven't done exactly what I told you to do, I call you non compliant in my condescending, judgmental, harmful, arrogant, institution centric way, which is horrible. And instead for us, it's a journey. People live their lives in context over time. We make it so that they can always see the same people pretty much every time. We've guaranteed same day access for over 25 years and now we've moved on to the concept of immediacy. If we're not in contact with you within a few seconds, you're going to give up on us and you're going to do something else. Because we live in a culture of immediacy and so we need to be able to respond to that. So phone, text, email, video, or in person, they drive how they interact with us and we accommodate them. Which means 70 to 80%, even before COVID was being done virtually and essentially asynchronously. Because they control, empower how they connect, we guarantee access whenever and however they want to connect to the people who know them. So every conversation is part of a single story over time. So what we've done is taken best proven practices from literally all over and put them in this philosophy, run on principles, not rules. And then we have Executed. And that's a big part of our story, is having actually done what a lot of other people talk about and pulling it all together into one system, one place, uh, that actually works based on this philosophy that April's articulated and that our entire system is, uh, based upon.

Speaker C: You remind me a little of, uh, I was just listening to, um, Dr. Chen, who started Chen Med. His two sons, you may know, wrote a book called the Calling. And when. When Dr. Chen started his. His company, his. His idea was, okay, how many patients can I see in a day? And. And. And I'm not suggesting this is your model, because I know it's not. But he said, oh, I. I think I could see 20 patients in a day. And then he said, but I want to see them every month. So if I see a patient every month, how many patients can I have? My panel. And the math worked out to 450. So he started with 450 patients panel, and he saw them every month because paraphrasing what they were saying is that his idea was to help people work with them to get the sense b. To have them do behavior modification, which you need to trust for people to do that. You need to establish a relationship over time. And after three or four or five, six months, the patients get that. And again, I know I call them patients, and I'm sorry for that. Um, the customer owners, you know, start realizing, oh, you've got my interest in mind. And hence his company, Chen Med. So I think your model, if I remember what I heard when I heard you speak before, let's put a little meat on the bones of actually what the model looks like, you know, who's the provider, Because, Doug, uh, to your point, I've said this many times, this podcast, most of us learn, learn diagnosis and treatment. That's what we're taught in medical school. We're not talking about. We don't talk about prevention. We don't learn about nutrition. We don't know about sleep and stress. We don't learn about the continuum of disease. We just learn diagnosis. I say diabetes, you say, you know, metformin or glucophage. I say hypertension, you say as orbs or beta blockers. We're taught diagnosed treatment. We're not taught about the continuum. And listen, I learned in medical school, but native Alaskans have a lot of health problems. They're prone to diabetes. They're prone to obesity or prone to suicide. I still remember prone to alcoholism. You know, the dark winters. So you guys didn't examine. Exactly. You start with a healthy population. So tell me a little bit about what the model really looks like. What's the nucleus of care? I get immediate access. People contact you, they call you, they get in quickly or they communicate with you through text phone. How do we get them out of the emergency department to actually know what's the model that they come to?

Speaker A: I'm going to tackle that John. I'm going to start a little broad and then we'll dive into kind of now what is our current clinical service delivery model in this longitudinal relationship primary care place. And Doug, I'll ask you to fill in some of those details as well. But I just, I just want to comment that, you know, what we know is that communities, families and people are very good at understanding what their needs are and of uh, designing solutions. Right? That, that our people have been doing that for, you know, generations. So there's this, this idea that if you empower communities and you ask them, you know, what's happening for you in your life, what do you need? What if we built that, what could be your partner? It requires that the competency you build as an institution is the competency of being in relationship. And I just want to begin by the fact that those relationships happen at many levels. First of all, you can't just say your community owned. What does that mean practically, how do you be led by your community? So this idea of macro level ownership and being driven by community and then how do you create that as the way of doing business is important. And then you have to acknowledge that there is is no right clinical service delivery model because the needs of your community are forever evolving. So the relationships are intended to allow you to continually hear what your community needs. So how our community will interact with us is going to change. Right? We're interacting with cell phones more than we are with phone calls. And so how will our healthcare system be what our community needs in the future? The answer to that question is by A creating the way to be in relationship to hear from community and B innovating based on that community's direction. It's very hard in the US when the pressures that are driving you are all of the regulations, accreditation, how you're paid, risk of litigation, all of those things. We're accredited, we're managing all of that risk too. We're just not allowing it to be our driver. So that macro level relationship is important and that competency of being in relationship at a micro level is also important. So how do we think about a family and who they interact with in our system? And how we create touch points in that interaction so that that story can be shared and that relationship can be built so that we can walk in somebody's journey with them in a positive way. And the thing that we've invested a ton in is how we do that within the primary care model. So now that I've gone big, if we can dive down into primary care, Doug, I might ask if you want to do a little bit of that.

Speaker B: Yeah. So the core competency needs to be trust, coaching, influence and partnering, uh, with people. And that's not how I was chosen to go to medical school. It's not what I was taught in all my clinical training, including even my family medicine residency. So we have to own training and teaching all that competency to all of our staff, which we do in a very specific, sophisticated way. And April can describe to you core concepts and all the ways in which we retrain. Essentially, we don't replace, we add, you know, because we still want your clinical competencies, but we want it in a different package. So our teams today have 40 to 70 touches per day, but only 10 to 12 of them in person on any given day. Because we've created a, uh, system built off of how they want to connect to us, which turns out they don't really want to come to our exam room most of the time. And if we've known them forever, we don't need them to come to or exam room most of the time. So our panels are right around 900 to 1,000. Uh, we think it's too big. We think they should be 7 or 800 ideally, but that's what we can afford. Uh, we are not rich. Our per capita spend is well below the national average. But we created panels right away from the beginning. We created case management, care coordination. So every provider had a nurse case manager full time right from day one. And we moved over six months time from weeks of waiting to guaranteed same day access for anything and everything you wanted five days a week to your primary care provider and case manager, manager guaranteed. We've done it now for 25 years and then we pull in additional resources and that kind of evolved over time. So we did those three things first. The next thing we did was add behaviorists. And these are not co located psychotherapists, these are behaviorists. They do cognitive behavioral therapy, short term, practical problem solving. And in fact, if you want psychotherapy, we have behavioral health clinics we send you to. By moving to that kind of basic underpinnings, you drive down the need for specialists. You Drive down emergency room and hospital use. You drive down lab, pharmacy, and X ray, but you drive way, way up. Behavioral health, we have, as, uh, April said in her introduction, we have arguably the biggest, most sophisticated, sprawling behavioral health system and all kinds of programs, all kinds of programs, from residential to crisis, uh, addictions to, you know, psychotherapy, family therapy, all the whole range of things. And we have, like, five times the usual amount of that. Because when you go deeper, dive, there's no here's a symptom, here's a pill anymore, right? We're deep into generational trauma, depression, anxiety, parenting, marital stuff. I mean, all, you know, the deep stuff that drives, really, health outcomes and health conditions in practically everybody. Uh, that's where we live. And so our people have to be skilled at doing that. But it turns out total cost goes way down, and health outcomes actually go way up. You asked earlier about kind of the. So what, uh, our whole population as a whole was in the bottom fifth percentile for pretty much every HEDIS outcome measure that exists, including screening, prevention, but also car, chronic disease management. I got real aggressive and went to the board and said, hey, I want to set, you know, 50th percentile as our goal, which is ridiculously high from where we are. And our board says, so you want to be average? I said, yes, because we're no close. And they said, well, we don't want to be average. So for 25 years, the goal has been the 75th percentile. And after all this time, we are achieving that, except for two. I think there's two measures. We're not there, but we have pretty much achieved the 75th to 90th percentile. And pretty much every chronic disease management prevention screen screening, all the HEDIS measures, there's like 75, you know, different measures we benchmark to. And so we've moved in an entire population from the bottom fifth to the 75th to 90th, uh, while driving down total cost, while having satisfaction ratings of people using the system at 96, 97, 98% positive, even asking things like whether their culture was valued, whether they are an active participant, whether they own their own health journey. Things that both health systems don't even ask. We ask and get that feedback. And our staff retention, positive feedback from our staff, runs about 90, uh, 5%. And our turnover is well below industry averages. So happier people on both sides of the encounter, less total cost, very expensive primary care, but way less total cost, uh, to the system, way happier people, better retention, and dramatically improved outcomes. So this actually works better and our story is specific to us, and some things we do are very specific culturally to Alaska Native people. But these basic principles and premises and approaches is literally work anywhere in the world that there's, uh, healthcare. That there's a system, you know, something called a healthcare system, and it solves many of the evils and problems of the modern medical system.

Speaker C: April, you want to add anything to that, to what Doug said so far?

Speaker A: No. I'll just say that the experience from the perspective of community has really been night and day in a system where we used to access the ER and the hospital. We've decreased ER utilization, hospital stays, and lengths of stays. And we are redefining what this word primary care. What does the word primary really mean? And our vision is a Native community that enjoys physical, mental, emotional, and spiritual wellness. We think far too often the medical model focuses on the physical wellness of an individual. And we know that our wellness is really multidimensional. Physical, mental, emotional. It's no longer okay to say, don't worry, we have behavioral health. It's in that other building over there for that one uncle in your family. Instead, we're saying what's primary is really your whole self, and not only your whole self, but that we journey in life with others, and our wellness is impacted by others. So we're thinking about wellness for people and for families and for communities. And so our interventions look like interventions individually, involving family in those things, and then really being part of the fabric of community and thinking about community fabric as it drives wellness. So when we think about what our NUCA system is, it's really beyond just healthcare and has to do with, like, you know, how do people live and what can our role be related to how we can live with more balanced wellness in that multidimensional way.

Speaker C: Right.

Speaker B: We've evolved this thing now over 25 years, and where we started is no longer where we are. And so the first big ad was all those behaviorists, and they continue to be completely fundamental. Primary care is primary care for medical, it's primary care for mental, it's primary care for social services, all in the same place. You call the same number, which, uh, is your team, by the way. You don't even call the front desk. You connect directly to your team.

Speaker C: Nice.

Speaker B: The case manager has what's called a case management support person, one for every team, and they're the traffic cop. All the phone, email, texts, whatever are going to, that person literally sits right by the nurse. That literally sits right by the provider. And they decide together, sort of who to pull in for what. And that gets to the next point, which is over time, we decided to start pulling in expertise to the hub instead of sending people all over the place for expertise. After 25 years of evolving this, we've reached what we think is kind of the proper balance. So you can't co locate everything, eventually it becomes unwieldy and impossible to manage. Uh, but we did pull in a lot of things. So basically really high volume stuff and high frustration stuff. And also we right sized all of our clinics. So we used to have big monster clinics and we've broken them all up. So it turns out the sociology of the workplace tells you you can run on family dynamics with up to 15 staff, up to team dynamics, up to 70. When over 70 you become a bureaucracy by definition. So all of our clinics are 60 to 70 people, which is five or six primary care teams, and then all the associated other people. And so like in our main building here in Anchorage, we have nine identical primary care clinics in one building. And you always go to the same place, you always see the same people. So as far as you're concerned, there's one clinic, but there's actually nine in the building, all identical. And in every single clinic there are five or six of these teams of four people. Right. So the provider, the nurse, the case management support with the nurse, and then cma. A, uh, CMA that's helping move people in and out of the rooms.

Speaker C: Doug, let me interrupt for a second. Just so I clear. The provider is a, uh, family medicine physician or a nurse practitioner or internal medicine trained.

Speaker B: So about 80% percent are, uh, family physicians. We have one or two general internists and we have several very high end PAs or nurse practitioners who started with us in other roles, but we're super superstars and now manage a panel pretty much same as physicians too. So There's a few PCPs that are nurse practitioners or PAs in our particular model in the city. Now we also support over 60 remote villages. And let's come back to that as another topic, okay? Delivering healthcare to rural and remote locations is a worldwide challenge. We are world class at that as well. In every single clinic there are four or five of those teams. Ideally there would be a behaviorist for every team, but we haven't figured out how to afford that yet. So we're at a basically a two to one ratio. So there's two or three behaviorists in every one of our clinics. There are two or three midwives. Pregnancy is a primary care condition. So all pregnancy that's uh up through kind of moderate risk risk is handled in primary care and there are midwives who help the teams with that. But it's in primary care all ages are seen. So children, elders, women's health, everything. So there's a pediatrician in every clinic. So one pediatrician for every five or six thousand total population. They help with complex children and they help the generalists with children in general so that we don't ever miss developmental delay, autism, any kind of, kind of challenge that children might have. Because if you get them very early in their development you can completely change the trajectory of their lives. So there's a pediatrician, they are supportive of the teams but co located in every clinic. There's a dietitian in every clinic. There's a clinical pharmacist like a um, PhD level PharmD level pharmacist in every single clinic by a mandate. Every elder who is on five or more medications gets a pharmacist review because polypharmacy and elders is a massive problem generally resolvable if we get smart, smarter. The pharmacists are an irreplaceable, incredibly important part of every clinic. Tremendously underutilized in healthcare in general, but not here. Oh, and there's a um, structural social worker person. So not a clinical social worker but a, you know, logistics social worker in every clinic too with placement and just logistics of frail uh, people. Uh, by the way, our behaviorists, we started thinking we were going to hire a bunch of psychologists. Turns out clinical social workers are the best behaviorist. So we do have some psychologists, we have family therapists, but the majority are clinical social workers that are behaviorist because they're willing to do short practical stuff instead of long term psychotherapy. And then shared across those nine clinics are as a whole other layer of people. There are four psychiatrists. And it turns out by having psychiatrists help family practice people or generalists, uh, manage psychiatry things, they can triple the caseload that they can handle. And you never have enough psychiatrists. So hugely impactful to, to put psychiatry right into primary care. There's a fellowship trained pain doctor with 10 years of experience before coming here, very high end pain specialist who does diagnostic workups. So helping both the provider staff and the uh, family and the person with lived experience understand if there is a miracle cure or not or if they have to live with it the rest of their life. And then there's a psychologist with 30 years of chronic pain experience helping all the generalists manage people living with pain for the rest of their Lives, chronic pain. Yeah, massively impactful addictions is another thing. We've put expertise into primary care. We have home visitors. There's teams of people in every clinic who can be extenders of the primary care team. So rather than a separate standalone home health agency, they're just built into the clinics and extenders of the primary care teams, but they can go into homes. We have a particular emphasis on super high risk families with babies, newborns, children under the age two, uh, home visiting support for them. We've actually taken on parenting as part of what we teach everybody because it turns out society sucks at parenting. And so we've taken it on as

Speaker C: something we now most important job we all have with the least education.

Speaker B: So the idea is we're taking responsible for everything that matters to health and healthy families and healthy multi generational, uh, realities. And then we're pulling in all these experts physically into primary care. And then all the other ologists are still sitting in their separate offices. So cardiologists, pulmonologists, gastroenterologists, dermatologists, all those people are somewhere else. But they support the whole tribal system, which means they're used to doing phone and video consults for generalists. They respond quickly to us, they'll give us pretty immediate support, which then cuts in half the people that are referred to them and keeps the work in primary care through phone and video connectivity of, uh, specialists. I actually think AI is going to make a big difference here too, in terms of helping generalists get to specialized knowledge when they need it. So we refer to specialists 65% less than we used to. And the whole thing thinks and acts and works as a network pulling information, people and support towards where you are.

Speaker C: And those m, those specialists are not. If I, if I gap gathered what you said, it sounds like they're sep, quote unquote, separate. You said separate. You mean they're also not employed by

Speaker B: the ones, the ones that are physically in our space, like the psychiatrist. And all them, they are salaried the same as all our people are. The other people are primarily employed a little bit by us, but mostly by our sister company who primarily operates the in hospital and uh, adult surgical and medical subspecialties. They're on the same campus, but they're, you know, half a mile away or whatever on the other side of the, of the campus. And so they support us virtually and we can send people to them if need be. But because they work in a system, they cooperate with us and everybody's on salaries. I in particular, but Our system as a whole thinks that individual pay for performance is evil and corrupts and deprofessionalizes people and needs to be avoided at all costs. Let me take a breath there, see what April wants to add and questions you have.

Speaker A: I'll just add that this tension between how much to integrate into primary care care, how big for any one primary care clinic to be, how to be able to sit in relationship within a primary care clinic and when is the right time really to refer to a specialist. This is attention that we have played in for a long time figuring out the right balance of. So we find there's a whole bunch we can do when we bring expertise to a generalist team or that generalist team is expert in the relationship. Right. The relationship's what's most important and we value that. There's times you are going to need to go see a cardiologist. And so our relationship between the primary care practice and the cardiology practice is important. The service level agreement where the two clinics talk about what do we expect as cardiologists from primary care, how do we write that down, what's going to happen before that referral, what will it include and then what is the like pull discharge back into primary care where that longitudinal relationship says. And so uh, we talk about relationships being important, but we haven't really hit on sort of structurally how do you think about relationships across parts of our system. And that has been an important part of our system journey. Not perfect, but something we worked really hard at.

Speaker C: Yeah. And over time of course primary care of docs are getting or providers are getting smarter by that relationship they have with those specialists. And as Doug said, I think AI might actually start even accelerating that if we use.

Speaker A: John, just following that comment, if we use psychiatry as an example, we began by co locating psychiatrists and the psychiatrists were physically working in the primary care clinic, but they had a caseload of people who they were delivering services to. And then we piloted the integration of psychiatrists. So rather than psychiatrists delivering care, their customer group was the primary care teams and they could provide consult services, case reviews to primary care. And what you find is that primary care provider who is in good relationship with a family is able to manage a certain amount of complexity, try a certain number of depression medications independently, but when they have a colleague in the practice who they can confer with, the level of complexity they can manage is much better. And you end up serving people and you don't. We call it lose them to the stairs. You don't refer them somewhere else in the system that they never get to, because it's called behavioral health, because you've brought that expertise into that behavioral health environment. So the expertise that exists in primary care, either by way of, uh, those primary care providers or their colleagues who are there, really improves the delivery of care. It leads to people look at our system and say, how could you ever afford that? And the answer is just think about what would it look like if we had really robust, strong primary care and how would we save money in other parts of our system? And there's a lot of talk about that. There's a lot of talk about what that could look like. Very few places where you can see it. Decades in practice.

Speaker D: Yeah, I was going to say it's just tremendous what you all have built over time. And you really have embraced the core concepts of whole person care and integrating everything into primary care. I believe completely in what you're saying about behavioral health. If you don't have access to those resources, you can't attack the medical conditions as well. Um, and I come from a previous system, before this job where we had integrated behavioral health. We were fortunate and it's just remarkable what can be done with primary care and behavioral health put together. But, um, what I was curious as I was listening to you describe what you have built, do you think your model is portable to other places in, in the country?

Speaker B: This is portable literally everywhere, especially everywhere that the medical model exists, which is like 90% of the earth. We just had our big international health conference that we throw every year in the summer. And we had people from Singapore, Sweden, Australia, New Zealand, all over Canada, the US that came here for a deep dive with us for a week. So, I mean, Singapore is arguably the most efficient, cost effective system in the world. And starting 15 years ago, their primary care system system for complex individuals was a pretty much exact clone of our system after coming and spending a whole lot of time with us. So it's definitely affordable anywhere. The problem is most of the powers that be in modern medicine don't like us. We use less pharmacy, less lab, less X ray, less specialists, less er, less hospitals. And at least in the US that's not financially popular with anybody. As it turns out. Part of the reason we have a positive margin every year is because we decrease cost by more than we give up revenue. We probably give up between 20 and 30% of revenue we could be making if we forced everything into visits. But we also save 30 to 40% in per capita spend by driving down all the expensive stuff and so our margins are great, but more because of decreasing cost. Healthcare doesn't understand this. Healthcare says they understand it, but they really don't. They just keep trying to figure out ways to increase their market share, increase their throughput, use Six Sigma to drive out waste, which is, you know, fine stuff. But that's not the core problem. The core problem is the wrong model.

Speaker D: How did you pivot economically to the point to be able to afford the level of resources that you have in terms of primary care and behavioral health? And what's it like to recruit the right talent into your model? What's that experience like for you?

Speaker A: I think it required us to be willing to imagine a different model, to grab onto these principles that were going to be important to it and to give up other things that existed in the system. So we had, you know, nurses who were the specialists of this or the specialist of that, and we sort of did away with all of that. And that was hard for people because those were their babies and that they had. And we put all of our eggs in this primary care basket. And you asked Lisa, so what does it mean to hire people into that? I think the first, like just before that is how do you walk with your current employees who are transitioning into that new way of thinking? And Doug was part of that. That took a lot of strength to do. And then, uh, we got really good at figuring out what our core workforce competencies are. What are our values? I mean, I hope what you're hearing hearing is we're really pushing against the hierarchy of modern medicine where the healthcare system is in control and people and families are patiently waiting to be recipients of something. And instead of that, we want that control to change. So the control sits with community. And we're asking for our healthcare institution and the people who work in it to rebalance to a role of shared responsibility and partnership. Bring your expertise, but value equally the expertise the family is bringing to that relationship. So we had to get good at figuring out who are the people, people who are somewhere aligned with that way of thinking, that it makes sense to them. It doesn't mean if you like to golf, you're going to take Fridays off. This is not a, ah, this is not a provider centric model. Even when you join us, as Doug mentioned, what we're doing really goes in the face of how you've been trained, how you learned to practice before. And so we're going to help you onboard into this system. We spend a lot of time intentionally walking with people as we think about how do we sit in relationship with each other. There are, there are no physician lounges or doctor's offices. You are a partner with the community member, case management support, who is on your team. What does it look like to be in relationship with that person? That's a lot of the work that I do that I really enjoy. So we're investing in that workforce, being ready for it. If I can add just one more thing, it is a task to change what is the culture of healthcare into this newcosystem of care. It takes intentionality. We work at that every day. But that's actually easy. Easier than reorienting a community to its relationship with an institution of healthcare.

Speaker D: Mhm.

Speaker A: Community's orientation to healthcare happening generationally over time where people feel that sense of ownership and responsibility that they are in the driver's seat, that they have voice that they can tell us what do they want out of their, out of their healthcare system. And I think it's exciting to see us, uh, increasingly achieving that different relationship between community and system.

Speaker B: We didn't leave that to chance. We very directly and purposely. For 10 years after we took over, for 10 years, we used newspapers, we used radio, we used websites, and in all kinds of ways to message what the role of the individual, family and community was different in this system, as well as staff learning what was different. Everyone had to relearn in the system. It took a decade.

Speaker C: Yeah, changed the model. You changed the paradigm. You changed the whole model.

Speaker B: Took 10 years, uh, to change it. I will say there was a little bit of a generational thing going on there too. If you were under 30, you were like, well, finally about time, you know,

Speaker C: and if you, my kids, my kids

Speaker B: say yeah, if you're over 50, you kind of said, well, this is not what going to the doctors. Like, I don't like this. The other thing that, that we haven't emphasized very much yet, April's mentioned it indirectly a couple times, but there's a massive amount of infrastructure under this that we also had to be very intentional and good at. We spend, you know, five to 10 times more on primary care than the usual system. We also spend 10 times more than the usual system on workforce development. Development, workforce training, massive investment. We have a whole huge building that's dedicated to workforce training. We over over 150 courses that we formally teach. Literally everyone goes through a three day core concepts training, which April directly leads as a CEO every single time. It doesn't happen if she's not available, but then pretty much everybody takes coaching courses and motivational interviewing and then tons and tons of technical courses. We have a whole infrastructure around helping people use their computers and electronic health records. Records optimally, uh, which is massively underdone in, in healthcare, we have about 10 times the usual amount of improvement staff. We have about 45 full time improvement advisors and improvement specialists scattered around the whole system which helps staff and support improvement projects at any given time. They have four to seven different projects they're supporting, all of which are led and staffed by staff. So that means we have somewhere between 75 and 100 major improvement projects happening across the company at any given time. And we still do that that even 25 years into this journey. We already mentioned we have many, many times the usual amount of behavioral health. About, uh, 15 years ago, we bumped into the Baldrige framework. Um, and that was very important for us. We knew that all these other areas needed investment. But healthcare thinks if you do operations well and you measure and give people feedback, that the rest will take care of itself, which is completely not true. And Baldrige makes it very visibly not true. They expect you to put as much time and energy into leadership, leadership strategy, customer voice, corporate culture, data workforce and knowledge management as they do into operations. And healthcare does not understand this. Even if you go to an IHI conference, it's 90% operational design, safety and measurement and all the rest of that stuff. You have to be super intentional about all those different dimensions. So we did, starting 15 years ago, beef up the areas we weren't as strong in. We're still the only healthcare company in the entire United States to win the, the national presidential award in Baldrige twice. And, uh, we were one of the finalists last year. Almost won it a third time. We did not apply this year. We'll apply again next year. And they don't hand it out for being cute and interesting from Alaska. We get other things for being cute and interesting from Alaska, but we don't get, uh, awarded by Baldrige.

Speaker C: Um, yeah, for our listeners and having thought about it, Steve Schutzer was humble before, but the joint replacement program that he really started actually was 99% on outpatient experience. They included outcomes, patient reported outcomes for a year after surgery. I mean, I can go on and on about it, but we thought, I thought about Baldrige just for that unit. And for our listeners who are not familiar with Baldrige, not only did you guys win it twice, you know, nobody wins the Baldrige twice. I mean, I think Ritz Carlton maybe won it twice. I mean, it's an unbelievable accomplishment. I wanted to segue for a moment at a hospital. So I'm a hospital guy. I ran a hospital. I remember when we interviewed Scott Kennard, who had a great primary care, big practice, and the hospital in town ended up buying them. And then soon after they bought them, they shut down their operation. Because you were so good, you were reducing hospitalizations, you were costing us money. So they stopped doing it. You guys actually ended up doing the opposite, actually buying a hospital, I think, because you didn't own the hospital from the beginning. Did you? Tell me a little about the hospital management? It's got to be a little bit different than what we talked about up till now.

Speaker A: So because we were designing a tribal health system that would serve Alaska Native. Native American people who are living across the state, our model was to create regional tribal health organizations. So we're one of those where the local community within that region would own and lead the development of services, decide what their priorities were, but in addition to what you can build across regions. Remember, we're the big. We're in the two big cities. But, uh, some of the regions have very small populations. You don't have the economy, economies of scale, to have the continuum of services in your region. Some of the regions have small hospitals, but every region refers in to the statewide hospital. Statewide hospital's hub is in Anchorage. Our hub is in Anchorage. So rather than having a, uh, big regional hospital and a statewide hospital, we put the two together. So we're on the Alaska Native Medical center campus. And interestingly, this campus that we're on and the partner that we have, anthc, who operates the state statewide services, and we operate some of the statewide services and all the primary care services. Um, their board of directors is all the regions. So rather than having sort of a corporate hospital system that then runs all the little things, you have the regional community system who runs the big hospital. It's really the opposite. And you know, we think that the services individually that we deliver are important, but the relationship between services and how we think of continuing continuum planning is important too.

Speaker B: Just to follow April. Part of the maturation of our system over time has been this, you know, increase in investment, conscious investment in leadership development and workforce and coaching and training and, and all those, all those improvement, uh, capability, all those things. But the other thing is to deepen our capabilities around very high complexity and very high risk subpopulations. So we've built out what I believe now is one of the top five pediatric and adolescent neurodevelopmental clinics. In the whole US So for the last seven years it's been a huge project. So if you have uh, autism or brain injury or fetal alcohol, uh, we have a whole huge integrated multidisciplinary team. They don't replace your primary care provider. They're in addition and there's a whole lot of in home and in school capability and stuff built into that. Uh, we have something called intensive case management where we use bachelor's level clinical social work people to come alongside people living with long term mental health challenges who will never live fully independent lives. And so we have very small caseloads, uh, it's called intensive case management. And again they don't replace primary care. They uh, just deepen the companion, uh available to help you navigate life. And these are people who otherwise are often, you know, homeless or an emergency room rooms or you know, just very expensive to the health system people. And we have dramatically reduced their total cost to the healthcare system by doing that. Traumatic brain injury is a whole category of people that are under recognized and undertreated and massively expensive. We have a whole approach there. We are like quadrupled the size of rehabilitation. So we have you know, pt, ot, exercise physiology, but we added chiropractor, massage and acupuncture to that list. So we built build in complementary and alternative medicine. We provide uh, vitamins and supplements, ones that we've reviewed and approve and so forth. We have tribal doctors, traditional healers and tribal doctors who often work with people who don't have so much physical findings as they have. And they're not classic mental health, they're sort of soul sick. They're experts in partnering up with sort of that subgroup of people. Uh, we've got all the usual stuff, maternal fetal medicine, gynecology, oncology, all, all that kind of stuff. Our ob gyns, we have a ton of ob gyns, but they're mostly gynecologists who do a little bit of super high risk OB in our delivery. The actual labor and delivery area is pretty much midwife dominated. So we're very midwife centric. And As I said 70, 80% happens in primary care. Just the really high risk stuff goes to OB or maternal fetal medicine.

Speaker C: So it's unlike the lower 48, you have a low C section rate. I'm guessing as a result we have

Speaker B: like the United States lowest, it's like 11, 12%. It's low but we don't want it to be dangerously low. It's one of the things we track and worry when it gets Too low because our staff considered a point of pride to not do sections to the point where sometimes it maybe is a little dangerous. So our problem is worrying about too low of a C section rate, not the.

Speaker C: That's uh, a good problem to have.

Speaker B: Other way it is. And then just a couple other things. We deofficed everyone about 15 years ago. So no doctor's offices, no offices for executives, no offices for managers. Everyone's right in the mix of the work that they do. If you can't see, feel and hear the work in real time all the time, I don't know how you manage it and supervise it seems obvious, but that's lost on everybody. As, as April mentioned, we eliminated disease specific. We don't have disease specific clinics, we don't have disease specific nurses because we can't afford it. We put all our eggs in the everything for everybody, whole person, whole family bucket. Because most healthcare runs three parallel primary care systems in the same system, which is the disease specific system, the whole person system, and the home visiting system. And we can't afford three different paradigms. So we're all in on one. The principle based approach to management is also sometimes called tight. Loose tight, meaning we obsess about philosophy and principles. That's the high tight. And we obsess about outcomes, that's the low tight. But so long as you produce the outcomes and are philosophically consistent, we're loose about how you organize your team, how you handle your work, how you structure your day. Day. You can pretty much do anything as long as you do all of today's work. Today, every single day, meet all the needs of your entire panel. And your happiness scores and your clinical scores are all excellent. You get a tremendous amount of freedom about how you actually, it reprofessionalizes the professionals. Sometimes called tight, loose tight, sometimes called complex adaptive system theory. And we are very expert on all of that, which goes back to running on principles rather than rules. For example, staff often want, you know, if you're more than 10 minutes late for your appointment, you're going to get scheduled instead of seen. Well, that's stupid. Because it's people who have the hardest time showing up on time who most need us. We also change all the words. So we talked about customer, owner. They own their health journey. They make choices like a customer. That's why we use that word. Um, we also hate the words compliant and non compliant unless it's uh, discussing whether staff is compliant or non compliant with the wishes of the person on the receiving side. We try to eliminate words like caring for. In modern medicine, Talk talks about caring for people all the time. We're walking with, we're partnering with, we're supporting. We're not doing things to people, we're not doing things for people. That puts us in power and them on the dependent side of the equation. So all those words, uh, modern medicine is just rampant with negativity and paternalism. And we're here to do to you or for you. And we're trying our best to eliminate all those words and all those paradigms because they're in control, they're in charge. We're guests at their table, and we're here to offer safe and reasonable alternatives and support and cheerleading, but they own their journey. Guests at their table, that is not caring for or doing to people.

Speaker C: You should start at medical school.

Speaker B: Well, so the Institute for Healthcare improvement asked me 15 years ago to write a white paper on the future of medical school education. And they asked about 20 faculty for IHI to write these papers because they wanted to attract more academic medical, medical centers to the IHI Club. So I wrote mine. I thought it was completely brilliant, but the title was why Medical Education as it currently exists should be abolished, which was not very good. I love it. It wasn't very good for attracting academic medical center. So they did not use my white paper. But I thought it was completely brilliant.

Speaker C: I'm sure it was. Doug, I just want to finish one thing you mentioned earlier about, you know, Alaska, again for us lower 48 types, just to remind everybody. I mean, Connecticut, tiny state, but if I have it right, I think Texas could fit twice in Alaska. So even though you guys are in the quote unquote, South Central, it's still a pretty large geography that's pretty spread out. And you have villages that you alluded to that you care for that can't easily get into the hub, so to speak, at the Anchorage. How do you guys manage those?

Speaker A: The answer is that we partner with a local community. The community establishes a, uh, health council that represents various families in different parts of the community. They become our on the ground around, uh, governance for their clinic. We work with them in all of the decisions around the budget, the type of employees that we have, the hours, the clinics open, sort of all the things around how it operates at, uh, a macro level. We as leaders spend a lot of time sitting with and listening to community. Doug hasn't mentioned this yet. We, the investment in listening and being with community as executives is just way more than I found in any peers that we have and we have a modified model, right? We're not going to have have FPS in 55 villages in our region. And so it depends on the size of the village. In a sub regional clinic, we might have advanced practitioners. And in a very small community, we have what's called community health aides. And community health aides are community members who've decided that they want to become their local healthcare providers. And we've created within the tribal system, not just scf, but the whole system, a training program where somebody can start as a trainee, come in, get training, um, have clinical supervised hours and experiences, work under a certain amount of autonomy based on the training they have, but be the primary care delivery system. And our smallest of communities, you know, have 48 people who live in that community, you can only access it by plane, 55 people who live in that community, you can only access it by plane. So it's a matter of working with community to say, what do you think might be the way that healthcare could deliver be delivered for you locally and being responsive to their ideas and direction and then working in partnership with community to design a very small healthcare system that is connected to that sub regional hub and that Anchorage community. So in Anchorage, our primary care teams, many of them, 60% of them, are connected to a village and they are the everyday connection to the community health aide in that village. Get an appointment and say, oh, I'm managing the prenatal care, but I'm noticing this red flag. I'm going to reach out to my Anchorage team and have a conversation with them about that decisions can be made for that individual to coming into the sub regional hub, huh, for services or to come into Anchorage for services based on the complexity or what's happening. And then we can also notice the frequency that that community might need somebody to travel in to provide care. So we'll operate specialty clinics and have Anchorage based folks come in, some like for a three day trip or four day trip. So that's how we deliver dental services. For example, we don't have full time dental providers who are in those areas. So they do community trips and go out and do them throughout the year, different places. So we haven't talked a lot about, uh, rural and remote, but I think remote in Alaska is a whole new category. Traveling in a tiny plane with a lot of really heavy dental equipment.

Speaker B: But all around the world, governments struggle with how to get health care to rural and remote locations. And all around the world, their favorite answer is to bribe doctors, nurses and pharmacists to go live they don't really want to live. And, uh, all around the world, this model fails all the time. And it continues to be the model that's perpetuated all around the world. And so you go to these conferences or whatever on rural and remote health care, and they're all trying to figure out how to bribe doctors, pharmacists, and nurses to go live where they don't want to live. It's a stupid idea. It is not sustainable. It has failed for many decades. So instead you do what April just said. You find people who already live there and who want to live there, who are willing to be trained up, and then you support them. The urban health care system must have as part of its obligation the support of rural and remote health healthcare. So almost all of our primary care providers have one, two or three villages. In those villages are what April described. And all day, every day, they're giving same day access to those people. But those people are the PCPs. Our people are the support. The people on the ground are the primary care providers, even if they're brand new health aides. Uh, health aides have five different levels of certification. By the time you get to the fifth level, you're like a physician assistant. But the early levels are way more simple and they require all day, every everyday phone, video, whatever, support. And our urban people understand that's part of their job. We also do telepharmacy, uh, which is pretty cool. In every village, there's a bulletproof vending machine that has a ton of medications in it. The person gets seen if there's a medication needed. The health aide puts that in the computer. The physician in Anchorage concurs. The pharmacist in Anchorage then controls the machine remotely, which drops the med and the label.

Speaker C: Wow.

Speaker B: Puts the label on the med in video view of the pharmacist, shows the pharmacist system, hands them to the person. And the person responsible for managing the inventory is the pharmacist in Anchorage. So this pharmacist overseen and led prescription management up to, you know, a thousand miles away, with support from, uh, the physicians in Anchorage. Works extremely well. This is the answer to rural, remote all around the world, find people who already live there and want to live there, and then figure out how to support them delivering the service. But it means that the urban system has to be on the hook for making that all happen.

Speaker C: Well, especially today when, you know, we're connected through cell towers, it changes the entire landscape. To your point. But we're still trying to do it. We're still trying to do it the old fashioned way.

Speaker B: Most of our villages, we can do X rays and we can take pictures of funduses of eyeballs and eardrums and skin and we can listen to breath sounds, heart sounds, all, you know, through phone and video connectivity. My favorite village story, we have these carts that have all this technology and you also want to make them plug and play. So you want them to be composed components and when a component fails, you unplug the component, send it in, you get a new one. Because we can't afford to send repair people, you know, a thousand miles into the villages all the time. So you need plug and play. We learned that early on. But my favorite story is a brand new clinic was built in a village way down the Aleutian chain, Got super cold, way below zero. The furnace quit. It was brand new furnace, the clinic was, you know, six months old. New furnace, furnace quits, has to be worked on by someone who can do the warranty work because otherwise you lose the warranty. So they're panicking, the thing is going to freeze up, everything's going to break and whatever. And the husband of the health aide says, well, I'm kind of a, uh, I'm kind of a know it all, do it all handyman kind of person. How about you get the technician in Anchorage on the video cart? So the health aide wheels a video card in the furnace rooms, uses the video camera that we use for ears and throats and whatever, and her husband sits there and takes instruction from the certified repair person in Anchorage and gets the furnace up and running and saves the all the whole clinic.

Speaker C: Robotic surgery from afar. Yeah, I love it, I love it, I love it. That's a great story. Listen, we took a lot of your time, guys, I want to, I'm going to leave. Uh, by tradition, we let Steve kind of ask the final question. Uh, Steve, you know what, I'm going

Speaker E: to take a prerogative here. Just ask one burning question that I've had for an hour. I think this is a really important message for our listeners. You know, one of the goals of these podcasts, and we have problems, we talk about our problems, but at the end of the day, we want to be inspirational to inspire young people, middle people, old people to do something positively. And certainly the message over the past hour or so is very inspirational. But I have to go back because it's just burning in my mind. You folks were given an opportunity in the 90s during this transition from federal to tribal ownership, but not everybody did what you did. There's only one nuca. Right. And I, I have kind of a founder's mentality. I want to understand what was a dean, uh, what was the thought process of the founders? What was it? You were given an opportunity. And as Seneca said, luck is when opportunity meets preparation. It's not totally luck, but you were given some latitude to build something. And I'm just curious, from the founder's perspective, what was it that inspired you to have that vision 30 years later?

Speaker A: I think it's a really good question because the easier thing to do is to replicate what you know and see healthcare do. To be the harder thing to do is to imagine something different. I think the thing that happened was embracing the idea that community, that people, that families really should inform how we redesign the system, that we're going to listen to their voice. And Doug described this process that happened and people, I hate to say community needs assessment because it's something a grant tells you to do and you, you check a box, you did it. So it's not that it's going out and understanding from people what do you need out of a health care system. And when we did that, community told us their priorities were domestic violence, child abuse, neglect, addictions. I mean, they told us things that were, that had nothing to do with what the old medical model was. And it forced us to think differently about how we're going to interact with community. And it's important to know that, that learning from community, community became the way we do business. So the way we do business is by continually asking and listening to community, redesigning and innovating what we do based on how communities are experiencing their lives and their wellness, and how we can understand from them how we can be welcomed as a partner in their story. Right. And if we do that, it means, as you look at our system, everything Doug said about the current partnership, primary care, clinical service delivery model, absolutely amazing things. But more important than that is our willingness to not be the experts who know exactly what health care should be, but be expert in listening to community and allowing community to drive what we do. And that should mean don't make it here to Alaska for 10 years. And you get here, you will see that the system has changed. We've improved and changed the service delivery model because our community's needs have changed. But the principal principles are the same, which is that the customers are going to own the system, that we're going to hear their voice, because we invest in relationship that that happens at a micro and a macro level, that we are going to check all the boxes that allow us to be accredited and build and avoid risk of litigation, all those things. But the driver is going to be what the people tell us to do. We're flipping the idea that we're the experts. We'll tell you in 15 minutes. We'll judge whether or not you're compliant. We're asking community to give us that direction, and then we're showing them what we did with the direction we gave them. And we're asking, asking them, how do we do right? Were we compliant? Did we follow your direction? We get it right. And knowing the answer is always going to be not quite. Keep working on it. This is what we need. And that's our forever journey in relationship of, uh, innovation, improvement with community.

Speaker E: That's something in your collective DNA that may not be innate in everybody because not everybody did what you folks have done. So kudos to you, to your inspiration and your vision. And so we have a, we do have a tradition as we wrap up these wonderful conversations. We usually ask, what will your vision be for the next three to five years in US Healthcare? But I think for you folks, that doesn't do it for me. I want to tweak it out a little bit. But if the IHI really gave you the latitude to redesign US Healthcare, informed by all that you've learned over the last 25 or 30 years, where would you start and what would you do?

Speaker A: I think we have to ask ourselves whether fundamentally we are willing to change, change how we see our role as executives, leaders, policymakers in healthcare, whether we think our job is to have the expertise to design the system, or whether we're ready to say that until we walk away from our perspective in order to understand the perspective of community, until we really are willing to understand how community is receiving our system, we can't redesign it to meet their needs. And I just don't know if we're ready to think that big as a country, but I sure would like to be part of that conversation if we are.

Speaker B: I just want to echo April. The core question is, for whom does this system exist? Yes, it does not exist for universities and medical schools. It does not exist for the doctors and nurses. It exists for the people who receive services from the system. Baldrige says no matter what your product is, Baldrige is product ignorant. You say what you're trying to accomplish and they tell you all the elements you have to pay attention to to, to succeed. And core to that is obsessing about what the customer wants, no matter what you're producing. In our case, we are trying to produce services to help support people on their health journey. It's required that you obsess about what they want, what they need and what they determine as their goals and aspirations and how we are going to use all of our training and expertise to support them on that journey. And what we've done done is take the best known practices from literally all over the country in the world, pull them all into a single system that align with our principles and execute them at full scale with obsession for 25 years.

Speaker C: Amazing. Amazing. Doug and April, I can't thank you both enough for joining mtva. And uh, on a broader scale, I just can't thank you enough for what you've done, uh, over all the these years and to really show us that there is a better way to do it down here in the lower 48 and around the world. I've seen those people from New Zealand, Australia and Iceland who come to see you and they rave about it and they're trying to come back to their countries and do it. And I wish we could just do it here. And it sounds like we could, but we need that determination, that obsession and most importantly to focus on the communities we serve. And uh, I think it's not, it's not. We serve. I shouldn't even say it that way, right? That's the wrong way to say it. We don't serve them there. I'm getting, I'm getting. Yeah, I love it. Thank you so much for joining us.

Speaker E: Appreciate it.

Speaker C: I really appreciate it.

Speaker E: We will be seeing you soon.

Speaker C: Yeah, yeah, absolutely. We're going up there not to fish. We're going to take, we want to get orientation. We're going to our conference.

Speaker A: We'd love to have you.

Speaker C: It's every summer. M right? You guys do it every, every year?

Speaker A: Every summer. It's in June. Uh, the material is fun, but what's really fun is the co cohort of people who choose to come. It's the cool, innovative thinkers who are there that also make the conference pretty great. It's a small conference, but it's got a cool group of people.

Speaker B: Yeah. But our daughter and a couple her friends and I caught 104 fish on Saturday. So, you know.

Speaker C: Wow.

Speaker B: There is, there is a little bit of fishing too.

Speaker C: That's great. Thank you guys. Thank you so much. To learn more about MTVA and how to join our community, visit Our website website movingtovalue.org if you enjoyed this conversation, please follow us and leave a review on Spotify or Apple Podcasts. Thanks again for listening and for being part of this important movement.