| Interview with Don Kashevaroff |
 Don Kashevaroff is the new CEO at The Alaska Native Tribal Health Consortium (ANTHC). ANTHC has a third of a billion dollar annual budget, serves 130,000 Alaska Native people, and is the largest and most comprehensive tribal health organization in the country. In many ways ANTHC as an organization is an extraordinary success story and a national and international model. On the other hand, for the first time in its history, ANTHC was recently forced to eliminate 40 staff positions. Mr. Kashevaroff discusses the monumental challenges ahead, and possible solutions in this engaging interview. This interview occurred June 4, 2008. It has been edited for length and clarity.
AHPR: First, I want to congratulate you on your recent appointment as CEO of ANTHC [Alaska Native Tribal Health Consortium]. However, I have to say that after taking a look at Mukluk magazine and talking with some of my colleagues, it appears that these are particularly difficult times for ANTHC. For example in March, for the first time in the history of the organization, there were personnel cutbacks. About 40 positions were affected. What were the principal causes of this fairly drastic action?
Don Kashevaroff: If I'm placing blame, it's really on Congress and the president. We are running a Native health care system we took over from Indian Health Service in 1997, 1998, through a method called compacting. Before [the takeover, the Indian Health Service] was supposed to provide you with the health care. Then, we come in, we compacted it out, and they pretty much give us a lump sum payment [with which] we provide the health care.
Every year we negotiate. It's pretty much the same amount of money plus what ever increases. Well, in the last 10 years since we've been in operations, the increases have been very small. Maybe we started out getting 4% or 5% at first and then the last five or six years we've been getting 1% or 2% increases for health care. You could probably ask anybody on the street, "What has the cost of health care been doing over the last decade?" and they'll [say], "Shooting through the roof!" Pharmaceuticals. Supplies. You go and see your dentist. It all goes up 5%, 10%, 15% every year.
But we are stuck with a 1% or 2%--maybe up to 4% in the early years--increase. So it's very hard to keep the same things we were funding with such a small increase. Congress and the president haven't actually recognized this medical inflation. We've been fighting for the last couple of years for them to recognize it and they finally did. They said, "Oh, okay, you guys do have medical inflation. We'll [talk with] the Office of Management and Budget, the gurus of financial, and they will give you your medical inflation. And you know what? They gave us 3.9%.
So for a year or two, we got 3.9% for inflation, then Congress takes a recision on that, and by the time it gets to us it's very small. The first years weren't too bad, but it's getting tighter and tighter every year. And that's what we're faced with right now--very tight budgets from the current administration and Congress--and we are hoping that the next administration that comes in is going to understand that the Indian Health Service and the tribes that compacted provide direct service care. It's not like all the other parts of the government that may give grants out, or they're doing non-services that don't actually impact the people that we do.
AHPR: That's a nice lead-in to my next question, which is: how are the future prospects for revenue for ANTHC?
Don Kashevaroff: Well, it really depends on who gets elected for president. I heard McCain was going to [push for] zero funding for everybody, and I heard Obama was going to fund IHS 100%, so it really comes down to that. Now those are campaign speeches, so who knows what actually happens. McCain has been chair of the Indian committee on the Senate side so he knows the issues. Obama, hopefully, is going to put money in and, hopefully, McCain will put money in.
So from the federal side maybe we do have some prospects of more funding. From our side we're looking at, of course, how we can become a more efficient operation. There's always got to be some ways we can become a little bit more efficient to take up the slack when the government's not funding us. Our problem is when they don't fund about a 10% gap every year, it's pretty hard to make that up, but if we can get that down to about a 5% gap, we could find 5% efficiencies every year in this operation.
" ... the goal is to keep improving the way we bill, and also to figure out
how to get the folks with private insurance to want to come to the
hospital."
AHPR: I wish you the best in that. But I believe that revenues also come from other sources--for example, private health insurance that some Natives carry who are employees somewhere. What are the long-term prospects for that?
Don Kashevaroff: Right now about half our money comes from Indian Health Service and half comes from Medicare or Medicaid, or private insurance as you mentioned. Now IHS hasn't been going up, so over the last 10 years we have hit the Medicare, Medicaid, and private insurance very hard. We changed the government-run system that we took over that billed a bit, but they didn't really worry about it so much, into a system where we're trying to be like a private hospital, where we actually will go out and do the billings.
Under law, we are what they call the payer of last resort, meaning that we legally have to bill everybody's insurance, and we have to bill Medicare and Medicaid. We have been trying to improve the system that [we use to do] that. And now we're up to where over half our money comes from that, and the goal is to keep improving the way we bill, and also to figure out how to get the folks with private insurance to want to come to the hospital. [This is] not a marketing blitz or anything like that, but if we can provide better service, be a better hospital, get word-of-mouth going around that [the Alaska Native Medical Center is] not too bad of a place to go, then you will get folks that happen to have insurance showing up at the door.
AHPR: I imagine that you are also fighting the long-term trend in the United States of more and more employers dumping health insurance or providing very inadequate health insurance for employees, and so when they come to your door, they may not have adequate health insurance or they may have none at all.
Don Kashevaroff: Yes, I suppose that is a trend. We've seen that a bit, where some of the folks that used to have insurance have the option. If you're Native you have prepaid health care, and that means that you have a health system that, because you gave up your land and your oil in the past, you get health care now. So there is that "opportunity" for businesses to let their Native employees insurance lapse, even non-Native insurance employees, and people are doing that, but it's not the right solution. That's the problem, so we need to combat that with education.
If you want to have a good business, and you want to be successful, you've got to have successful employees. That means you've got to have employees that are happy and aren't sick or aren't getting injured and then finding out ["I don't have health insurance and] I'm in trouble now. I've got my family worries now." That doesn't make a good employee. That is not going to help your company run. So we've got to educate the employers out there that the whole reason we had insurance in the first place wasn't just a perk, it was so you had well employees, and they work better for you. Somehow we have to get the education out and that's another thing we have to work on. [There are] many things we have to work on here.
AHPR: You may have already answered this, but in case something was left out let me just ask you: What will the most pressing challenges be, in your opinion, during the next 10 years, to accomplish the ANTHC mission?
Don Kashevaroff: I guess it's lack of funding coming in, that's for sure. The biggest issue is that we are tied to the government and we don't know what the government's going to do in a given year. When we look at the part of the company that we can control, we can say, "Well, we can become more efficient, better focused, do things better, and we can go market ourselves better, and bring in more folks with revenue." That, I think, we can do. It's that half that the government is paying; we don't really have a clue. And every year you have an election, and 10 years from now we'll have a new president who's somebody we don't even know of right now, so we never know what we're going to do about that.
So our goal has been, for the last 10 years, to start getting self-sufficient enough that--even though we are tied with the government--we can actually provide the services over and above the government. We've been trying to do that, and I think we've been doing a successful job of it. It's basically what our customers, who are our owners also demand of us. They want the best health care system, and we're trying to give them the best health care system--with not the best funding system.
"In my mind, if you can solve the financial issue, you can solve the
labor force issue because even though there might be a shortage of
nurses, there's still a lot of nurses out there. They just might not be
working for you."
AHPR: When I talk to other policy opinion leaders in the state in terms of challenges in the coming years, they often bring up workforce issues, particularly primary care physicians, for example. Do you see that as a problem? Or maybe your situation is different.
Don Kashevaroff: We have the same problem that all the other hospitals have in the state and in the country, and that's that the workforce in many specialties is an aging workforce. The medical schools aren't pumping out the docs like they used to--or like maybe they should be--for the growing [need]. So you've got the docs getting older, the nurses getting older, and shortages across the country in specialties that affect us right now. There are docs positions that we want to hire, that we have [some] funding to hire, that we can't hire because we don't have enough funding.
A lot of it is supply and demand. If you're in high demand, you can ask for some more money, or you expect to get more money, or you have just many more options. Why go north to Alaska--even though it's a great place--when you might get to go to Florida or California or something like that? There's this competition amongst us--we have that as an issue too. In my mind, if you can solve the financial issue, you can solve the labor force issue because even though there might be a shortage of nurses, there's still a lot of nurses out there. They just might not be working for you. The idea is how do you get them to work for you.
AHPR: Now I'm changing the nature of the questions a bit. How are the rapidly emerging consequences of climate change affecting the mission of ANTHC? Or are those issues affecting ANTHC at all?
Don Kashevaroff: We have the hospital--Alaska Native Medical Center--that we co-manage with Southcentral Foundation. They've got the primary care and we've got the in-patient specialty side, and then the other big part that ANTHC does is the division of engineering and environmental health. They basically do a lot of the water and sewer sanitation throughout the state. They help build facilities, build clinics throughout the state. They are kind of impacted by climate change.
Whenever a village is impacted by climate change, we are the ones that are usually putting the services into the village and that makes a bit of a discussion, not in our realm, but in other realms. Do you fund a village that the climate is going to wipe out, or do you put the money into moving the village? We're faced with the idea that either way they go, we want to be there to help, so we're willing and able to put water and sewer systems into any village, and also to help move villages.
I think there's like a dozen villages that are in that boat--maybe even 20--that might need to be moved within the next few years. So that's the biggest impact of climate change. We have a lot of engineers and they're very smart at building the right systems, and as the climate changes and the permafrost decreases they are able to adjust and take care of that.
AHPR: I think ANTHC really is an extremely unique organization nationwide for a number of reasons. And one of the reasons that [it] strikes me as so particularly interesting as a model is that we're talking about health care, water, and sewer all in the same organization. That's the classic public health approach rather than the exclusively medical approach.
Don Kashevaroff: They [the Centers for Disease Control and Prevention's Arctic Investigations Program in conjunction with the Alaska Native Tribal Health Consortium] did a study on drinking water. If you have water and sewer in your house, you have a lot less complications in health, and that's a whole part of our vision statement: "Alaska Natives are the healthiest people in the world."
We have a hospital to treat the people today, but also our water and sewer folks are treating the people for the future, and we have a whole community health service division, too. That's the next biggest division we have. Their job is the public health, and their job is to be out in the prevention field, and the promotion field, and the research field to try to make sure that we can get everybody to be healthy in the future.
" ... we have a very good relationship with the state at the moment. I don't
foresee it changing; actually, it's a win-win. Any time that they can
help us provide more service to Natives, it cost them less money. We're
happy because that's in our mission and vision."
AHPR: How would you assess the current relationship of ANTHC with the State of Alaska? Are there rough spots, and if there are, what would make them better?
Don Kashevaroff: We have a good relationship with the state. I've only been on the job for six days, so I can't tell you all the rough spots. We've been working with the state. For water and sewer, the state has been providing water and sewer to the villages and we've been working with them to make sure that we efficiently and effectively implement those systems. Actually, with the state we have a very good relationship.
Sometimes the federal agencies, other than the state, have asked for more accountability. It's between them and the state, and we've kind of been in the middle. We've been working through those and we're happy to be accountable to anybody and everybody. We just want to make sure that whenever folks are throwing more rules at [us]--the government loves rules--that we don't slow down the progress that we've been making. We've been working on putting the honey bucket in the museum--remember those days? We're still working on that, [but] we're still a ways from that and we don't want to slow down the progress on that.
That's on our statewide focus. Internally, even on statewide, on Medicaid we been working with the state very well. There is the idea in the state that, first off, if you're Native and you get service at a Native facility and you're on Medicaid, it really doesn't cost the state anything because the federal government picks up the whole tab. If you're non-Native and you go to get service there's about a 50-50 breakdown, so the state actually has to take state money and pay for it.
So, if the state can help Natives go to Native facilities, it saves them Medicaid money. So we've been working with the state on ideas on how to implement that. The last couple years we've been working on it, and the state has actually funded some studies for us. So we have a very good relationship with the state at the moment. I don't foresee it changing; actually, it's a win-win. Any time that they can help us provide more service to Natives, it cost them less money. We're happy because that's in our mission and vision.
AHPR: You were a member of the Governor's Health Strategies Planning Council. I'd like to ask you: were you satisfied with the final report, and do you believe that some type of statewide health planning council should be a permanent body in the State of Alaska?
Don Kashevaroff: I think I was satisfied with it. Going in, a lot of folks had very high expectations. [These individuals] may not have known each other before they all walked in the room. I knew a few of those folks, and you give them a very short timeline--I think we only had, by the time we finally started meeting, about six months--and it took them six months to get the concept out the door. We had six months, we all had regular jobs, and we were meeting maybe once a month, I can't remember exactly, so it could be six meetings to do something.
Maybe we could come up with some better stuff, and maybe we could put more time into it but it wasn't everybody's job, so I think the recommendations we came up with covered a broad range of things. It gave the governor some good advice. Health care is a complicated issue, and it's an issue that needs to be looked at. I'm all for our governor taking on the gas pipeline and the oil companies and things like that but while they're doing that, don't forget about health care.
The whole idea of a long-term health strategies council or health board, I think, is a very good idea. These issues aren't going away. Just a couple of years ago the state was out of money, Medicaid was going to get cut, all these woe-is-me type of things were going on, and we really needed some planning then and we didn't know what we were going to do. Right now we're flush with money, no one's worried about it. Well, I'm sure somebody's worried about it. It's not in the headlines anymore, because right now the headlines are how to give away all the money.
So now is a good time to have a council. While you happen to be rich for a couple of years, figure out the solutions, so in four or five years from now when we're broke again we'll already have implemented the system so we won't have to be, "Oh my gosh we've got to cut something today because we should have been working on this four years ago." So now's a good time to get a health board like that going and to get the ideas moving.
AHPR: I wonder if you would discuss your reaction to Senate Bill 160. Are you familiar with that bill? It's the Alaska bill modeled after something like the Massachusetts health reform bill requiring that most people in Alaska carry health insurance.
Don Kashevaroff: Did that pass?
" ... the whole question of: do you have mandatory insurance or do you have
voluntary insurance--in my mind I'm always a voluntary type of guy, I
like people to have a decision. You should be able to choose if you
have insurance or not."
AHPR: No it didn't. It kept getting changed as it went on, but it didn't pass. It offers subsidies and waivers to those who cannot afford to carry health insurance. Is that bill or that kind of health reform bill in Alaska of interest to you, or do you follow it, or do you have any reaction to that?
Don Kashevaroff: No, I haven't read that bill lately. But the whole question of: do you have mandatory insurance or do you have voluntary insurance--in my mind I'm always a voluntary type of guy, I like people to have a decision. You should be able to choose if you have insurance or not. Then there's this "public good"--if you don't have insurance does it impact the public good? I still think you need to be accountable to yourself, and if you don't have insurance and you go to the hospital, you should expect that the public isn't going to pay for it, but we will anyway. That's the problem I guess.
If you went without insurance and you actually went to the hospital and then you had a $10,000 bill, then by gosh, it would be like my student loan. I would've loved to have said, "I don't want to pay it," but I had to pay the thing back. It might take you years to do, but I'm kind of for people being responsible for their health care. Now there's lots of ramifications to that, and we don't live in a system where we don't come to rescue folks. We live in a system where we do, so I'm not sure, but I still don't think mandatory [health insurance] is the right way to go.
You know, when we were on the Governor's Council, we looked at a lot of data. From my recollection, it sounded like most of the people that are uninsured are [in] the 18 to 28 [year old] group. I remember when I was that age I didn't have insurance, and I didn't really care about insurance because when you're 20 years old, you know, you're racing down the road without your seatbelt on because you're invincible, you're never going to die, you're never going to need to go to the hospital, why would you put money into insurance?
Now, you could say that's a reason for mandatory insurance. Actually those 20-year-olds, they don't end up in the hospital much anyway, so that's a reason that they don't have insurance, because just statistically they're not going to be the ones needing the service, so they don't buy insurance. If you got employers to understand that it's good for business to have your workforce be healthy and happy, then I think we might be able to get over some of these hurdles, but I'm not the guy that's going to figure it out here. We need a health council to sit down and look over it and figure it out.
AHPR: Jumping to another program: the dental health aide therapist program caused quite a controversy in the state and even nationally among dentists' organizations when it was first implemented. How is the program faring now, and how would you assess the controversy at this time?
Don Kashevaroff: The controversy is not in the news at this time so it would be nice to say it's over with. The dental health aide therapist program is one of the best programs that has come out of the Native health system. I think it's going to be a model for the whole country, and that's where the controversy comes out. I sat through some meetings--it must have been five or ten years ago. The IHS was presenting at some national meeting, and they were going through all these stats and saying, "Oh, by the way, dental--we have a problem. All of our dentists are age 55. In 10 more years they are all going to retire. We can't hire any more. What are we going to do?"
I think that's across the country. Dentists are in their 50s and in 10 years maybe they will all retire, and the dental schools, of course, aren't putting out the volume that they need to be putting out. Being a dentist is a hard thing, I mean it's not something that folks want to go do, so I appreciate all the dentists out there that actually take the job and do it. It's terrible having everybody scared of you. So the dental health aide therapist is a program that says you don't need a dentist to be working on your teeth. Just like when you go to the hospital sometimes you don't get the doctor, you get a nurse, or nurse practitioner, physician assistant, depending on the level of severity, that's the person you get. You're right sizing. You say if you are not needing the doctor, you don't get the doctor because it costs too much to give the doctor. We save--the whole medical system saves money--by matching the person to the right provider.
That's all we're doing in the dental health aide therapist program--saying you don't always need a dentist. If you're going to get a root canal maybe, or some really, really complicated stuff, sure, you get the dentist. But you can take a dental health aide therapist, who didn't go through all the medical school stuff, but they went through the school that put hands in the people's mouths, as much as the dentist got in school, and you say, "What's the difference there?" Can't this person go and fill a cavity for you? I'm not a dentist, I have dentist friends, but I mean you are just filling a cavity. You're not doing brain surgery.
So, we have dental health aide therapists out in the villages taking care of people, and they're not just filling a cavity but they're building a relationship. And when they build a relationship, next time they see the kid down at the store, and they go, "Oh, Joey, are you drinking soda pop again? Wasn't I just working on your teeth yesterday?" And they get that relationship building and the kids are looking up and saying, "Oh, that person became a dental health aide therapist. Maybe I could do that in the future, maybe I should be listening to this."
We have this model that's working great in Alaska. It might be replicated across the country, and that's probably what the dentists are all worried about. Maybe you're sitting in New York right now and you're trying to call around for a dentist and you can't find a dentist, and you're thinking, "Boy, I wish there was a dental health aide therapist I could just go to because my tooth hurts, (or something like that,) and I just want somebody to tell me what it is. I can't get into the dentist but can I get in to somebody else?"
This could be something that is going to sweep the nation in the next decade or two, when the dentists' numbers drop. If I'm running a dental practice, in my mind I'm thinking, "Bring it on." I want this because I want to bring in more people through the door and have a lower-paid person treat, and charge the same amount I was charging to see [the patient]. I'll manage the dental practice and have a bunch of dental health aide therapists working for me.
That's what all the docs do now. They get the midlevels to help you out, and they make more money that way. That's the good old American way--get somebody else to do your work and you make more money off them. There was a lot of controversy. I think it was just a lack of education, and maybe we didn't do our good part of educating with the dentists, and working with the dentists beforehand, but like I said: we didn't quite know it was going to blow up on the national side, [rather than] just the local side. And you know, you go out to the village and there's no dentist to talk to anyway, so there was no one to work with.
"If you want to be a dentist, or if you're thinking about going to
dental school, you should go because there is just a huge need out
there. We need more dentists and we need more physicians of all types."
AHPR: So if I understand correctly what you're implying, it sounds like the controversy is mostly now national rather than in the state of Alaska.
Don Kashevaroff: No, I think nationally it's died down a bit, I think the controversy is probably in the state. I don't hear much of it anywhere, really. There are some bills in Congress, [for example the] Indian Health Care Improvement Act--that we had a compromise worked out between everybody, but that hasn't passed yet. If that passes then I think everything is done. Everybody's waiting to see if the compromise goes through. If somebody's going to come in at the last minute and try to make a change to it--if that's the case then everybody goes back to fighting about it.
In the state, the dentists in the state were the holdouts. I haven't heard much from them. Hopefully, they've looked at it and said, "Okay, we can live with this." We've been running for a couple of years and I just asked the dentists, "Did you make less money this year than you made last?" Highly unlikely, because no one was going out to the villages making the money anyway. They're making the money in Anchorage, or in the urban areas, and there is more than enough need for all the dentists. If you want to be a dentist, or if you're thinking about going to dental school, you should go because there is just a huge need out there. We need more dentists and we need more physicians of all types. As we talked about earlier there are shortages and I guess our education system is kind of failing in the state because we're not training the people, giving them the prep work so they can go to college, go to medical school.
[Referring to a recent report about the drop-out rate of first year Alaska college students] We're like the 40th state, in the bottom 10 states. Well, if you can't graduate college you're not going on to medical school. So what are we doing on that front? That would be something that we need to look at. It's all tied together.
We can't get the good docs if we can't convince people to come up from the lower 48, but we shouldn't have to do that. We should be able to look within the state and say, "How many kids just came out of medical school that want to come back to Alaska?" Usually if you go out of state you might not want to come back unless there is a reason. We need to be able to have the people educated and qualified at UAA or the university system to be able to meet the needs that we have.
AHPR: I wonder if you could comment on the relationship between ANTHC and the Denali Commission since they seem to be building clinics all over the state that apparently have some impact on ANTHC, and also they're putting increasing amounts of money into the training of health professionals.
Don Kashevaroff: The Denali Commission is a good thing. I think that what they've been doing has been great for the state of Alaska--the brainchild of our senior senator. What was it 5, 6, 7 years ago [he] created them. And he saw the need that in Alaska we lack infrastructure in many rural parts to have sustainable economies. What he saw from the Denali Commission was an emphasis on taking care of some of the things that somebody created a long time ago when we had an oil boom and revamping them--the bulk fuels and things such as that. We got involved with the Denali Commission, I mean we, ANTHC, years ago, when they started looking at what can we do for health care.
One of the biggest problems we had in the state was we had all these clinics built [perhaps] 30 or 40 years ago, and they're just literally one-room buildings, very small. ANTHC has been working with Denali Commission to help replace these clinics, and they have put a lot of money into them over the years. It's a good thing--no one else has come to the aid. The Indian Health Service--one could make the argument--should do it, but the Indian Health Service has a priority that's for construction and we have Barrow Hospital on it, Nome Hospital on it, and Phoenix Indian Medical Center on it. Congress used to give about 100 million, the President cut it to zero. Congress now gives about 30 million a year. You take 30 million a year and you can't build one of those hospitals anytime soon, let alone all three. So that clinic is never going to be on the priority. There's [something] like a $2 billion backlog for IHS construction, and that's not any clinics in Alaska, really, that you want to do. So if you're sitting out there in the village and you have a clinic that's 30 or 40 years old and you step through the floor, and it's very inefficient on heat, forget it, you're not getting it replaced.
Along comes Denali Commission--thank you Senator Ted for funneling money through that--the Denali Commission sees the need, starts rebuilding clinics, and we've been working with them to help rebuild the clinics. Same thing with workforce development--the Denali commission sees the need. We were just talking about that, that somebody has to do something. They step up to the plate and they're starting to do something so we've had a very good relationship with the Denali Commission, and hopefully, that will continue for a long time, and hopefully, they will be around for long time.
"That's the goal here, we're going to stay on that strategy and focus on
that, and hopefully you'll come back in a couple of years and we'll be,
"Problems? We have no problems!""
AHPR: Are there any other issues you would like to address or final words you would like to leave with the readers of Alaska Health Policy Review?
Don Kashevaroff: I think we covered a lot of them. Our challenges here are great. Like I say, I've been working here for six days now, but I've actually been around with the consortium since the start of it. We have great challenges, and what we've been doing here for the last few years is trying to become a better company, be more strategy-focused. Our goal is to focus on improvements. In the next year or two or three we're really going to be focusing on customer service. If we can have happy, healthy customers, and we have happy, healthy employees I think we can overcome many of the challenges we face.
Our physician recruitment we have problems with, but nursing recruitment we don't have problems with. [At the Alaska Native Medical Center] they've created a system they call "magnet status." It's one of the top hospitals in the country for nurses. So we have lots of nurses that would like to come work for us. We got a lot of awards. That's one of the reasons they would like to come here because we work with them great, so if we can take things like that and expand it to the rest of the organization so we are the employer of choice, people want to work here and people are happy to work here, people provide great customer service from that then the customers are going to want to come here, too. That's the goal here, we're going to stay on that strategy and focus on that, and hopefully you'll come back in a couple of years and we'll be, "Problems? We have no problems!"
AHPR: Well, thank you very much for taking time for this interview in your sixth or seventh day of working here.
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| Interview with George Cannelos and Denali Daniels |
As a result of funding and support by the Denali Commission, as of the end of 2007, 84 primary c linics have been completed, 37 more are under construction, and an additional 50 are in planning/design across the state. The Denali Commission is a major player in the formulation and implementation of health policy in Alas ka. In this featurewe interviewed George J. Cannelos who was appointed federal co-chair of the Denali Commission in 2005. Prior to his appointment, he served as president and chief operating officer of KPB Architects, and as director of the Heritage Land Bank for the Municipality of Anchorage. We also interviewed Denali Daniels, health program manager at the Denali Commission. She is responsible for the Health Facilities Program, is the nonprofit/philanthropic liaison for the Commission, and handles public affairs requests. This interview was recorded April 29, 2008. It has been edited for length and clarity.
AHPR: I noticed that you have a distinguished group of Alaskans who join you as commissioners on the Denali Commission. What are there duties, and are they legally mandated or is it strictly an advisory board?
Cannelos: The Commission will be ten years old this October, and the act is unique in American government in the way that the commissioners were appointed and what their intended duties are. As you already know, there are seven commissioners. I serve as the federal co-chair, so I'm the CEO, if you will. I'm federally appointed by the secretary of commerce, as are all the commissioners. The governor is the state co-chair. She has designated that duty to Karen Rehfeld, who's the state OMB Director. Karen does a marvelous job, and is asking all the right questions as the major state partner. Then we've got Dick Cattanach, who is the head of the Associated Contractors, and Dick is now emeritus by his own title. He's retired from that position, and John MacKinnon will be assuming the duties at our next commission meeting. Julie Kitka, then, is the longest standing member of the body and she represents, of course, the Alaska Federation of Natives. Kathy Wasserman is the head of the Alaska Municipal League. Karen Perdue represents the University of Alaska for Mark Hamilton. Vince Beltrami represents the AFL-CIO and trade unions.
To the point of your question, they were appointed because they represent what Senator Stevens and congress believed--and we still do--to be among the most important policy making and influential organizations in the state. The point of this is that these folks, while very influential and knowledgeable in their own right, because of politics and the way things work, would not normally sit down together. The statute requires them to sit down at least twice a year at the call of the federal co-chair, and by custom, we meet four times a year. We're meeting tomorrow and the next day in Cordova. Tomorrow's a retreat and Thursday morning is a public session. These are the folks that are tasked to attempt to find strategic approaches and answers to vexing, long-standing systemic issues facing rural Alaska.
For example, when we report to you that we've replaced about half the bulk fuel storage tanks in rural Alaska--behind that is a deliberate strategy that wasn't there before the Commission started. When we report that we've now built, through our partners, about 80 primary care clinics, we doubt that would have happened without the Commission. That was a deliberate strategic push from the commissioners. That's the kind of thing they do.
"They are actually special government employees when they're on duty. They're more than a citizen advisory board ... "
AHPR: The commissioners help set priorities for the organization?
Cannelos: Yes, exactly right.
AHPR: Is this a legal mandate? Do they have legal powers and authorities, or is it an advisory board?
Cannelos: That's evolving. They are actually special government employees when they're on duty. They're more than a citizen advisory board, which means for example, that they have to very aware of conflict of interest, and we've had a lot of training on the part of the Office of Government Ethics. We've got a retired judge and other folks to make sure we're on the right side of the line.
AHPR: I can see the potential for conflict of interest. I just happened to notice that your last monthly newsletter indicated that there were several large grants to the organizations represented by the people on the board. I could see where that could be a problem.
Cannelos: That's right. They have to stay away from any of those deliberations.
AHPR: The Denali Commission has designated rural health care as a top priority and is building the infrastructure of health clinics all over Alaska. Why does the Denali Commission have that particular focus versus so many other areas of health that you could invest in?
Cannelos: When you look at the building blocks of a high performing, well community, access to primary health care is one of those. Congress in its wisdom, shortly after the formation of the Commission, essentially told us to get into the business and that's how that started.
AHPR: Specifically, primary care?
Daniels: Health facilities.
AHPR: In rural Alaska. That's another emphasis, is that correct?
Cannelos: Yes, although we're careful not to put a boundary on what's rural and what's urban. So, you'll note for example, if you get into our database, that we are funding the design of the Community Health Center in Anchorage.
AHPR: I didn't realize that. That's good to hear.
Cannelos: Yes, it is. But primarily, it's remote rural, yes.
AHPR: How is it determined where and when a clinic is built?
Cannelos: Let me turn that over to our program manager, Denali Daniels.
Daniels: As you know, Larry, the Denali Commission's health program uses a model that we've called, "the universe of need." Through a needs assessment that was conducted early in the program, around 300 communities were identified as needing some infrastructure improvement or replacement. That list was then ...
AHPR: That was around 2000 or 2001. Is that correct?
Daniels: That is correct--2000. Each year, we've updated and made revisions to that list but it's around 300. It's gone from 288 to 340. You have communities that populations decline--less than 20. Things happen in communities, and that list moves quite a bit. Basically, the idea is that there are three phases to facility development--and our funding is strictly for facilities. We don't have any operating funds, so really there's a gated process.
Our commissioners, through the sustainability policy, which I believe was the first policy that they actually adopted--before the health program--have recognized the value of planning. The idea there is that $50,000 spent on the planning of a facility that doesn't get built, is much better than $5 million spent on a facility that should have never been built to begin with. You have three phases, the first being planning. There are some requirements in the planning process that essentially get a community, or an applicant to the next level, which is design.
In the planning process, you have two milestones: one is a business plan, which is a fairly substantial effort that can take two to four years, generally speaking, for an applicant to get through--just depending on what needs to be done [and] what needs to be agreed upon. Then secondly: site control. That's fairly straightforward--either you have it or you don't.
"We've been fortunate enough that we've had enough design funding over
the last several years to fund everyone that has been eligible and has
applied, which is good."
AHPR: For clarification purposes, would the community that wants a Denali Commission-built clinic, apply? Is that how the process starts? Or do you invite applications?
Daniels: Usually, what happens is we hear from a community or from a regional health corporation or another entity that's directly involved with the need. Really, that's where it starts, is validating that a need exists. Either they're on the needs assessment that was established in 2000, [and] if they weren't, then we may actually send some engineers out and establish where they're at and whether or not a need exists, and what that need might be. So, really it's planning, design and then construction.
Once you have your approved business plan and site plan checklist, then you're eligible to apply for design funding. We've been fortunate enough that we've had enough design funding over the last several years to fund everyone that has been eligible and has applied, which is good. Once design is complete, that's really the point in time where folks are going after their cost share match, and that can be challenging--depending on funding cycles, varying deadlines, dealing with different requirements from other agencies and organizations.
Once that design is complete, then you have a final cost estimate. That becomes your number that tells us whether or not you have all of your match in place. Then your match and your final design--those are your two requirements that make you eligible to apply for construction funding. Really, it's [a] three-phase process.
AHPR: Is there a queue currently waiting for construction funds?
Daniels: That is correct.
Cannelos: In fact, last year, the program was so robust that there were more clinics ready for funding than there was funding available and, if you understand the way our money comes from Congress, most of the allocations are restricted by topic so, for example, our health dollars need to be used for obviously health facilities and health related topics, but what we call our base funding-the energy and water appropriation--can be used for energy and other things. Last year, in a major exception, the Commission agreed to take $8 million of that money and give it to the clinic program, which is very significant.
AHPR: To shorten the queue?
Cannelos: Yes, to shorten the queue.
AHPR: Could you explain the "open door policy"? I found that an interesting concept, and I'm sure there must be some historical reason it exists.
Daniels: The "open door" policy is one of the only policies that was established just in response to the health facilities program. The idea there is, in Alaska, we have two distinctly different health delivery systems: the Indian Health Service has a system and then there's essentially, everyone else.
The Commission is really interested in funding projects that will serve anyone. Now, each situation may have its own variables that we need to deal with on a case-by-case basis but we have an open door policy that requires that anyone be seen. That has been a policy that, to my understanding, has been in place since the beginning of the health program.
AHPR: I'm guessing that, at least initially, that that came into conflict with some of the Native health organizations--in terms of how they traditionally have used their facilities.
Daniels: It does pre-date me, but the manner in which that is handled has been that a Native health corporation--or maybe it's an actual village corporation--they are required to change the way that they allow folks to come in the door. They cannot deny services if they are applying for Denali Commission funds. That's something that has to be established through a vote of the board and resolution. That's a condition for our funding.
"When we talk about things like: what is the definition of primary care,
we really get into those juicy discussions about the role of behavioral
health and mental health and the like."
AHPR: What is the relationship between the Denali Commission and the Alaska Mental Health Trust Authority? I believe that there is some kind of a relationship, particularly with regards to the "Bring the Kids Home" program.
Daniels: Our health steering committee, which is our advisory committee to the commissioners--there has historically been a seat, held by Jeff Jesse, the CEO of the [Alaska Mental Health] Trust so that organization has a seat at the table in terms of policy making. When we talk about things like: what is the definition of primary care, we really get into those juicy discussions about the role of behavioral health and mental health and the like.
Specific to your question about "Bring the Kids Home," that particular initiative was a state initiative through partnership with the Alaska Mental Health Trust Authority--I believe it's been going on three or four years now--the Commission was approached to participate on the facility development component of that initiative and as a result, the number of beds has actually increased in a positive manner, from what I'm hearing based on the information back from the state about the number of kids that are no longer out of state and so our role has really been the facility development piece.
Of course, there have been a number of operational and systemic issues that have needed to be coordinated in order to get to that sustainability requirement that we have as well.
Cannelos: We like to find multiple funders for a given project, and when Jeff approached us with the idea of including behavioral health space within the clinics, he also brought dollars to the table. So as we do a clinic, and we have behavioral health space, what you're doing now is Mental Health Trust dollars [unintelligible]
AHPR: That's very interesting. So encompassed in the actual, physical facility, is a philosophy also of primary care, that in this case it would include mental health.
Cannelos: And dental.
AHPR: You mentioned something about advisory committees.
Cannelos: Part of our model is trying to find "ground truth," and we do it in many ways. The health steering committee is our longest standing committee and it's really served as a model because of its composition and its willingness to listen to innovative ideas and move forward.
We have several others, transportation notably, and most recently, an economic development energy training--all of it different because the programs are different but with the same philosophical bent that we really need to be open to as many new and good ideas as we can, and we find the committee model to be a good one.
AHPR: Is there a list of the advisors on these committees somewhere?
Cannelos: On the web site.
"Recruitment and retention, in my opinion, is the chief concern when it
comes to sustainability to all of the projects that we're funding."
AHPR: What is the Denali Commission's involvement with health care workforce issues? There is a growing shortage of health care workers in Alaska and prolonged vacancies. I'm quite certain that this must affect the clinics that you've been building. I wonder if you could talk about that issue.
Cannelos: One of our other major programs is training. We've been fortunate to receive about $7 million a year from the federal Department of Labor. We in turn, use a good amount of that for training medical health professionals across the board.
Daniels: We recently--about a year ago--created a position at the Denali Commission to oversee the training program. Previously, it was handled by program managers, as part of their entire workload. By virtue of recognizing the importance of training and having an entire FTE dedicated to that program, what we're seeing now is a much improved collaboration and coordination with existing training dollars and our training dollars, specifically bringing them back to the projects that the Commission is funding. I can say from the program management standpoint, you are absolutely correct. Recruitment and retention, in my opinion, is the chief concern when it comes to sustainability to all of the projects that we're funding. We're very much interested in how we can be part of the solution with all entities that are recognizing this issue.
Cannelos: I'm very impressed with community health aides. We've visited a number of clinics now. One of my most recent visits was to Steven's Village last summer. We were there in the evening--we arrived at the clinic. The health aide was very hospitable and greeted us and gave us a tour but it was very evident that she was working alone, by herself, and there was a sign on the door that said essentially: "There is only one of me, and I'm entitled to Friday afternoons off. Thank you." Recruiting and retention is a major problem but it's a powerful story to have local folks receive adequate health care--treated by a local resident.
One of the other aspects of training we're doing is we fully support the dental health therapist program and we've used some of our dollars, for example, to fund the Yuut training center [Yuut Elitnaurviat People's Learning Center] in Bethel, and that's the facility where these students will be receiving their second year of training. As an aside, the Rasmuson Foundation is receiving a very prestigious award this week in Florida by one of the national dentistry groups for their advocacy on the dental program.
AHPR: One of the extraordinary things about health care as a concept is that it intersects with just about everything. Is there an intersection currently, or do you plan one in terms of your work, between health care on the one hand and climate change on the other?
Cannelos: There is, in terms of the design of the infrastructure. We're getting more and more concerned that if we build permanent infrastructure in communities that are threatened with a move--or that are moving--we're making a mistake. Yet, if we withhold infrastructure to a community because we believe they're going to move--but maybe not for ten or fifteen years--we think the right answer is to continue with the program fairly normally but to emphasize sort of a modular approach to facility work.
AHPR: So the idea is that these could be just literally picked up in some way and moved?
Cannelos: Yes, exactly right.
AHPR: In terms of health issues in general in Alaska, where will the Denali Commission be headed in terms of a focus in five or ten years? Is this an issue you are discussing now?
Cannelos: It's very timely because we're now entering our tenth anniversary, so it's very timely to look back and look forward. When you look at Denali's impressive map of where the clinics are completed, we're beginning to see exit strategies in a couple of regions around the state. What we'd like to do is declare a victory on primary care clinics, for example, but then move into the next stage of solving health--whatever that may be.
AHPR: Any inkling of what next stage means?
Daniels: The health steering committee has been discussing that. You may be aware that we have a program that we lovingly call the "other than primary care program"--for lack of a better term. No one came up with a better term. Basically, our mandate in the health program has been to fund a mix of health and social service facilities. We've taken that very seriously. Our appropriations language each year tends to sound something like that, and so as a result, we've continued to fund primary care clinics with the majority of the funding, and then fund a few other areas like Bring the Kids Home, elder housing, [and] assisted living.
We have really kept to the primary care clinic program and we've resisted the temptation to get into the hospital business. That being said, rural hospitals tend to have a lot of needs facility-wise, and we've had the primary care in a hospital setting program, which has been a very successful program. My crystal ball tells me we're going to see more behavioral health facility development. Detox was identified as the number one need in a needs assessment done about five years ago-a behavioral health needs assessment. A lot of work will need to be done to get there.
Cannelos: What about senior housing and assisted living?
Daniels: I think that senior housing and assisted living is going to continue to be a priority for us. That planning phase I described--we've invested in a lot of planning, and we've had some low hanging fruit that we've been able to invest in but there are barriers to sustainability in that program area that will need to be addressed in order for facility development to follow. There's certainly a need. Population-wise and demographic-wise, I think we all know that we're heading down a path that we're going to have to address very soon.
AHPR: Do you anticipate a shift of funds from infrastructure development to more training development or educational assistance--because my crystal ball tells me that there's going to be more facilities with fewer and fewer practitioners at all levels in them. That's the trend nationally, and it's especially bad here in Alaska--particularly for the higher professions because you're trying to attract from a national market. Do you see a greater growing focus on training health professionals at all levels?
Daniels: I think the question of whether we're just a facility organization or more than that is really one of the things the commissioners have been debating. Our funding for the health program, the HRSA (Health Resources and Services Administration) dollars are restricted to facility development only, and so only time will tell if that level of funding will continue. We've been fortunate to have $40 million for the last five years in that program.
Cannelos: It's a great question. I think it's very difficult to say where the Commission will be in five or ten years but clearly without training and without building human capacity, I think all of our efforts would be greatly diminished. Great issue.
"I'm very concerned about the future of Alaska's small places--about our
villages--and as we look out at climate change ... the unaffordable cost of energy; Alaska's remoteness and
isolation; changing demographics ... "
AHPR: I feel like I haven't done justice, in terms of my questions, to this huge, diverse enterprise you have here. Do you have any additional issues that perhaps I've missed or that are on your mind that you would like to discuss that relate to health care?
Cannelos: I'm very concerned about the future of Alaska's small places--about our villages--and as we look out at climate change, as you already mentioned; the unaffordable cost of energy; Alaska's remoteness and isolation; changing demographics, it's very difficult for us to say whether we're winning or losing in the big picture. Health is an absolute key component of that, and what I would like to find--and I invite your readers to come back with any advice they have--is how do we measure the true worth of the infrastructure building in health that we're doing. We know, for example, that we're greatly improving access to health care but the professionals tell us beyond that, it's extremely difficult to say, that because of our efforts people are healthier, and that's the bottom line.
AHPR: That's difficult to study under any circumstances.
Cannelos: And that seems to be the consensus of professionals, so we may have to be content with outcomes that say there's greater access, perhaps there's less need for evacuations, etc., but I'd be interested in what your readers have to tell us.
AHPR: Were there any other final words you wanted to say, or any other subjects you wanted to address?
Daniels: I have a plug. I think this is very timely. One of the things that the Denali Commission recently underwent was an evaluation. Part of the follow up to that evaluation was that the Commission's policies were inconsistently organized, so to say. Across programs they may have been applied inconsistently, so we're currently undergoing an effort to actually consolidate all of the policies in one place. We also have recognized that we have Commission policies and then we have program specific policies. We're currently vetting all of the Commission-level policies through each of the advisory committees.
Once we have a policy document that lists every policy, once we are done with that process--it'll be around July or so--this is actually going to be going out for public comment. It's an opportunity for us to hear back from the public how things are going with the policies that we have, and whether or not they're improvements. About that same time frame, we'll be better developing our list of program specific policies, and it's my expectation that we'll go through a similar process. My guess is your readers will be very interested in seeing the policy documents and having the ability to provide input.
Cannelos: Another aspect to tell you is we have this amazing health facilities program and we have one program manager, Denali, and we couldn't do it without the program partners. There are many but notably ANTHC, the Mental Health Trust, and then just pick a map around the state--SEARHC, YKHC, Maniliq--great number of success stories.
AHPR: Thank you both very much for a most informative interview.
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| Budget Analysis: Historic State Support for Community Health Centers |
Community Health Center (CHCs) advocates celebrated historic state funding this Memorial Day weekend. Governor Palin demonstrated strong support for Alaska's CHCs by keeping both the capital and operating funding items designated for CHCs intact in the budget. The $3.85 million represents first-time direct state support for Alaska's 26 CHCs and the 124 clinic sites they operate.
In the capital budget, Governor Palin approved $2.5 million allotted for health IT infrastructure for CHCs. These capital dollars were added to the budget by Senator Stedman and the Senate Finance Committee. The governor also approved the $1 million in the operating budget added by Senators Hoffman and Olson and the Senate Finance Committee. The Alaska Primary Care Association (APCA) has proposed that the Department use this $1 million to assist with the number one need for CHCs: workforce recruitment and retention of primary care providers. The governor had included in her original budget $350,000 for CHCs for senior citizen access.
Neither of the two larger budget items were in the governor's proposed budget prior to the legislative session. The Alaska Primary Care Association and CHC supporters had their work cut out as they educated policy makers and the administration on the CHC model and the need and common sense for state support. Advocates were diligent in their efforts, first to convince the legislature to add the funds and secondly, to win the support of the governor. Alaska Primary Care Association extends gratitude to the supporters across the state that helped, became involved in the legislative and budget process, and advocated all the way to the finish line. In particular, the APCA would like to thank Senator Bettye Davis for her staunch support of CHCs and for her work with the Senate leadership. The APCA would also like to thank the Senate Finance Committee for their assistance in getting the items into the budget.
APCA Executive Director, Marilyn Kasmar, who has worked for 12 years helping establish and assist CHCs in Alaska, was delighted with Governor Palin's decision. "The Community Health Centers have been stretching the dollar and operating as efficiently as they can, but the elasticity of the dollar has its limits. We needed the state to help in order to provide adequate primary care access to the medically underserved."
Not only will the funds provide access, but they will also help the health care system statewide. APCA Government Affairs Director, Shelley Hughes, emphasized that the more inexpensive primary care we have in Alaska, the less more-expensive specialty care we'll need in Alaska. "That means it will impact everyone's wallet, whether it's the state's, the individual's or the employer's." Hughes appreciates the administration's decision to move Alaska in this direction.
The CHCs function as the safety net, charging on a sliding fee scale and accepting all patients, regardless of insurance status. CHCs serve populations and areas where there is no competitive marketplace, providing access and health care homes to individuals who otherwise would not have their basic medical, dental and behavioral health needs met.
The CHCs have become particularly important to senior citizens across the state who are finding it increasingly difficult to locate primary care physicians willing to accept new Medicare patients. The CHCs accept senior citizens on Medicare. As insurance premiums rise, the number of hardworking families without insurance is increasing. The CHCs provide access to the uninsured as well. CHCs are the cost-effective solution for basic quality health care for more than 80,000 Alaskans.
Total CHC State Support including individual site capital: $9.6 million
Including the capital funding various individual clinics received, a total of $9.6 million in state funding was appropriated for CHCs for FY09: $1.35 million operating ($1 million proposed for workforce recruitment/retention and $350,000 designated for senior access); $2.5 million capital (for health IT - ACHIN); and $5.8 million capital for individual CHCs (for building, remodels, etc.).
FY09 State Funds for CHCs
Anchorage Neighborhood Health Center (Relocation/Construction of New Facility): $5,000,000
Hughes City (Clinic): $16,600
Teller Health Clinic: $210,000
Venetie Health Care Clinic Project: $150,000
Native Village of Diomede (New Clinic Building): $420,000
Total Capital for Individual CHC Clinics: $5,796,600
IT Network for CHCs: $2,500,000
Total Capital for CHC Health IT (ACHIN): $2,500,000
Direct Services Provided by CHCs: $1,000,000
Senior Access at CHCs: $350,000
Total Operating for CHCs: $1,350,000
Summary
Capital for Individual CHC Clinics: $5,796,600
Capital for CHC Health IT (ACHIN): $2,500,000
Total Capital: $8,296,600
Direct Services Provided by CHCs: $1,000,000
Senior Access at CHCs: $350,000
Total Operating: $1,350,000
Total Capital and Operating funds: $9,646,600
[This article originally appeared in the May 28, 2008 issue of Alaska Primary Care Association Legislative Update, and is reprinted here by permission]
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Commentary: Cross Cultural Communications
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Or why did you say what I heard you not to say?
Wilson Justin was born in Nabesna, Alaska and is of Althsetnay and Athabascan heritage. He is Executive Vice President of Mt. Sanford Tribal Consortium in the headwaters region of the Copper River system. He has held many positions of leadership in the past, including former Presidentof Ahtna Inc. He is standing Vice Chairman of the Association of Tribal Health Directors, serving on numerous statewide health committees.
If there is a magic wand for us to use in the long and tedious journey to provide timely and quality health care to beneficiaries, it would have to be the ability to cross communicate complex statements to those who are not used to hearing such things. In every part of a health professional's life there is the issue of living a field that has a specialized way of learning that is not reflective of society at large. We all think like we are taught. The way that you are taught may not be the same way that I am taught, yet we both will think exactly as we are taught in our everyday responses.
Notice that I said, "taught," not "learn." We learn differently for different reasons, yes, but we can only think the way in which we were taught. This means that response to questions that require complex answers will trigger thought patterns that will not be coherent for some time. When I speak on health matters in our communities, the response is typically either a rolling of the eyes or anger, or a shrug of the shoulders. Yet it's not the language that I use that angers some, or even the subject matter. It's the fact that the listeners who are beneficiaries were taught that everything including health is either an inheritance, or an entitlement.
Entitlement language is selective and interpretive. Specialty language requires listening skills that are consistent with retention skills. In the health field you have to be able to hear and retain what you hear in order to put into practice certain standards and conduct that are vital to the health field. The entitlement language on the other hand only requires that you hear what you like, and react to what you interpret as being rewarding to you. It's no secret that I attend a lot of meetings alongside of many, many professionals in every walk of life. It's also no secret that I can actually understand and repeat for the most part what I am hearing no matter the complexity. What is a secret however is where I got that from.
Well here it is. I got that from Houston, Johnny, Adam, Lena, Paul, Ruby, Jack, and a whole host of others who used to tell me that Indians see with their ears, and once you learn to see with your ears you can teach yourself to do what needs to be done. The eyes aren't used to teach, only ears. So yes, learning can be different for each of us. But all us have only two ways to be taught--by our ears or our eyes.
Why do you think we heard so often in our youths, that phrase..."how come you make big eyes?" or "why you got big eye?" The statement was to let you know that greed was the driving force behind what we see, whereas hearing first gives you the ability to understand what you see. Well, like all things this is supposed to be about health and it is. You might want to read this again. Until you can see the words in the back of your ears. Prevention is 100% effective in letting you see your grandkids grow to their potential.
Father Michael Oleksa's new book is called, "Another Culture/Another World". Father Oleksa has become quite famous in certain circles for his thoughts and presentations on cross cultural communications. Why all this you would think? Well because we quit communicating with each other a long, long time ago. Now we talk to each other but the talk is devoid of meaning and does not lend itself to action. You "see," I "hear," and neither one of us can make sense to the other.
Well, the topics I chose are big topics and not suitable for one page, but it is clear to me that once upon a time we didn't need others to tell us what's wrong with us, or what is the right way to live. Now we do. Until we can get past that, the cost of doing health will break us all in the future.
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