Well, good afternoon, everyone, and welcome to this webinar entitled Aspirational Healthcare. My name is Dr. Angela McIlyde. I'm the Vice President of Programs and Education at the American College of Preventive Medicine. We are pleased today to hear from Dr. Douglas Eby, Vice President of Medical Services at the South Central Foundation, and Daryl Moon, who serves as the Chief Executive Officer at ORIENT. Our session today will be moderated by Dr. Michael Perkinson, Principal, Community Health. The American College of Preventive Medicine is a professional medical society of approximately 2,000 physicians dedicated to improving the health and quality of life of individuals, families, communities, and populations through disease prevention and health promotion. Our members are licensed medical doctors who possess expertise in a broad range of healthcare skills, including biostatistics, epidemiology, management of healthcare organizations, research, and the practice of prevention in clinical settings. Our members work in hospitals, government at the local, state, and national levels, the military, laboratories, businesses, and academia. I have just a few housekeeping items to share. First is that the audience has been placed in listen-only mode. We will be posting a recording of this webinar on the ACPM website in the next day or two. We ask you to please populate the chat box with questions, and we'll be answering those at the end of the session. And of course, we want to know what you thought, so please fill out the evaluation that you'll receive immediately following. I'm so pleased to present a dear, longstanding member of the American College of Preventive Medicine, Dr. Michael Parkinson. As principal of P3 Health, that's Prevention, Performance, Productivity, Dr. Parkinson works with national employers, organizations, and innovator startups to improve health, reduce excessive medical costs, and optimize business competitiveness. Dr. Parkinson most recently served as Senior Medical Director, Health and Productivity at UPMC Health Plan and Work Partners, overseeing members and employer health care and performance strategies. Dr. Parkinson is a past president of the American College of Preventive Medicine. He was also founding principal and EVP of Chief Health and Medical Officer of Illuminos, a national pioneer of consumer-directed health plans and a WellPoint subsidiary. A retired Air Force colonel, his first spinal assignment was Associate Director of Medical Programs and Resources in the Office of the Surgeon General. While assigned to the U.S. Public Health Service, he provided oversight of federal programs in public health, geriatrics, and preventive medicine training. He served on an Institute of Medicine committee evaluating NASA employee health programs, as faculty for the 14 cities Robert Wood Johnson Foundation's Aligning Forces for Quality Project, on the American Heart Association Great Rivers Affiliate Board, and the American Board of Preventive Medicine. Dr. Parkinson now serves on the Department of Defense Health Board, the University of Iowa NIOSH Midwest Center for Workforce Excellence Advisory Board, and the Editorial Board of the American Journal of Preventive Medicine. He obtained his AB from Cornell, MD from George Washington University, family practice training at UCLA, and his MPH Preventive Medicine Residency and Chief Residency at Johns Hopkins. Dr. Parkinson, I turn the podium over to you. Well, Dr. Michelide, what a joy to be reunited with you. Angela and I worked many years ago on the original U.S. Preventive Services Task Force, and we're still jointly on the campaign to improve health and reduce preventable disease, and also to take a systems-based approach to improving health and healthcare. That's why, when I was approached to moderate today's session, I saw it as a great honor and privilege to introduce Dr. Doug Eby and Mr. Daryl Moon. Let me give you a brief thumbnail sketch of both. You know, when I was at Johns Hopkins, one of my mentors was Dr. Edith Schoenrick, many of you might have known, and she thought that the greatest compliment you could pay to somebody was to call them a change agent, and both Doug and Daryl are national change agents of the first order. Doug Eby is Vice President of Medical Services for South Central Foundation's Malcolm Baldrige Award-winning NUCCA System of Care. Doug is a physician executive who has done extensive work with the Institute of Healthcare Improvement, IHI, and other organizations around the Triple AIM, Accountable Care Organizations or ACOs, patient-centered medical homes, whole system transformation, workforce, cultural competency, health disparity, and other topics. His speaking and consulting includes work across the United States, Canada, Europe, and South Pacific. Doug has spent more than 20 years working in support of Alaska Native leadership as they created a very innovative and integrated system of care that has significantly improved health outcomes. He received his medical degree from the University of Cincinnati, sorry about the Super Bowl there, Doug, and his master's in public health from the University of Hawaii. Daryl Moon is a colleague who I've interfaced with over the last 20 years since I began on the journey for greater health emphasis and transparency in consumer-directed care. Daryl is Chief Executive Officer of Orient since 1996, whose goal is to change the dynamic of healthcare and give employers some control over the ever-increasing cost of the healthcare benefits they offer their employees. Daryl believed that engaging individuals in the management of their own health was a key that had to be inserted back into the economic equation of healthcare. Daryl received both his Bachelor of Science in Finance and his Master of Health Administration for Brigham Young University. Daryl managed 10 different medical and psychiatric hospitals throughout the country prior to creating Orient. Daryl is a Forbes leading contributor and a regular speaker to CEOs through Vistage, the world's leading CEO organization. So with that, I'll turn it over to Dr. Eby for his presentation. Then we'll hear from Daryl Moon. Then we'll have time at the end to take on your questions and comments for about 10 minutes at the very end of our presentation. So Doug, let me turn it over to you. All right. Thank you. Thank you for having me. I'd just like to open by saying that it's an incredible privilege to have been part of the journey here at the Alaska Native Medical Center now for actually over 30 years. And my entire medical adult professional career pretty much has been working in support of Alaska Native leaders, Alaska Native people, as they have driven a consumer-driven redesign of an entire healthcare system. So it's a real privilege, honor to be allowed to speak on this topic and to be allowed to speak on behalf of this system. I certainly do not speak for Alaska Native people, but about the system that we have been excited to help create over the last three decades of work. And this is a complete transformation of an entire system in a consumer-driven perspective. And just for a little bit more orientation, our name is South Central Foundation. We're not really a foundation in the classic sense. When we were created 40 years ago, someone thought it would help raise money. We are a nonprofit healthcare service delivery system, and we have a partner, the Alaska Native Tribal Health Consortium. And between the two of us, we employ right around 6,000 people and provide support to just over 200,000 people across the entire state of Alaska. At the bottom of this slide, it says 65,000 voices. That's the local population that we are the entire comprehensive provider for, but we are the hub site for support to the entire state and a network of somewhere over 50 community health centers. So we are the tribal system. We are also the VA. We are the community health center, FQHC system for the majority of the geographic area of Alaska, and especially for Alaska Native people. If you don't know, in Alaska, about almost 20% of the population are Alaska Native. And especially in the last decade or two, by far the biggest economic engines and employers in the state are tribal organizations, both for-profit and nonprofit organizations. So it's a very different reality than in the rest of the country or really in the rest of the world in terms of presence, importance, and power by the indigenous population of this area. So the company I work for sits on Dena'ina land, and we honor their custodial caretaking of that space and that land across many thousands of years. If you go to the next slide, please. As was already mentioned, we've taken a healthcare system and dramatically changed it, and we do everything. So since this is the Preventive Medicines Association, I'll just mention we do everything. We do everything from water and sanitation, facility and construction development, dental, optometry, behavioral health, both outpatient, residential, addictions and substance abuse, community-based elder programming, and then all the way up through the usual medical clinics and hospitals. The Alaska Native Medical Center is a level two trauma center. It has NICU, PICU, ICU, CCU. There's a little bit that we buy from other systems, but relatively little. And in fact, most of it outside of Alaska, things like transplants and severe burn people and so forth. About 98% of what we do is within the system. So we are very much a vertically integrated public health, prevention, wellness, in addition to medical service system. And that's extremely important because, and we've done a lot of good things. As you can see on this slide, we've done very well at reducing high cost things, dramatically improving customer owner outcomes, both in terms of satisfaction, but also HEDIS. Our governance decades ago said they want to be in the best 25th percentile for all clinical measures. And we are pretty much there. About 95% of our HEDIS comparable measures put us in the best 25%, with dramatic reductions in cost, use of hospital lab, x-ray pharmaceuticals, while dramatically improving health outcomes, massive generational change in every measure that you can possibly think of. And we are still the only healthcare organization in the United States to win the national presidential Baldrige quality award twice, which they don't give to you for being cute or tribal or from Alaska. Next slide. So the key of this is this idea that consumer driven healthcare is way better than professional driven healthcare. And the last thing if people took this on several decades ago, and have said about rethinking and redesigning absolutely everything about the system. Next. A lot of fundamental things were done to be, to help drive this whole thing. So here we have our vision, mission, goals, and so forth. The operational principles are particularly important. If we had more time, I'd go through them because every decision we make, everything we decide about what we do or don't do, and where every penny of the budget goes is determined by the operational principles. So not what the CEO wants, not what I want, but what the people want as expressed through the principles that they developed on which we try to make then every single decision. So the corporate culture and the process of community driven design, community driven voice is actually very, very real and consumes a huge amount of the time and energy we've put forth in developing the system. Next. The idea, the fundamental idea is that humans are on lifelong journeys in the context of their families and households, and in our case, villages. Let me just say we support about 25% of every human in Alaska's health journey. The majority being Alaska native people, and the idea that health happens at an individual level is completely ridiculous. Health happens in the context of household, family, community, culture, history, and so forth. So for us, the main currency we deal in is in story. And so the story behind our eyes is very central to absolutely everything we do. Next. So the summary statement about the foundation is that we've replaced medical culture. We've replaced professional centric medical culture by relationship, shared responsibility, customer ownership, story, and complex adaptive system theory. And I'll race through this really quickly, but this is the fundamental difference of our approach. And I should also say in terms of money, we are primarily a fee for service environment, although we do get some Indian health service and VA and so forth money, it's a minority of our money. So we are in a capitalist fee for service environment primarily. And we produce this though by thinking and acting at a whole system level with public health, prevention, wellness, behavior, medical, all together as a single integrated enterprise rather than separate standalone things. And core to this is one of the most powerful comprehensive primary care systems you'll ever see, which I'll talk at a little bit more length about in just a minute. Next. Core to this is this idea that the medical model is the fundamental problem. So even in single payer systems, so we do a lot of consulting in Canada, Australia, New Zealand, and all across Europe, which are single payer systems, but they have the same fundamental problem that we do in the US, which is this blind adherence to the idea of the medical model. And about a quarter or maybe a third of what we do in modern medicine, it works fine. So in surgical operating rooms, intensive care units, trauma situations, the medical model actually works okay. When the patient or what we call the customer owner is passive and we do things to them. But in two thirds of what we do, that is not it. It's people living with chronic conditions, and that's a very different reality. And the medical model fails almost completely to be able to handle this. And it's the majority of both the personnel and the costs in modern medicine. So we need to get away from the medical model in dramatic ways. Next. Central to this is the idea that we need to become consumer driven and consumer responsive rather than professional centric and make people come to us on our terms. It's completely ridiculous that in order to get to healthcare, you have to make appointments, come to our facilities and interact with us around our rituals and our professional centric structures. It's ridiculous. And the idea that you must have an office visit before we can interact with you is paternalistic and also ridiculous and ineffective. Next. So at the very core of this is this diagram. In a high acuity environment, the system has control. So in an operating room, the patient is passive and we do things to them. And the fact the system has control is fine and the medical model actually works. But again, for two thirds or three quarters, depending on how you define it, we really are dealing with people living with chronic conditions and challenges that exist over months and years in a lifetime. And in those situations, they are in control. The patient or what we call the customer owner in the context of what we would call family or household is where the power lies and the decisions are made. So whether to take medications, alcohol, drugs, tobacco, exercise, nutrition, sleeping habits, how we treat each other when we get frustrated, all those things are under the control of the individual and their context in which they live. And it drives the outcomes and therefore the costs of the majority of what we call health care or modern medicine. And health care is in denial about this. They think that if you come to us, we give you a diagnosis and a treatment plan, and then you go on your way. Somehow we've done our part. And then our paternalistic, judgmental, horrible, abusive way, we call people noncompliant when we don't do exactly what we told them to do. It's offensive, arrogant, institutional, professional, centric, and needs to go away. Next. There's an analogy from complexity science about rocks and birds. Very quickly, if I have in my hand rocks, I can make them hit the target because they're passive. I can control them. I can learn from experience, best practices, and ritualization or standardization of practice. If I have a live bird in my hand, I can push it towards the target. But when I let go of the bird, the bird decides where it wants to go. Based on its values and priorities, it may go sit on a telephone wire. But more likely, it's going to go where its other birds and its babies and family are. And so it's up to us to adjust our model and our targets and our outcomes and our processes to have them, to join them in the targets they want to go to, rather than saying you must come to our target and our terms or you're noncompliant. Next. So we know it works. And all around the world, this has been proven over and over that we need to do, that we are a service industry. Two-thirds of what we do is a service industry, which means it needs to be provided when, where, and how it works for them, rather than how it works for us, like any other service industry. And we already know what works. There's things called navigators, health partners, health coaches, community workers, and what our preferred model is, super capable primary care. Over and over, better outcomes, lower cost. And by the way, we produce what we produce at about 60% of the per capita spend compared to the rest of the US. So we are better outcomes, happier people, better retention, and at a relatively small amount of annual cost, despite being a super high risk and super complicated population. Next. So this is called a Stacy diagram. It basically says the same thing I've already said. Just leaving medical people to their own devices is called chaos. Medical model extreme standardization is in the bottom left-hand corner. That works in one-third of the time when we're in a rock-throwing environment. But for two-thirds of what we do, we need to be in the middle, which involves an awful lot of conversation, complexity, being target-oriented, but a tight-loose-tight management theory, a lot of creativity, innovation, and re-professionalizing all of our staff to take ownership and control and continually modify and adapt what we do to the people and institutions on the receiving side of our services. Next. So I already said this. We're in the business of both being manufacturing and service, and we need to know the difference between the two. So one-third manufacturing, operating rooms, to some degree intensive care units, trauma situations. Service model is everything else. All of the low-intensity hospitalization, ER, and then everything outpatient. We keep applying the medical model to this, and it's completely ridiculous. We need to rethink everything. Next. So one of the things that modern medicine thinks is you have to have an office visit. In fact, one of the great disappointments of the COVID pandemic is that it gave us a great opportunity to rethink what we did. But what almost everyone did was just virtualize what they already do. So they just took the office visit and made it virtual, which is ridiculous. But if you look at these components of an office visit, only the ones with a double asterisk do you actually need to be physically in the same room, which are only two of them. And then there's a couple others with one asterisk where there's kind of a mixture of in-person and virtual. But it turns out 80% of what we do, especially in what's called primary care, but anything that's cognitive-based medicine or the public health prevention and wellness activities can be done, especially once you establish relationship. Once you establish trust and relationship, you can do it other ways. So for us, even before the pandemic, we were about 60, 70% virtual, part synchronous, part asynchronous. So phone, text, email, so forth. This thing called a smartphone is how we do an awful lot of things in our lives, but somehow for modern medicine, it's not acceptable. And that's just completely ridiculous. Next. So this is the actual structure. We spend way more on the budget of people in primary care, and we've taken apart lots of part of the system and put it into primary care. So about 80% of what's different, well, it's somewhere in the system that we moved to primary care, and then we just added other certain things. So for us, everyone in our population chooses a primary care provider, a single primary care provider, and entire households, families, and extended families get the same one unless they opt out. So if grandma moves in from the village, even though it may be the biggest panel, they get the same panel as their whole extended family because health happens in the context of people around you and so forth. So in the middle is a customer owner and family. And then an immediate relationship is a primary care provider, nurse case manager, and then supportive people, CMAs, and what we call CMS, a case management support, our own local invention. And increasingly, the behaviorist or BHC is also part of that intimate group. And for 22 years now, tens of thousands of people have been guaranteed same-day access by any method they want to connect to that group of people. So phone, text, email, in-person, video, whatever they want, they get same-day access all day, every day, at least five days a week, and there's ways we accommodate into evenings and weekends as well, which is part of the logistics I don't have time for today. But then fully integrated with them are the people that are orange in this circle. So pharmacist, behaviorist, midwife, dietician, and social worker or community resource specialist. And there are multiples of these in every clinic, and they're immediately available to just join the conversation. They don't have separate rooms. They don't have separate appointments. They're just part of the team that's shared across primary care teams. And by the way, we right-size every clinic. You don't want your clinic to be either too small or too big. And so, for example, in our main mothership in Anchorage, we have nine primary care clinics rather than a great big primary care clinic. There's a whole conversation there about the sociology of the workplace. It's very important, but we don't have time for it today. And then we've co-located physically in primary care additional people. So the idea is you live your life, you have intimate, trusting relationships with people you know, who you can connect to anytime by any means you want, and then they pull in expertise as needed to that hub. So again, physically located as well in primary care are a bunch of psychiatrists, a fellowship-trained chronic pain doctor, a 30-year experienced chronic pain psychologist, an HIV expert, lactation experts, colorectal cancer screening people, because that's a really big deal in our population, people available to help you use your electronic health record. And increasingly, all ages are seen in these clinics. And so rather than a separate pediatric clinic, the pediatric expertise is now co-located and integrated right into all ages primary care. So mind and body back together, whole family, all ages, and we pull in experts and then care coordinate across everything. So this is by far the most powerful, highly capable, complex care capable primary care I've seen anywhere in the world, but we don't understand why everybody doesn't do this, because it's actually the secret to making the whole system work. We do public health, we do prevention, screening, wellness, it's all done in this paradigm. And then around the outside in the pink in this diagram are the specialists that are not co-located, and then we retrain them to do consultative support rather than destination center of excellence work. So rather than sending people to multiple centers of excellence, they make themselves available to join and consult in real time, usually by video, and bring their expertise to the already existing trusted relationship. So it's completely redesigned of the entire system around the customer owner, consumer driven design at their convenience in their locations, and we adapt to them. Next. So what's listed here is a lot of the co-located expertise in primary care. So I already said some of this, but HIV, diabetes, chronic pain, psychologists, physical therapy, psychiatrists, adult complexity experts, pediatric complexity experts, palliative care, addictions people, and then there's a very extensive array of home visiting people, and then people like lactation, midwives. Pregnancy was moved back into primary care about 10 years ago, and in fact, prenatal and birth and postnatal is one single episode of care to us, and consistency of messaging around parenting, family dynamics, cycles of violence, generational trauma, those are all dealt with in this comprehensive primary care setting with extensive, extensive behavioral health capability provided. This is not medical primary care, this is whole person primary care. And then we connect also extensively into community resource, social work, and all of the other networks, housing, nutrition, WIC, all of these other things in the community, not separate, just extensions of our hub and all the work we do here. Next. Again, no time to get into facility design, but we spend an awful lot of time on design of physical spaces. Everyone's in integrated care team spaces, there are no private office for anyone, there's no doctor's lounges, there's no doctor parking spaces. Even executive management, myself and the executive team, we're in a shared office environment. In fact, most of the time we're in the clinical areas or out in the community. So no private offices for anywhere in the entire system. Next. And the contingencies and adjacencies are all very carefully designed. This is what we're working on now, more complete integration of pediatric expertise, more about really complicated children, especially neurodevelopmental affected children. We have a whole project called New Generations in which we are tripling our effort around parenting, parent partners, and this merging of prenatal through two years of age is a single thing in which we emphasize physical, emotional, nutritional, and intellectual optimization. We're doing a lot now around home wearable devices, more and more around home visiting, a ton we continue to work on around opioids, narcotics, addictions, and then the whole end of life, palliative care, and so forth. And again, all of this is done at their convenience, when, where, and how they want to connect to us, phone, text, email, in person, it's their choice. Next. You'll notice that all of these projects are not office-based and they are very team-based and mostly virtually delivered. Again, the point is when, where, and how they want it and it works best for them. And if you think about this financially, you get very fast turnaround return on investment by dramatically reducing the cost of chronic conditions, but then you get long-term ROI by doing prevention, wellness, self-care, population health, and public health, all again in the same paradigm. Next. This is just something to call out. We have about 95 learning circles every single week in our main campus location and then lots out in our satellite areas as well. And these are like expert patients, right? So these are people with lived experience who come and share their lived experience with other people going through the same challenges. So there's a ton of these on everything from parenting, to depression, to cancer, to caregiving, to end of life, to parenting adolescence. It's a whole range, diabetes, HIV, whole range of these things. We have expert staff present to help support, but the primary interaction is from expert patients to people who are in the journey. So lived experience, learned experience from the community. Next. And I already mentioned this, but the same model gets to acute illness, chronic illness, living with incurable issues, behavioral health, family wellness, personal wellness, prevention screening, health promotion, and then population level, public health, things all following their lead on their terms and partnering with them very extensively. Next. There's a lot to learn from the National Baldrige Framework. You have to invest in all these dimensions. You can't just do system design and measurement, which is what modern medicine thinks. We invest 10 times the usual amount in workforce training and development and retraining because medical people come with all the wrong paradigms and preconceptions. We have to completely retrain them in the arts of listening and partnering and coaching and inspiring people. In fact, to give people diagnosis, treatment plan, pills, that's just the beginning. The real issue is to inspire and influence them. And in fact, if after encountering us, they don't go home and do something different than they would have done, we have not had impact. We have not been responsible stewards of their money in providing support to them. So just doing things to them, diagnosis, treatment plan, here's some pills, is just tools in the tool bag, influencing, partnering, coaching, changing behaviors when people go home. That's what they ought to be able to expect from us. So 10 times the investment in workforce, 10 times the investment in consumer voice and attentiveness to the environment, 10 times the investment of usual healthcare and improvement capability. We have tons and tons of full-time improvement advisors and improvement specialists driving projects. We've got 75 active projects in our primary care system alone right now as we speak, even after over 20 years of innovation and change. We massively invest in leadership, management, strategic planning, and all of that in addition to the usual things modern medicine thinks of, which is system design and measurement. Next. By the way, we hate individual pay for performance. It deprofessionalizes and dehumanizes people and needs to go away. This is our big, huge clinic in Wasilla in the valley to the north. All of our big buildings are gorgeous, beautiful, and extremely carefully designed, all integrated whole person type approach within the physical facilities, but also beautiful and inspiring. We are Alaska native, and 25 years ago that meant the second rate place down the road and no longer does it. Our places are show places. They win awards. It's a source of pride, honor, and dignity. And if you don't know this, the number one thing driving health outcomes among human beings is self-confidence, which ties to pride, honor, and dignity. So a lot of our work is around pride, honor, dignity, self-determination, shared responsibility, because a person with high self-confidence has much better life. Their health is better. Their income and work life is better. Their parenting is better. Their children turn out better. Everything's better. And so an awful lot of what we do is around raising pride, honor, dignity, self-worth at a system level, at a population level, but also at an individual and family level. And we partner with people around all the elements of that, whether it's nutrition, intellectual development, the creation of the miracle of new life, learning how to parent, et cetera. Next. Just a few closing words, and I'm just five minutes away from my time limit, so I'm doing well here. We also do remote service delivery. So this is a challenge all across the rural parts of the U.S. and all across northern Canada and anywhere in the world where there are far-flung rural populations. So for Alaska Native people, about half people live in urban, semi-urban, and about half people live in rural and remote. For us, we are the urban-based system. So for us, about 85% of our core population is urban or semi-urban, but 15% are not. We run 14 FQHC community health center locations in which everyone is seen, Native, non-Native, everyone in the whole community. We work with the VA. We work with HRSA, FQHC, in addition to Indian Health Service and tribal leadership. And part of the answer to this is a workforce that's based in the community. So rather than sending outsiders in, we hire people in the community and then train them to become what are called community health aides, which are many medical people, behavior health aides, self-explanatory, community health representatives, which like many social workers, dental health aides, which actually do drill and fill on cavities, in addition to preventive oral health. And then we support all of this by a spoken hub model where we have massive amounts of dedicated time and energy by physicians, dentists, and behavioral health people in urban environments, supporting this far-flung network of people who are from the places that they work in and support. This is the answer to rural and remote staffing problems all across the U.S., Canada, and all across the world. And it amazes me that this isn't replicated in rural and remote places all around the world. Next. All right, we're down the home stretch. At the core of this, as Baldrige would say, if you want to be a high-performing organization across decades, you need to become a learning organization. And that means being humble about what you know and you don't know and continually checking with the people on the receiving side. Value is only determined by people on the receiving side. And healthcare doesn't understand this. We're the most arrogant, institution, professional-centric thing on the planet. It's crazy. We are a service industry, and we have their money, and we have to responsibly spend their money in ways that work for them. We exist for them. And it has to be when, where, and how it works for them, not around our convenience. It also means we need to be humble about what we think we know and we don't know. What is illness? How do you affect illness? And how do people live with challenges across their whole life? They are way more expert than we are, so we need to continually adapt to them and follow their leadership with our expertise in shared responsibility. That means truly becoming a real learning organization, which many organizations claim to be in healthcare, but very few actually are. Next. Then there's a whole presentation to be made around social norming. And I'm just going to close with this, and I have two minutes left. So this is the other thing, which is social norming. Negative social norming, positive social norming are extremely important. So there's a lot of people out there who want to fix what's broken. And so they go into populations, especially populations that are challenged and haven't exactly thrived in healthcare terms over time, and then they show up to fix people, to fix broken things. Well, that is completely ridiculous. What you want to do is find the bright spots. Who are the people, the families, the locations that are thriving despite all the problems? And then how do you learn from those and replicate that work? Medicine is very deficit-based. We're here. We got to get there. We got to close the gap. Should be the opposite. Where is excellence happening? Where is good health happening? Where is resilience and protective factors overcoming big detrimental historical issues? And then how do we replicate those? How do we pull towards the positive? How do we create aspirational positivity among Alaska Native children and youth and families about the wonderfulness of who they are, the strengths they have, and the wonderful places they can go, rather than using ACEs scores to tell them how screwed up they are and how their life is going to suck because of their horrible childhood and generations of trauma? That does harm. Negative social norming does harm. Modern epidemiology is full of negative social norming and negative labeling. Medicine is full of negative, disparaging, accusatory ways of getting at societal issues. We have to change this. We have to be aspirational, positive. This is the public health preventive approach of what's working, what are the bright spots, what are the resilience and positive protective factors and strengths? And then how do we build on those with intentionality in response to those who actually have control, which are the people living the lives in their communities? And the final point is, part of doing this is to hire from the communities you want to influence. We're at like 62% Alaska Native hire. When we took over from the government, we were at 15%. We're at 75% of our leadership and management positions being held by Alaska Native people. And we don't understand, if you don't go to the expertise of the community and hire in the community and then add the medical expertise, we have no idea how you're going to succeed. Yet modern medicine insists, even in challenging environments, to hire all these professionals from other neighborhoods and other places and then bring them in to save the disadvantaged people. It's arrogance, it's paternalism, it's judgmental and it's offensive. All right. With that, I will close and turn the mic over to Darrell Moon and apologize for my excesses, except I hope I did piss off and frustrate at least a few of you. Dr. Eby, I never get tired of hearing from you. I love your story. Thank you so much for spelling out such an incredible approach to health care. Aspirational health care is really a movement to move. So wouldn't it be nice if we could all just buy our health care from the Native Alaskans in Alaska? Wouldn't it be nice if every employer could just simply say, sign me up for the NUCCA model? And unfortunately, that's not the case. They're going to keep focusing on perfecting their system for their 65,000 members and we all, the rest of us, have to figure out how do we take the principles that they've proven and apply them in such a way that we get a better health care system instead of this dysfunctional, impersonal, deficit-based system that we're so used to in the lower 48. So we're calling that aspirational health care because that's what Dr. Eby refers to in the books up in NUCCA. It's not deficit-based, it's aspirational and it's not just about introducing a point solution. It's about complete health care transformation and this movement is about really trying to help employers see that they're a major influence in the way health care works in this country. Next slide. It's about helping employers who purchase almost 50 percent of all the health care in the United States. Uncle Sam's the big one. But if employers will realize that they're the driver in health care and the way they spend their money is one of the most important ways that we can drive change. And so it's about helping those who make the decisions, particularly the business leaders, the CEOs, and it's really as simple as three primary strategies. Alignment, choice, and relationship. We're going to go through each one of those and we're trying to help organizations across the country. This movement is about helping employers realize that they can offer aspirational health care benefits by simply changing the way they spend their money. Now it's not going to happen overnight. It's not like just by changing the way you spend your money we're going to be anywhere equal to the NUCCA system up in Alaska. But it's about moving in that direction and by investing in those things that the NUCCA system has proven works and works the best. So I'm going to go through each of these. Let's go to, yeah, thank you. So alignment. I love to get in front of business leaders. I speak to CEOs regularly. I've spoken to over a thousand in the last few years and I love to ask them the question, why do you buy health benefits for your employees? It's often your second largest cost of doing business. What in the world do you even want? Why do you spend the money in the first place? And they look at me like, you mean I get to say? Yeah, you're the customer. You're the one that's writing the check. You're the one that's buying health care benefits. And for sometimes the first time in their life they've actually sat down and thought, what is it that I want? Why am I spending this enormous amount of money? And when they think about it they always tell me the same four things in this order. I want to attract and retain top talent. Number one reason for why I buy health benefits. My product is better. My customers are happier when my employees are healthy and productive. So that's the second thing I want. And I want my employees to feel like what they're getting is good health care. They want to be satisfied. And never the first, but always included is, I wish you were more affordable. They'll tell me all the time. I'll spend the moon to attract and retain top talent. It's like, don't carve away the fact that I need to be able to offer a benefit that's going to attract good employees and keep them with me and stay on my team. So yes, I want it to be affordable, but they don't want that affordability to interact with their ability to attract and retain. And then I usually ask them, OK, that's what you want. Do you ever give your CFOs a bonus to create profitability? Do you ever reward your salespeople to increase your revenues? Of course. Have you ever rewarded or incented or recognized the very people within your organization, your own internal benefits team, your benefit managers, your HR directors? Have you ever recognized or incented them to actually bring you the four things you just said you wanted? And they look at me like, no, but that's a really good idea. It's like, that is the heart and soul of why health care is so broken in this country. The very customer that buys it is not aligning even their internal team to bring them what they want, much less the rest of the health care system. And so creating that alignment within the internal team and secondarily to the external team is one of the three primary strategies that employers have to adopt if they want to produce something even close to what the folks up in Alaska created. And then external benefit consultants. So often we pay brokers and they get more money when the employer doesn't get what they want. It's like the consultants, the benefit consultants across the country should be put on a fee-based contract and their compensation and bonuses and rewards should come because we're getting what the company says they want, the objectives of why they're paying health care in the first place. And what very seldom ever gets done is an actual continuous process improvement plan, which is what the whole Malcolm Baldrige award is based on. Why don't we put those plans in place at the employer level where we're actually monitoring, are the benefits that I'm offering working at attracting and retaining tough talent? Are they working to produce a healthier workforce? Are they working to create customer satisfaction? I could probably name on one hand the number of organizations, even fortune 500 companies across this country who simply do this basic one-on-one business strategy for this part of their business. They'll do it for every other part of the business, but seldom do we ever see companies implementing this strategy for their health benefits. Next slide. The next key thing is choice. If we want to drive satisfaction, stop putting all our eggs in the same basket. We in the American employer world, we think I'm just going to buy a health plan, I'm going to pay for an insurance plan, and I'm hoping it'll work. Well, I'm sorry, but the BUCAs, the Blue Cross, the United, the Cygnus, they don't offer anything close to what the folks up in Alaska built. And if employers want to get that, it's not about waiting for Hospital Corporation of America to build it or any other health care system to build it. It's about employers simply saying, I'm going to put my money in different baskets. I'm not going to put all my money into just a plan, a medical plan. Yes, you want to put money there, but create a defined contribution and let people choose what's going to work best for their family. One of the philosophies that's killing the cost of health care for the American businessman and woman is the fact that we believe that if it's not good for everyone, it can't possibly be good for anyone. That principle is killing us. If we'll simply use a defined contribution, offer up the money, and let people purchase what works best for their family and for them, we will see between 20 and 50 percent reduction in health care costs. And I won't go into all the details. I don't have time, but there's no question that giving people choice and allowing them to choose what's best for them creates a much better end result than us trying to decide for people what's best for them. Now, let's talk about the family doctor. Unfortunately, so many of the primary care practices in America have been bought up by the health care systems, tacked as a funnel source into the broken system. I, as an employer and members, want to have a primary care front door of the system that works for us, that is aligned with our goals to keep people healthy, not to be incented to drive people into a broken system. So we're recommending, and many employers are actually putting a defined contribution in place for their employees to choose to use the employer's money to subscribe to a subscription-based primary care model, like a direct primary care or virtual primary care, where now they have a physician that's independent of the health care system, who's working for the member and is actually coordinating the care and is involved in all levels of care. And clearly, someday, I think we'll get to the point where it may be close to what they've built up in Alaska. But the idea is we can't force people into that subscription-based primary care, but we can offer up money and say, look, this is for you to have a different kind of relationship with primary care. If you don't want it, that's fine. You don't get the money. If you want to go into the traditional plans, insurance plans, and how they pay for primary care, you want to go to the traditional primary care, that's fine. I can't force you, but why not offer up money that says, look, I'll pay for you to pay that subscription-based monthly subscription for you to have a different experience with primary care. And that's how we start building something that might someday be as close to what they've built in the best health care system in the world, the NUCCA system up in Alaska. Now, the third thing is one of the things that I'm so impressed with Dr. Eby and the group up in Alaska is that they use storytelling and they teach practitioners, doctors, nurses, case managers, how to be coaches. And they've done a marvelous job of helping to build this relationship of trust that influences people to take ownership in their health. Well, it's going to be a long day before we teach every doctor in America how to be a coach. So employers simply put money aside into an incentive, pay for the coaching, but not just pay for the coaching, but be willing to give members an incentive to actually engage in a trusting long-term relationship with a coach. Now, the incentive does not drive behavioral change. And I would be the last person to ever say that it will, but it can drive people to do simple tasks. And that simple task is to have a relationship with a coach. It's the relationship with the coach who doesn't sit there and tell you what to do, but helps you accomplish what you want to accomplish and live life to its fullest. It is so instrumental in driving population change, which then drives population health. And the final defined contribution is medical cast. We want to put money into an HSA and HRA, the new ICRA or the new EBRA to encourage people to make their choices with the money that the employer gives them, and then to insert consumerism into the healthcare system. The ICRA and the EBRA have only been around for just over two years. And I find across the country that most people, even brokers have never heard of them. And they opened up the horizon for employers like never before when it comes to giving employees cash that they can use to make consumer driven choices in healthcare. Next. Next slide. So the final area to conclude with is this idea of relationship. And Dr. Eby's done a great job of explaining how important relationships are in healthcare. So we're simply suggesting that through this aspirational model, every single person, Dr. Eby's taught me what you cannot have an intense trusting relationship with 10 people. And one person's not enough. They build it around four. We're simply saying everyone should have a benefit expert that they can reach out and contact and help them navigate the complexities of insurance and benefits. They need an independent medical provider, partner that can coordinate all their healthcare, and a partner that's a coach can help them live life to its fullest. Next. The aspirational movement is really trying to build the advisors, the administrators, the education, and the advisors and the providers that really create the infrastructure to allow employers to build this kind of benefit for their employees. Next. I won't go through all the steps, but there's outlined steps of how you can actually implement as an employer strategies to get this kind of a benefit. Next. Let me conclude with this. So often employers think that their goal is to buy a health plan. And even the brokers believe that's their goal is to build a health plan. That's not the goal. The goal is what the employer objectives are. The goal is to attract and retain top talent. The goal is to create a healthy, productive workforce. The goal is to improve employee satisfaction and create affordable healthcare. That's the goal. And everything should be built around a process to accomplish those goals. Next. Okay. We're time for questions. Well, thank you, Doug. And thank you, Daryl, very much. What a provocative one-two punch. Ridiculous, arrogant, crazy. Heard them mentioned many times. And Daryl, your solution in the Southern 48 to try to disarticulate some of the non-value-added practices and thinking to approach what Dr. Eby and Nuka is doing represents practical steps to get there. Doug, I want to thank you for responding to many of the comments and questions that have happened in the chat room. So I won't restate those a limited time. I've got one question for you. Culture lives in such things as what we used to call guiding principles. I like your term even better, operational principles. That's your true north. Can you highlight if it's possible for our audience to see what those operational principles are and to use them almost as a yardstick for their system or for their employers that they work with to say, does your system have operational principles that treat employees as customer owners and you as the employer as somebody who's a true partner who's listened to? I would find that fascinating to see your principles and think whether or not they could be used in that fashion. Yeah. So they were on that one slide, Stephanie, I don't know if we can go there. And they were there with a lot of other things. And I don't know if there's a way to enlarge it to make it easier to read. But they're the same. So the way we got there was when we actually took over the main hospital part of the system from the government. So that was 25 years ago. We already had five years of planning before that about what we would do. But the first thing we did when we actually took over was a four-month, very showy listening process. Because we wanted the message in the community to be when we got control, the first thing we did was listen to the community. The first thing. So we did tens of thousands of surveys, over 1,000 one-on-one interviews, met with the staff we were inheriting, met with them endlessly, did learning circles, I think like 150 learning circles. And we hired an outside firm to help us do all this work. So we took all that massive amount of information and distilled it down to what at the time we called elements and requirements of an ideal health system from the community's perspective. And then those became the operational principles. So that first big thing, listening and consumer-driven. But what they say, the acronym they spell out is the word relationships. Because we think that's the magic juice above everything else, our relationships. The world runs on human relationships in all kinds of ways. But what they say is that the relationship between the customer owner and the care team will be optimized, that we will get to the whole person, mental, behavioral, spiritual, so forth. And then there's a lot of practical things like it will be at their convenience. It will be when, where, and how it works for them. We'll avoid duplication. We'll encourage working at the top of your license. Financially sustainable. We'll hold ourselves accountable for outcomes. And then the last few are critically important. We will build it around their priorities and their convenience rather than ours. And we will build it on the strengths that they bring to the table rather than the deficits. So the strengths of Alaska Native people. There was a great question about, is this all built around Alaska Native culture? The short answer is yes. The long answer is yes and no. It turns out that there's a lot of specific things we do that are specific to Alaska Native people. But the fundamental premises of this translate to every place in the entire world. It turns out humans everywhere, this works better for them. So the core and our operational principles are not culture specific. They're principles. If you do the principles though, you build on strengths, you hire from in the community, you adapt to the person in front of them. Their priorities drive your care planning and their convenience drives your access. Then by definition, you will build it on the cultures, values, and traditions of the people because that's what your principles say you will do. So the principles are agnostic of culture, but specific cultural elements, but they make you incorporate specific cultural elements. Does that make sense? Absolutely, absolutely. And Daryl, if I may, one for you. Many of our physicians in ACPM are aligned with businesses. They're aligned with obviously large health systems, public health agencies, and we deal with the public. It would be wonderful if our membership can reach out to you in their given communities to try to find change agents that would be aligned with your message. How would they go about doing that? Well, that's exactly what we're doing is building a group of aspirational healthcare advisors, which you can look up on aspirationalhealthcare.com around the country who have agreed to work for the client company and not the broken system. And they're doing this for companies across the country. They're actually helping to build this alignment, this choice and relationship for the communities. I want to thank you both very much. Angela's going to wind up with a few comments, but you have blown us away today in a very positive way. What's possible all around listening, the community, prevention, public health, the built environment, every buzzword we've ever heard, you've actually tried to put in practice. Thank you both very, very much. Dr. Michelide? I concur. Thank you for these excellent presentations and to you, Dr. Parkinson, for such fine moderation. The recording of this session will be available on our learning management system in a couple of days, and we encourage you to share your learnings with your colleagues and friends. In addition, connect with us on our website and social media. We'd love to have each and every one of you be part of our American College of Preventive Medicine family. So this concludes our webinar. Have a good rest of your day and thank you.

Aspirational Healthcare

South Central Foundation

consumer-driven healthcare

relationships

whole system approach

comprehensive primary care system

employer objectives

choice

trusted relationships