Genocide by Bureaucracy: The Healthcare Plight of Native Americans, with Dr. Terry Knapp

This week on our show we have Dr. Terry Knapp – Founder, Director, and Chief Medical Officer of CareSpan Holdings, Inc.  Dr. Knapp has a storied 50-year record of achievement in health care and business. His company CareSpan provides a comprehensive, integrated digital healthcare “Clinic-in-the-Cloud” solution by creating unfettered access to care for the underserved, with an emphasis on the care of chronic illness. Dr. Knapp has devoted his life to working with native peoples throughout the world and deeply understands the health problems and impediments to better healthcare that afflict Native Americans.  In this episode, he is here to share his views in order to raise awareness for the plight of indigenous peoples in our country who are receiving sub-standard care.

There are some deeply emotional moments in this episode, as he discusses the failures of healthcare delivery as promised by the U.S. government more than 100 years ago. He describes American Indians that are dying a slow and agonizing death.  Their land – a reservation – is a concentration camp where they are treated as third-class “citizens” by receiving medical care that is killing them. He talks about the bureaucracy of the Indian Health Service, the failure of the IHS to provide enough good doctors, the lack of choices by patients, and the lack of respect for Native American ways by a health system that ignores their culture. He discusses the denial of access to modern medical care and posits that the Indian Health system actually makes them sicker by exacerbating psychological trauma and socioeconomic challenges associated with their physical imprisonment (as seen by rates of substance abuse and mental illness). The inhumane treatment that Dr. Knapp has observed firsthand has made him speak out about what he sees as a slow-moving but progressive bureaucratic genocide of our Indigenous peoples.

The Native American phrase Mitakuye Oyasin means “all my relations”.  This is said at the end of every prayer in the Lakota Nation, and it reminds us at all times to honor all of our relations – past, present, and future. This transcends our human relatives and includes our relation to all of creation – the water, the plants, the animals, and the Creator. Indigenous people think intergenerationally as well, by honoring those in the past, present, and future. In thinking of value-based care, how can we consider all of our relations – which includes Native Americans who have suffered irreparable harms from a deeply flawed healthcare system?

Episode Bookmarks:

02:00 Introduction and Background to Dr. Terry Knapp

03:50 Dr. Knapp is speaking out after seeing firsthand the inhumane treatment of our Indigenous peoples by the healthcare system

05:20 The Native American phrase Mitakuye Oyasin (“all my relations”) as a reminder that value-based care must consider all of our relations – including Native Americans who have suffered irreparable harm

07:10 Dr. Knapp discusses his medical training and life’s work to make a social impact as a surgeon, inventor, and entrepreneur

13:00 Insights as a cancer patient led him to develop a “clinic in a cloud” integrated digital care company (CareSpan Health) that leverages technology to enable health equity

14:45 The catastrophically high rate of COVID-19 cases and deaths in the Native American population (and similarities to the 1918 flu pandemic)

15:15 Tribal healthcare facilities are underfunded (in 2017, US healthcare expenditures were $9,207 per capita but only $3,332 per capita for Indian Health Services)

15:50 Unethical medical practices of the past (e.g. Native American women undergoing forced sterilizations in the 1960s and 1970s)

16:20 Dr. Knapp’s early experiences in treating the Yurok and Hupa tribes in California as a medical resident

18:00 Treatment of disadvantaged people in Mexico, Peru, Ecuador, Columbia, Chile, and other parts of Central America

18:30 How a friendship with Gene Thin Elk taught him the importance of native healing and how to live in harmony in nature through ceremony

20:50 Lessons learned from the Lakota Sioux nation about how community support can help warriors heal from PTSD

21:20 An invitation to speak the 18 tribal Chairmen to share views on modern medicine and virtual technology

21:50 The horrific stories shared by John Yellow Bird Steele about the suicide of 7 young women in one week, the death of a young boy, and other suicides and drug overdoses on reservations

24:00 Insufficient access to care to Native Americans due to lack of providers willing to live under reservation circumstances

25:00 The shock of seeing such alarming grievances expressed by tribal Chairmen when meeting with a federal official representing HIS

27:00 Dr. Knapp explains how the 638 Self Determination provision for healthcare prevents the IHS from sharing resources (e.g. Internet signal) with a tribal system clinic on the same site!

28:00 “There is something amiss when it comes to the bureaucracy that will not allow the sharing of simple, potentially lifesaving resources between an IHS facility and a tribal clinic.”

28:50 The insufficient, outdated, and essentially unusable RPMS Electronic Health Record system used by the IHS that needs either significant improvements or a complete overhaul

29:30 “The RPMS Electronic Health Record used by the IHS kills people. It was first developed in the late ’70s and hasn’t had a complete overhaul since 1982.”

30:30 Bringing telehealth to the reservations is virtually impossible since it cannot interoperate with RPMS

31:00 “The lack of interoperability of RPMS actively denies health equity to the Native Americans.”

31:40 The Native Americans call their IHS ID Number their “Auschwitz number”

32:00 Dr. Knapp discusses how the United States of America will not allow Native Americans to be self-determinant and has robbed them of their identity.

33:40 Treaties signed with the US government guaranteed that healthcare be paid for in perpetuity, but the care is poor with no choices to receive care in the private sector.

35:00 The failure in our country of the healthcare system to provide optimal outcomes for chronic disease (and how chronic disease is so much worse on the reservation)

36:00 Dr. Knapp discusses Social Determinants of Health,  Whole-Person Care, and Blue Zones

37:30 Realigning economic incentives with care delivery that leverages digital health approaches to primary care

38:00 Why we need to focus on outcomes instead of value (since value is so hard to define)

39:30 The importance of relationship-based, tech-enabled, coordinated, whole-person, holistic care and how that could benefit indigenous peoples

41:00 Dr. Knapp provides a personal definition of health equity and what it means on a population health basis, i.e. how the overall health of a society adds benefits and opportunities for all

43:00 The sad truth of declining life expectancy in the United States, yet we spend more on healthcare than any other country in the world

44:00 How technology can enable value-based care if it is properly integrated to drive a systems engineering process (P4 Medicine)

45:00 Development of a digital ecosystem that monitors data, delivers comprehensive care, engages patients, provides continuity of services, and utilizes predictive and outcomes-based analytics

49:00 Honoring Native American traditions and heritage through the provision of culturally-competent care

51:00 Keeping an open mind to indigenous Native American Healing traditions and why Western Medicine should partner with native healers

52:00 “The only way to create a sustainable healthcare paradigm is to pay for outcomes-based care in a risk-adjusted, capitated fashion…”

54:00 How the flawed fee-for-service model limits access to primary care and raises per capita costs

56:00 Dr. Knapp discusses how technology can be used to create health equity in our country

57:30 The failure to address the drug predators who prey on American Indians to create a massive public health crisis

58:20 “Drugs like Fentanyl, Methamphetamine, and Heroin are weapons of mass destruction.”

59:30 The public health crisis of obesity in our country

60:00 Delivering the same level of care to Native Americans while also respecting their culture is a “great life’s work”

61:20 Dr. Knapp provides parting thoughts on the inhumanity of the bureaucratic state and how COVID-19 has “opened a window” for change