Many of us in leadership positions are here to serve our communities. Striving for improved health outcomes and greater health equity, we carry these objectives as our driving force, day in and day out. We stay focused so we don’t get lost in the minutia. Through our work, we interact with community members, and it is always enlightening to hear comments about their delivery of care and any improvements that may be needed.
More than three years ago, one of these interactions highlighted the vital need for cancer care in the Navajo Nation and started me on my journey to bringing cancer care to Tuba City (Ariz.) Regional Health Care Corporation—the first and only cancer clinic on any American Indian reservation.
A volunteer with the organization’s foundation, whom I had just seen and shared hellos with during a meeting, succumbed to cancer after being diagnosed only four to five months prior. I soon learned from her family the many barriers she faced to receiving cancer care. Transportation was one obstacle. She did not want her grown children to miss work and school to drive her 150 miles round trip to the nearest cancer center. Also, many of her family members did not have the money to make these trips. Weighing these factors, she decided not to get treatment.
The Case for the Cancer Center
Personally seeing the result of not having accessible cancer care, my executive team and I got to work looking at the presence of cancer in our community. In addition to no local access to cancer treatment and no reliable sources for assistance with cancer care, numerous other factors put the Navajo Nation at a higher risk for poor cancer outcomes and increased health disparities. These risk factors include lack of water and electricity, high poverty rates, environmental issues and, prior to our healthcare being managed by this tribal organization, poor access to primary care services.
On our executive team, which is made up of 11 Navajo tribal members who had grown up on the Navajo Nation, half had lost a primary relative to cancer. The need for accessible cancer care was obvious.
The Vision
To set the vision of providing cancer care at Tuba City (Ariz.) Regional Health Care Corporation, our team traveled to the Alaska Native Tribal Health Consortium in Anchorage, a consortium of 253 Alaska Native tribes, for input and inspiration. The health center had successfully launched a culturally sensitive program 10 years prior, and we learned about the program’s history and implementation tactics. This helped set the stage for developing our program to achieve health equity for our community.
The Preplanning
The first step to bringing cancer care services to the community was obtaining commitment from an oncologist team that would relocate and work for our organization. Once we had this team lined up, the executive team was one step closer to making cancer care a reality.
The second step, and a major hurdle on our journey, was determining the reimbursement model within the U.S. Indian Health Service all-inclusive payment system. We do not get paid fee-for-service; we receive a flat rate for outpatient care from Medicare and Medicaid. The cost-of-care process for American Indians involves state Medicaid programs paying providers for delivering care, called a “pass-through.” This means that they pay for the care and send the bill to the federal government. As most healthcare executives know, the costliest part of cancer care is the pharmaceuticals. We had many meetings with our state Medicaid program in which we asked for allowance for at least the reimbursed cost of medications, in addition to office visits, and the Medicaid director in Arizona eagerly made this amendment for us.
The next step was to get more data on the cancer care of American Indians. We quickly learned that very little information was readily available, particularly how exactly to plan these types of specialty care.
Our pivotal moment came in a meeting with the National Cancer Institute’s Cancer Moonshot Task Force at the White House. We met with a room full of cancer advocates, and we highlighted the lack of available cancer treatment on tribal land. Advocacy groups then assisted us in talking with the National Comprehensive Cancer Network and the Cancer Support Community, which provided us with a great deal of helpful information.
The Implementation
Next, I presented the data and findings to our healthcare organization’s governing board, and it approved the project to build a cancer program with capital funding. We worked with a successful cancer consultant and modeled the clinic with a replicable workflow that occurs in hematology/oncology clinics. We crafted job descriptions based on best practices and built a sustainable program with input from oncology experts.
The Opening
We publicized the opening within our tribal communities and state and national partners without the use of direct federal funds. The now-first lady Jill Biden, EdD, visited our program and helped us get additional publicity for the first cancer center on tribal land.
Today, through persistence, we have a successful hematology/oncology service offering care that improves the quality of life of our community and provides a culturally sensitive program that welcomes and imparts kindness to our patients who have received a cancer diagnosis.
As I look back on this extremely challenging task, the takeaways include the importance of setting a vision for your team, working with each other’s strengths and keeping community needs in focus. As a CEO and leader, knowing I have impacted many lives gives self-gratification and purpose to this courageous career path I have chosen. Building on the positive impact of the cancer care offerings, Tuba City Regional Health Care Corporation will continue to improve health outcomes and strive to achieve health equity.
Lynette Bonar, RN, FACHE, is CEO of Tuba City (Ariz.) Regional Health Care Corporation (lynette.bonar@tchealth.org).
Editor’s note: Tuba City Regional Health Care Corporation, which is located about 78 miles north of Flagstaff, is the first and only cancer clinic on any territory belonging to American Indians, and Bonar is the first woman to lead a Navajo healthcare system. The program so far has had about 1,300 visits. The facility combines traditional healing with modern medicine, and staff, including Bonar, speak Navajo.