Alaska Health Policy Review  comprehensive, authoritative, nonpartisan
May 2008 Vol 2, Issue 16
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Interview with Mike Hawker
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Interview with Tom Hunt
AHPR Staff
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From The Editor  

Dear Reader:

We have two extraordinary interviews in this issue of Alaska Health Policy Review.  They are both frank and wide-ranging, and they are both informative, but there the similarities end.

One is controversial while the other feels bleak and disturbing. One is the policy maker, and the other is the safety net provider. One sets the policy, and the other is subject to it.  One tries to save money, and the other tries to save lives. Both sit at the Alaska health policy table.

Representative Mike Hawker is a retired certified public accountant, who exercises tremendous influence over state health policy decisions as a member of the House Finance Committee, and as Chair of the House Health & Social Services Finance Subcommittee. In this extraordinarily candid and wide-ranging interview Representative Hawker discusses his differences with the governor on key issues; explains his position on the use of state funds for Community Health Centers; and discusses his dissatisfaction with SB 160, the most far-reaching health reform legislation proposed in the 2008 legislative session.

Representative Hawker explains why he believes a major plank in the governor's health policy was "doomed to fail at the outset." He discusses the issue of whether the state has an obligation to assist Alaskans without access to health care, and he candidly admits that Alaska legislators "are not particularly the brightest bunch."

Dr. Tom Hunt is the medical director of Anchorage Neighborhood Health Center. In his brutally frank, perhaps disturbing interview, Dr. Hunt discusses in detail why he believes safety net primary care services in Anchorage are in a "death spiral." He analyzes and ties together an enormous number of critical issues such as the local surge in heroin cases, the impact of the reduction in services of Anchorage Mental Health Services, state funding policies, service complications caused by the mix of funding sources, the growing shortage of primary care physicians, and a complex relationship with the Municipality of Anchorage.

Dr. Hunt discusses the desperate circumstances that force him to "turn away patients every day," and admits that people will die because of the health center's inability to treat every one that comes to the doorstep. He details all the ways the state could provide support but routinely fails to do so. Ultimately, he believes the single most effective policy change would be a national health program offering universal health coverage. Meanwhile, in the absence of additional state support, Anchorage's medical safety net is inexorably unraveling with fatal consequences.

Lawrence D. Weiss Ph.D., M.S.
Editor, AHPR

Interview with Mike Hawker
 

Angela SalernoAmong other committee positions held by Representative Mike Hawker, he is a member of the House Finance Committee, and chair of the House Health & Social Services Finance Subcommittee. In this extraordinarily candid and wide-ranging interview, Representative Hawker discusses his differences with the governor on key issues; explains his position on funds for Community Health Centers; and discusses his dissatisfaction with SB 160, the most far-reaching health reform legislation proposed in the 2008 legislative session. This interview was recorded April 28, 2008. It has been edited for length and clarity.


AHPR: You are the chair of the House Finance Subcommittee for Health and Social Services and a member of House Finance. As such, how do you evaluate good health policy versus bad health policy?

Hawker: You always have to evaluate every proposal on its individual merits. You have to reconcile the benefits to be obtained, or that may be obtained, with the cost of providing those benefits.

AHPR: I see that you are a prime sponsor of both House Bill 12 [Full Funding of PERS/TRS] and House Bill 13 [Retirement System Liability/Bonds/Corp.]. When SB 141 [Public Employee/Teacher Retirement/Boards] was enacted and completely revised the retirement benefits for public employees, it didn't actually revise the benefits themselves, but it seriously revised access to, and cost to retirees of the health benefits. I wonder if you could talk about whether either of these two bills would affect the health component of public employee retirement.

Hawker: First, for your records, I was one of the folks who opposed the original passage of 141. I did not support that approach. House Bill 12 and House Bill 13 have nothing to do with medical benefits. House Bill 12 ultimately became manifest in a bill that did pass, that was Senate Bill 125 [PERS/TRS Contributions; Unfunded Liability], which had to do with the state taking primal responsibility for the unfunded past service cost liability. House Bill 13 was a financial tool, a financing tool, that would allow the state to deal with the unfunded past service cost liability and reduced the ultimate cost of settling that liability, of funding it. Neither of those bills had anything to do with the ongoing provision of, or access to health care benefits. Frankly you'll hear folks debate on both sides [about] the consequence of 141 on the benefit system itself. I may be the wrong person to try to talk to about what differences those might be unless you care to itemize them yourself.


"Creating a defined contribution retirement system absolutely did nothing to help us, and closing the system, closing off the old system so that all new employees had to go into a new system, eliminated the ability of us to manage that system, manage it back into solvency."


AHPR: I appreciate what you said about being one of those who opposed Senate Bill 141. I wonder if you could talk about why you opposed it. You're a former CPA I believe, and I wonder if that had something to do with why you opposed it?

Hawker: My background as a financial professional was exactly why I opposed 141. I truly do not believe that the data points that were used in arguing in favor of 141 were accurate, valid, or will ultimately withstand the test of time. The way 141 came through, it still created a hybrid of defined benefit/contribution system for the medical side. It did create a defined contribution on the actual pension benefits, the retirement pay benefits.


If you look at the substance of what we were into at the time, the funding issue had to do nearly entirely with the medical benefit side; [it] had almost nothing to do with the retirement pay side as far as what it generated--the unfunded liability. Creating a defined contribution retirement system absolutely did nothing to help us, and closing the system, closing off the old system so that all new employees had to go into a new system, eliminated the ability of us to manage that system, manage it back into solvency. Instead, it absolutely guaranteed that we had triggered the bankruptcy of the old system. To me, that was not a wise way forward. The way pension plans work, we had literally a hundred years to work them out and make them solvent again. I believe we could do that.


We had a lot of support from organized labor to review the medical side of this equation, look at other alternatives that could alleviate the underfunding problems including revisiting some of the benefits available, revisiting some of the co-pay requirements, revisiting any number of the elements that could make this a solvent program into the long run, and I don't believe those were given an adequate vetting in the discussion.

AHPR: I very much appreciate your answer. I agree completely with what you said. In that light, what is your take on SB 183 [Repeal Defined Contribution Retirement Plans], which intends to--for the most part--return to the former system?

Hawker: SB 183 did not have the votes to pass out of the Senate. I think we had the votes in the House--barely--to get it through, but it did not have the votes in the Senate to accomplish. I would remain committed to continually revisiting this issue and seeing what the data supports as far as a policy forward. I believe at the end of the day, the data will support a return to a revised, but nonetheless, more defined benefit style of structure for public employees.

AHPR: You are a prime sponsor of House Bill 407 Health Reform Policy Commission. During the last session, there were one or two other bills that addressed a similar concept of a health reform policy commission. I wonder if you could explain why you decided to create a new bill to address this issue.

Hawker: Two years ago--this would've been the first session after the new administration came in to office--I had informed the Department that I had fully intended to introduce the bill that was essentially in the form that you saw 407 introduced. The Department of Health and Social Services asked me not to introduce that bill. They said they wanted to do it their own way.


Then in February of that year, they sat down with the governor and announced that she was creating her own task force of some kind. I stood down for a year. I let her task force operate for a year. I was, frankly, quite disappointed in the outcome. I was very disappointed in the administration's inconsistent responses to what I believe were the body of testimony developed in that process. So I stood back and said, "Well, it's now time for legislative initiative to come back on the table." At this point, we've raised the discussion, and I believe it's a discussion that will be a significant topic at issue as we enter the next legislative session.


"You don't send low-level staff--from say a hospital--that has to report up through three different levels of command before they get to a decision-maker. Then all you do is get somebody that sits there and say[s], "Well, interesting ideas. I'll take it back and talk to my boss. He'll talk to his boss. They'll talk to her boss. They'll talk to their boss. They'll talk to their boss. They'll run it up the board of directors, and then we'll come back and see what they all say. No, it's never going to work that way."


AHPR: I wonder if you could just say, in a little bit more detail, why you were disappointed in the commission as the governor formed it or as it progressed?

Hawker: I think it was doomed to fail at the onset because it did not involve an adequate cross-section of interests: stakeholder parties, interested parties--ranging literally from the corporate interests that provide insurance, the hospitals, the consumer groups, the spectrum of interested parties across the state including tribal health consortiums. It simply was not a broad enough mix of people, and the people that were brought there were not the right level of people in those interested disciplines for this sort of a process to work.


You must bring together people from an adequate variety of disciplines--or an adequate representation of the involved disciplines--and the actual people who participate in that discussion must be people of sufficient seniority and respect in those disciplines to influence policy making within those different disciplines. You don't send low-level staff--from say a hospital--that has to report up through three different levels of command before they get to a decision-maker.


Then all you do is get somebody that sits there and say[s], "Well, interesting ideas. I'll take it back and talk to my boss. He'll talk to his boss. They'll talk to her boss. They'll talk to their boss. They'll talk to their boss. They'll run it up the board of directors, and then we'll come back and see what they all say. No, it's never going to work that way. That's the critical difference between the way the administration approached this and the way I think it must be approached. We have to bring the right people, the right policy makers together at a very high level who have the unrestricted ability to influence outcomes in their own discipline.

AHPR: I'm assuming that your bill, 407, essentially accomplishes that end.

Hawker: I believe it very much does. It was specifically tailored to that end. Another significant difference between the approach I was offering and the approach the administration desired: the administration's first proposal--and it was said in committee--their decision makers in this health council were really just a bunch of their commissioners and division heads. It looked more like a cabinet meeting than it did a qualified group of competent professionals who had the ability to determine--and really propose solid policy distinctions.


I remain very committed that this cannot be a process that is beholden to the governor as an individual--people who get appointed because they're either a friend of the governor, or they get appointed because they will do what the governor says. They must be people who are independent thinkers, appointed objectively and with both the authority and expectation that they operate with intellectual objectivity and complete and total honesty.


That's why I set up an appointment process that had the disciplines being appointed--the membership being appointed--jointly by the president of the Senate and the speaker of the House. There you get, as objectively as possible, two people committed, representing different bodies of government, establishing this commission. It is very much more of a legislatively sanctioned policy making process than it is a[n] executive order process. The concept is very much tailored on our very successful education funding taskforce that we ran on the prior summer.


"We have all the makings for a[n] absolutely world class system if we could get the appropriate leadership--and vision manifest through appropriate leadership--where you've got politicians who will set aside their own personal partisan objectives in the interest of a global solution."
 

AHPR: What is your big picture take on health reform in Alaska, specifically Senate Bill 160 [Mandatory Universal Health Care]? When I say health reform, I'm really talking about some systemic change that could increase access for those who are either uninsured or otherwise do not have access to health care on a regular basis.

Hawker: I think the greatest fallacy that has been incorporated into most of the proposals that come before the Legislature, including Senate Bill 160, is they are too narrow focused. You want to increase access? Pass a law and mandate access. You're going to drive all the insurers out of the state but [if] you want to mandate access, mandate access. That's what's wrong with these isolated approaches that take on a narrow issue.


This issue of long term health care and its immediate sub-components--access, cost, quality and acuity issues--all of those immediate sub-issues to this larger issue of health care must be holistically evaluated in the context of the diversity of stakeholders. That is exactly why the approach I propose, is where we need to establish the credibility, the buy-in, to the development of an integrated policy that addresses these issues, is developed rationally, with very, very competent qualified people, rather than any one legislator coming in with a populous proposal to laser beam one issue--which is real easy, laser beam that issue--but you've completely then, missed the consequences on the whole, and for every thing you change on that laser beam solution, you're liable to create unanticipated complications and problems elsewhere in the larger health care system.


I firmly believe the state of Alaska, with our limited number of folks--650,000 people living in this state--[has a] tremendous foundation to a health system here. [We have] the whole spectrum--from Indian Health Service to our hospitals, to our home and community based care--which actually leads the nation in our development of that non-institutional approach to health care. We have all the makings for a[n] absolutely world class system if we could get the appropriate leadership--and vision manifest through appropriate leadership--where you've got politicians who will set aside their own personal partisan objectives in the interest of a global solution.


So much of this health care issue is so easy to laser beam, create the political straw man, claim you're the one that's going to fix it, and try to get elected--not considering that there are consequences to the whole of the system that have to be considered in the evaluation. That's exactly why, a properly managed [concept]--like this health care council concept--with the right people, the right authority, the right commitment, we can really move this ball forward.

AHPR: If I understand what you are saying correctly, something like HB 407, which would set up a health reform policy commission, you would look to that commission to formulate a global policy of the sort you're talking about. Is that correct?

Hawker: That is absolutely what my vision for the use of that commission would be. In areas where we know need to be addressed--things like access, affordability, quality of care--all of those issues have to be addressed and get the right people together. Legislators are just a slice of life they got down the street. We're not particularly the brightest bunch, not by any means. I'm not a health care professional; and we've got someone in there that may be a nurse or otherwise, [but] they've got a very limited focus on their view of their health care world.


That's why we have to bring together the right collection, the right accumulation of stakeholders representing the complete diversity of interest, and you have to bring together people who have the unquestioned authority to influence policy in those disciplines--the people who are at the pinnacle of their careers.

AHPR: Any attempt to seriously address access to health care in Alaska is going to also have to address the growing shortage of health professionals in Alaska. Do you have any comments on that?

Hawker: It's absolutely inherent in the concept I proposed in HB 407. You have the representation of both the providers and the consumers. Part of the provider issues that would then be brought forward in an intellectually honest discussion is where they would get adequate trained professional staff--as unquestionably part of the discussion.


"I think the solution that works on the Denali KidCare issue is not creating this higher cliff where if you are one penny over the 200% of poverty level, you get nothing and if you are one penny under it, you get everything. We have to work into a structure that provides some sort of a phased-out program with increasing affluence level of parents."

AHPR: I would like to ask you about Senate Bill 212 [Medical Assistance Eligibility]. It's the Senate Bill to increase the federal poverty level up to 200% for Denali KidCare--for admittance to Denali KidCare for children and pregnant women. That abruptly stopped and wasn't passed into law. I wonder if you could comment about your take on that bill.

Hawker: It's another one of those proposals that is far better addressed and will be better addressed, in the context of a more integrated health care proposal being brought forward rather than this laser beam solution. I just saw some numbers this morning, that almost 50% of the state's general fund spending, is directly to benefit children 18 years of age or under--half of the state's general fund spending already goes to benefit children 18 and under.


The provision of benefits to--at least health benefits--to children tends to be some of the less expensive benefits we provide. It's certainly a workable situation to increase this. [Let's set] the stage on both sides: we've got another side that would just as soon throw Denali KidCare out the window, viewing it simply as an unnecessary government welfare system that attracts the wrong kind of people to the state. We have both voices in the public. With all respect, you've got a medical community readership. There's a whole other community out there that thinks you're dead wrong on providing these benefits.


So politically, we have to reconcile those differences of opinions [and] find some place in the middle where we can rationalize the end decision to both interest groups. That goes back again to why we bring forward a respected, non-partisan, professional council to help work our way into solutions. I think the solution that works on the Denali KidCare issue is not creating this higher cliff where if you are one penny over the 200% of poverty level, you get nothing and if you are one penny under it, you get everything. We have to work into a structure that provides some sort of a phased-out program with increasing affluence level of parents.


It was apparent to me in my conversations with the Department of Health and Social Services this year [that] they have been sympathetic to that approach. The Department itself was not involved in the development of any of these bills that came through. So once again, until we integrate and have buy-in from the department and from the public on both sides of the spectrum, you end up with a situation that does not lead to an answer where there is an adequate public support geared to prevent any assurance that it's a durable answer.

AHPR: I appreciate your thoughtful responses to these questions. You are going into some depth and I appreciate that.

Hawker: I've been at this for six years now. That's part of the advantage I really believe I brought to this chair, is that I have not been involved in human services. I've been mergers and acquisitions and investment banking. My world has been a very high level Wall Street finance world but that's one of the reasons I was given the Human Services budget. They said, "You're the one guy that can understand it and bring a businessman's approach to what is really one of the biggest operating businesses of government."

AHPR: I see that you are a co-sponsor of Senate Joint Resolution 11 Supporting US Veterans' Health Care. That bill seems to address the question at the federal level as I recall. In the spirit of that bill, what can the state of Alaska do to support these veterans and their families who are in need of health care?

Hawker: That sort of resolution, truly, just to be completely honest, is nothing more than a strongly worded letter from one government to another. Simply, they're generally expressions of outrage, generally made for the political opportunity of the moment. That said, veterans' health, VA issues here in the state, with the large number of veterans that we do have in the state of Alaska, the aging veterans population as well as now a very rapidly increasing new bubble of current veterans coming in with a whole new world of issues, continue to make that a very significant part of Alaska's long term health challenges.


I'm talking around your question but the answer is the veterans' community is a very discreet, very identifiable, very significant community in this state, and absolutely has to be looked at and considered for its unique needs. Certainly as state policy makers, we don't control what the VA does, but that's one where I know particularly Lisa Murkowski has been working diligently in pursuing VA efforts. This issue of addressing health care in the state of Alaska is not just a state issue but it will continue to be a joint federal and state issue from the standpoint of policy making.

AHPR: It seems to me that there may very well be connections between the question of veterans' health care and the question of their children qualifying for Denali KidCare, and pregnancies that occur in their families that might be eligible for Denali KidCare. If something like Senate Bill 160 were to actually become law, then some veterans or family members of theirs may qualify under that. It seems to me that there's a lot of potential connections.

Hawker: It still gets us back to the problem of the cliff-vesting situation. All you're doing now is reaching out and grabbing another subset and still drawing a line and saying one penny more and you're not part of the subset--so it hasn't solved anything.


"The "front end loading," is what I call it, is the proper presentation of the health centers' concerns. [It involves] getting sufficient buy-in from the administration, buy-in from the Department of Health and Social Services and presenting themselves more broadly across the Legislature in a manner that people understood why we would be willing to override those voices that do not believe we need an expanded government health care system in the state and embark upon a new government mission. It was inadequately presented to us."


AHPR: I wanted to ask you about the direct funding of the Community Health Centers in the state of Alaska. There's about 125 of them scattered throughout the state. In my opinion, they're an important safety net. They deliver health care to tens of thousands of the uninsured in this state but it seems direct funding to them--in significant amounts--seems to be somewhat elusive. I wonder if you could talk about that.

Hawker: When they approached the Legislature this year, the approach was they had to have 13.5 million dollars or nothing. It was a penny less and they couldn't do it. Well, they didn't get their 13.5 million with those sort of demands. They suddenly came back and [said], "Well, we'll settle for a million here, a million there." Their greatest failure was in how they structured their approach. Again, [they were] coming forward with that unilateral demand, a demand that had not been vetted with the Department of Health and Social Services. It was a demand not supported by the Department of Health and Social Services.


These have been private institutions. The state has not supported them with direct financing, and this is the state making a policy of bigger government, making them wards of the state. We put a million dollars into it this year. I can see that the claim will be now that the state is obligated to support these operations. If the state ever chooses to now make the decision not to support them, it will be the state's responsibility [as to] why they're unable to continue. If they truly were unable to sustain themselves without state subsidy, they needed to bring that forward--what I call truth in budgeting--bring it forward honestly, explain why we have to have a state subsidy, why the state has to embark on a new government assumption of responsibility--and as I [said] before, you've got a readership that believes it's probably a good idea, but there's an awful lot of people in this state that don't agree with you. They're also voters. They also have representation in this state.


The "front end loading," is what I call it, is the proper presentation of the health centers' concerns. [It involves] getting sufficient buy-in from the administration, buy-in from the Department of Health and Social Services, and presenting themselves more broadly across the Legislature in a manner that people understood why we would be willing to override those voices that do not believe we need an expanded government health care system in the state and embark upon a new government mission. It was inadequately presented to us.

AHPR: What do you believe is the proper role of government toward the health of people? Do you believe that the state really has any obligation to [the people in Alaska who lack access to health care]?

Hawker: I think the issue is better cast as: What can the state afford, and how can the state sustain paying for the commitments we make. A few short years ago, we were looking at billion dollar deficits. A few short years ago we were looking at $18 a barrel oil--this was four years ago. Oil has now risen to $118, $119, and people think we're rich again. It has become very easy simply to say, "Let's just grow government as fast as we possibly can."


The challenge will be: We have not done a thing to eliminate our decline in oil production. Any [future gas revenues] are either so far off or will not be adequate to replace those oil projections. We continue to have the great Alaska fiscal dilemma, and that is that we are simply unable to continue to sustain this state much longer. Every time we establish a new cliff, a new investment, a new program, it raises that cliff a little higher [and it's] going to make it a little bit harder for us to sustain in a very, very few short years as production continues to decline.


There is both the social question: What ought the state do? If you want to call it the moral question: What ought the state do? Morally, I suppose, the state ought to do everything for everybody. What can the state afford to do? Well, we certainly can't afford to do everything for everybody, and there's a reconciliation point in there. That is the challenge that we face in the next few years here, and that's the reason why we need to be very diligent in expanding our spending commitments today without viewing those spending commitments in the context of our long-term economic reality.


That's where I think the single most profound bill that passed the Legislature this year was House Bill 125 [Budget Planning & Long-Range Fiscal Plan], a bill that I sponsored as chairman of the House Ways and Means Committee that will require every year--along with the annual spending plan--that the governor present a 10-year projection of all sources and uses of funds. That tool will start pretty crude but it will evolve, become more sophisticated, and it really will be the tool that we use to put these questions before the public and say: Here's our revenue. It's inevitable. It's limited. Here's our need or desire to spend. It's unlimited. There's the intersection point. Now, let the public weigh in and tell us what they're willing to pay for. What does public health, what does public welfare mean to the public?

AHPR: Thank you.

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Interview with Tom Hunt
 
Tom Hunt
Dr. Tom Hunt is the medical director of Anchorage Neighborhood Health Center. In this brutally frank, perhaps disturbing interview, Dr. Hunt discusses in detail why he believes safety net primary care services in Anchorage are in a "death spiral." He analyzes and ties together an enormous number of critical issues such as the local surge in heroin cases, the impact of the reduction in services of Anchorage Mental Health Services, state funding policies, service complications caused by the mix of funding sources, the growing shortage of primary care physicians, and a complex relationship with the Municipality of Anchorage. This interview was recorded April 29, 2008.  It has been edited for length and clarity.

AHPR:
You were saying something as we were walking in here about the history of the building, and you also mentioned there are some leaks in the conference room. What's happening here?


Hunt: The Neighborhood Health Center is about 35 years old. It started, I believe, as a trailer somewhere not far from here. Gradually, they got funding for this, and this was only half the building, and it's gradually been added on--like most health care institutions. So we have what we facetiously refer to as the rich side and the poor side. The rich side is a little bit better built because it got built later but we have leaky roofs and leaky x-ray machines. It's not an optimally designed building for modern ambulatory care because [of] its physical plant problems, and heating and cooling issues as well. From a design point of view, it doesn't help the patients flow through the system very efficiently. It's got this large central waiting room that's somewhat chaotic, and it's got a lavatory off in one corner where people tend to bunch up, and people have to cross the building to get to various places. A modern office design [would have] thought those issues out. But this is an accident of history. So it gets to the idea of us trying to get funding to build a new building.

AHPR: I keep hearing rumors, that in fact, you may have a new site or you are planning a new building or you have the money for it--various things from different places. Can you bring us up to speed on what the story is on that?

Hunt: You bet. We do not have a new site. We are seeking to land a site, and we've done that in conjunction with the muni [Municipality of Anchorage] and have identified some sites, and then it hasn't worked out in their master plan to relinquish control over those sites. Initially, it was thought we might blend services with the muni Public Health Department, and on paper that sounds logical. After all, they do reproductive health and STD treatments but then they refer out for primary care a lot of those things when they get complicated, and so they typically referred to us, and it seems that we could take over all those things.

But it's remarkably complex when you start mixing funding streams. Title X is an example. That's a government run program for reproductive health. Title X monies have different sliding fees and different income qualifications and different rights and responsibilities for the consumer than does a community health center. So that marriage has rarely been a successful one in other communities. So we looked at co-locating with the muni because their Ninth and L building needs to close. We probably won't co-mingle services, although for a while there, we were looking at co-locating on the same land in separate buildings. And we're still talking with them about it but the muni has not thus far been able to secure a site that's secure. We're looking for the land.

We have some money from the Legislature, from the 2007 budget, and we are still in the pot for the 2008 budget and awaiting. Hopefully the governor [will] keep that in. We have some money from Denali Commission. We have some other sundry monies, and then we're going to have to go out and do capital campaign. We're looking at 25,000 to 35,000 square feet.

"... a lot of what a new building would give us is better patient flow so they're not banging up against one another at various steps in the cycle. It would give us the ability to segregate services, if needed."

AHPR: How would that compare to what you have now?

Hunt: In our three sites, including Mountain View, we are currently at less than 20,000--more like 14,000 square feet, and that encompasses our administration site and then the two clinical sites. We're folding over the Mountain View [clinic] next month into Fairview and we're crowded, so we've been making new offices downstairs here [basement of Fairview clinic].

But a lot of what a new building would give us is better patient flow so they're not banging up against one another at various steps in the cycle. It would give us the ability to segregate services, if needed. For example, it's not optimal to have young families with children intermingling with chronically mentally ill street people. It's hard to build a women and child health program when they've got to intermingle. It's not that we don't want to take care of both but it scares away the kids.

So what we've designed into the conceptual framework, the conceptual design of the new building, is segregated waiting rooms. That should alleviate some of that issue. And then the other key thing that we're really looking forward to if we pull this off is bringing support services up into the care team. Traditionally in office ambulatory care practices [the care team] is the doctor and the nurse and the patients. But as medical care has become that much more complex, chronicity of disease has become longer, the rate of uninsured and underinsured has become greater, and mental health issues go unmanaged by specialty psychiatry.

More and more of our patients are socially and medically and psychiatrically complex, so what we think is part of the secret to our success--and our sanity--is to have case management support up in the care team area. We've done some of that successfully. For example, with our HIV care we have wonderful case management support and we have outstanding outcomes. That's just because HIV is relatively well funded. There is no source of funds for your standard back pain patient with a little diabetes and depression. So it's been hard for me to build these wraparound services financially, and in this facility. We're crammed to the gills upstairs; we're crammed to the gills downstairs. What we're doing in this current remodeling is to bring some of [those] administrative functions downstairs and push the clinical support services upstairs. For example, we moved all our medical records downstairs, and then we're putting some behavioral health and case management people upstairs so they can be in our midst.


AHPR: Plus, there must be some from the Mountain View facility. You must be relocating things and people here.

Hunt: Right. My big dream is to have a well-supported, wraparound primary care delivery system. A lot of that, we've built already. We have a pharmacy, and we have x-ray, and laboratory, and mammography, and we have some counseling services, some social work services. But we need substantially more of it. We have one or two patients doing 25 visits a month. We just admitted to the hospital a gal who's made 18 visits to the ER in April, and trying to wrap our arms around high utilizers like that, who really just need case management. They didn't have 18 emergent visits to the ER; they needed somebody to talk to them. So we admitted them to the hospital to try and get a hold of that and get her into a better housing arrangement. That's the kind of stuff that if we can build and the world will help us support it, we can continue to offer the community the cost savings that we already offer them because a place like this is substantially more cost-effective than regular medical care.

AHPR: I realize remodeling is going on and you need a larger building. Maybe that's the answer to this question, but is the Anchorage Neighborhood Health Center able to meet the demand for the services currently placed on it?

Hunt: No. The demand is much bigger than we can meet.

"There are people who do come and sit in our waiting room and are scared away by the mass of humanity that come. So there is a substantial amount of unmet need out there that we could meet. We could meet a great deal more of it."

AHPR: What are the consequences of that? Long waiting periods for new patients or appointments, or what does that mean?

Hunt: We turn away patients every day. We're only so many clinicians with so much time and space. Regrettably--parenthetically--on average 30% of our patients don't bother showing up for their visits, so at the end of the day we're relatively under-productive per unit of time and people than we could be, but that's the nature of the clientele that we work with. It's like the airlines. We need to overbook hoping that people won't show, but it's hard to have the courage to do that when some days they do show up and we're in trouble--like today. That's why I was running late. So we schedule ourselves fully and there's never a day when we're not fully scheduled so we are turning people away.

There are people who don't know we exist still. There are Medicare patients out there who are reluctant to come to Fairview or Mountain View because of perceptions of the neighborhood. There are people who are reluctant to come to us because of perceptions of us as being the poor people's clinic. There are people who do come and sit in our waiting room and are scared away by the mass of humanity that come. So there is a substantial amount of unmet need out there that we could meet. We could meet a great deal more of it.

What we need to meet it are a space, providers, and ongoing efforts to improve our flow processes. We try. We work really hard. Patients bring square pegs into our round holes and sometimes we tweak our holes [but] they don't fit anyway. The point being is that it's hard to move patients through any ambulatory care system, and all the more so when they're poor and don't speak English or [a patient] is mentally ill.


AHPR: I want to come back to a number of these issues you just raised but could you talk about the reasons for, and the impact of, the closing of the Mountain View Health Center.

Hunt: Happily. Mountain View was an experiment initiated about eight years ago between us and Southcentral Foundation of the Native Medical Center. The idea then was that there was a good deal of Native families living in the Mountain View area, and then two things happened. One is that [Southcentral] built their nice center on Tudor, and two is that the whole demographic of Mountain View changed. It's now populated largely by Asians and Pacific Islanders and African-Americans. The Natives have moved out of Mountain View. So between them not living there and them having this very nice facility on Tudor, the Natives stopped going to Mountain View. Consequently, Southcentral Foundation pulled out.

So we tried to run it ourselves and we did for many, many years. But several things happened out there. One is it's just perfectly wrongly sized to run an efficient practice. There [are] six exam rooms. If you're going to run three doctors, you'd really need three rooms per provider so you'd want to have nine rooms. If you're going to run two doctors, you could do it but then when one goes on leave, then you're down to one doctor at a time and it becomes very inefficient. So [there were] efficiency issues over there and frankly, our no-show problem out there was even worse than it is here--35% of people weren't showing up for visits. Finally, finding the right mix of providers out there was always challenging. If I'd staff it with physician assistants, it was cheaper but the acuity of the medical care was too complex for most mid-level providers. If I stocked it with docs, they were inefficient and it turned out not to be a good use of time, skills and money. It always ended up being a relatively inefficient operation.


Finally, the percentage of clients seen over there that actually came from Mountain View was relatively low. The vast majority of our patients were coming from south of the Glenn Highway. We weren't actually serving as a neighborhood health center over there all that effectively. Certainly, there were people who were walking to the clinic but not many. Since the demand was really coming from [the] south, it just made more sense to close up shop and consolidate. The final issue was that Fairview had provider turnover so we were running on a lean ship over here, so we had space that was unused. We were heating and staffing and supplying two offices [but now] we have the same number of personnel just utilizing this building better. It should save us several hundred thousand dollars a year, and we should see the same amount of people.

The losers would be those who were walking to the clinic from Mountain View. They now have to take two bus rides to get across the Glenn Highway [and to get] downtown [and then here]. We've proven it because Joan [Fisher, executive director of the clinic] did the ride herself. It's 30 minutes, but it could be worse. We feel bad about that, of course. We'll be more efficient over here. The better we can save money, the better we can do what we do.


AHPR: Presumably, the next step would be a new building versus, for example, looking to expand out again into some other second satellite clinic.

Hunt: Right. It's not logistically feasible to expand the Fairview site because of neighborhood and zoning issues. And to do expansion sites, in say Muldoon, which is where most of our clientele comes from--[other than] Spenard--poses logistical challenges that we just have never successfully managed very well. Girdwood, for example, would like to be annexed to the Neighborhood Health Center. Whittier would like to be annexed. We can't even run an efficient place in Mountain View. It gets back to personnel. For reasons we'll get to, people turn over, so when I've got a Girdwood that I've got to get staffed by [say] May 15 because somebody quit, then all of a sudden we've got a building and staff and clientele down there. [So we're] anti-expansion for a while.

"Most pressingly, is that US medical schools have not produced primary care clinicians at anywhere near the rate that they did in the 80s and 90s. That's largely because it's much more attractive to enter specialty medicine nowadays. Pay is better. The hours are better, and the complexity in primary care has gotten greater so that it looks like a very daunting job for the money."

AHPR: Why don't you go ahead and talk about the whole issue of recruitment and retention of staff because that's a national problem, it's an Alaska problem--a chronic problem and a growing problem here. I imagine you have that same problem.

Hunt: It's a problem for several reasons. Most pressingly, is that US medical schools have not produced primary care clinicians at anywhere near the rate that they did in the 80s and 90s. That's largely because it's much more attractive to enter specialty medicine nowadays. Pay is better. The hours are better, and the complexity in primary care has gotten greater so that it looks like a very daunting job for the money. You can go into something better. Consequently, the supply of primary care clinicians has been less, and they can sort of write their own ticket. So not only is there a lack of primary care clinicians nationally, but in safety net facilities like ours it's particularly acute because you could certainly find easier work [than] what we do.

AHPR: And perhaps better paying?

Hunt: Perhaps better paying. It's a complex issue I'm happy to get back to: pay. I don't mind going on the books as saying that we pay less than community standard. I have to qualify it to say that we also see less patients per day or per week or per year than private practice primary care clinicians. So, per unit of visit, we're paid well. Per complexity, we're underpaid for reasons [we have discussed]. The hours are hard and the patients are complex, which gets back to why it's hard to recruit and retain in safety net settings. That is, it's not simply enough to know what the current treatment standards are for diabetes--or even for HIV or what have you. It's not simply enough to know that. The art of being a safety net provider is knowing how you are going to get the patients the medicines, what language or culturally competent communication tool you are going to use to educate them about it, [and] what follow up method is really going to be feasible when they are homeless or transients.

So for a graduating family medicine or general internal medicine resident to look at working in a complex setting like ours, you really have to be mission-driven to come to a place like this. You could work with easier patients who, as a rule, will stick to the game plan and can afford to get the medicines that you prescribe them. I'm delighted to have delightfully poor patients who I love seeing, but poverty is a barrier to medical care. Poverty is a barrier to success, even if you can access medical care. In other words, I'll see people who are poor, but it's really hard to know how to get them the meds and/or the surgeries that they need, and/or the x-rays that they need.


AHPR: It seems like for a primary care physician, it would be an unparalleled learning experience to work in a place like this.

Hunt: Right. Alaska, and Anchorage in specific, is littered with graduates of the Anchorage Neighborhood Health Center. We've trained scores of great doctors who have risen in stature and leadership in the state. I mean very, very prominent physicians in this city and state have worked here. It's a great learning experience. Back to core issues of how do we recruit and retain: Retention is challenging, and I can't fix the beast. The beast is a very dysfunctional and broken medical care system--or lack of one--in the city and state and country. I can't fix that, so it's hard to make my clinician's job that much easier. People are poor. We can't fix that. People don't speak English. We can't fix that. People have two jobs or can't get their car started or have childcare issues. We can't fix all those things and I'm really sorry about that, but that sort of core problem I can't fix. So absent fixing those, retention is a problem because those things make professional life here harder. What do we do? We're trying to augment our clinical support services so that the providers can try to stick to medicine and less to social work, and we try to pay them appropriate for the amount of medical complexity that they do, rather than simply the visits that they do. Not all visits are created equal. We're trying, as hard as I can, to treat them with respect, and respect their time off.

AHPR: To prevent burnout.

Hunt: To prevent burnout. All I can do is keep trying to do those things.

"... what the state could do, if I were to reach for the stars, would be to provide us universal coverage ... Fixing that broken health system would be the best thing."

AHPR: Is there anything the state or the municipality can do to help you with recruitment [or] retention, or running this clinic, or supporting this clinic?

Hunt: There is tons. Back to recruitment: We've recently been gifted some recruitment support from the hospital, Providence specifically, and from United Way who, recognizing that recruitment of primary care clinicians is a challenge, have given us some in-kind and financial assistance towards recruitment. We're gifted--if the money sustains--loan repayment from the feds, to keep people here for two and sometimes three years, if they are working in this kind of a setting. The trouble is that money tends to run out because we're not as high a needs site as, say Barrow, but most years there's enough money for loan repayment for anybody who applies in this system.

Those are three sources of recruitment and retention assistance, but what the state could do, if I were to reach for the stars, would be to provide us universal coverage so I didn't have to suffer. Because with 50% of our patients being uninsured, and another 25% being Medicare--so we're losing money on 75% of our clients--how am I supposed to run a center and pay my docs what they are worth, pay the rest of our support staff what they're worth and build a new building and give us the clinician support services that we need? Fixing that broken health system would be the best thing. Short of that, the state has talked about, and has yet to implement, some coherent recruitment strategies.

The state has talked about, and has done something, to increase WWAMI enrollment. There are more students entering this year's WWAMI class than ever before. The state has put some money behind the family practice residency--as has [Providence] hospital--so there are two more residents per year now in their soon-to-be-graduated first year class. The state is going to put some money behind UAA's and UAF's nurse and allied health professional programs.

What the state could do more of, I believe, is continue to fund its recruiters--the recruiter down in Juneau who's trying to help place people, just had her funding cut a few weeks ago. The money she had to bring students up and other people up is cut, so the state was talking about these recruitment initiatives but hasn't really [followed up]. The state could put more money into the Alaska Primary Care Association, which is tasked with supporting the community health centers and recruitment and operations and financial lobbying efforts.

Finally--and this is much more innovative--the state could give us some monies to do some case management, like a few cases we just talked about. I know that I could save Medicaid hundreds of thousands of dollars by just case managing 20 people. I can name them today, and I can give you the stats to support that. [The health center's executive director] just gave us some of those stats. There are high utilizers, some of whom we can't control. They've got cancer, and had 16 surgeries over the course of two months, and spent all that time in the hospital. [We] can't case manage that. [That's] a disaster and it costs the state that much money. But there are high utilizers who [are chronically mentally ill] or substance abusers or other cognitively impaired folks who could be managed much more effectively than in the standard office visit milieu.

If we could get a handle on those people we could keep them out of the hospital. I know we can because we've done it. It's just that they evade our grasp, and it's not really our responsibility to go out to the camps and find them, or to go to the shelters and find them. We do that because we've got some Health Care for the Homeless monies to buy a little bit of that resource, but nowhere near what we need [so] I could keep those people of the hospital, which of course is where the money is. The state [has] periodically talked to me about that and not helped it. Here's another place the state could help: We do a good chunk of perinatal care. We are currently delivering about 180 women a year, and that number is climbing. Almost half of those women are uninsured and they're legal, qualified aliens but they are within the five-year bar so they are not eligible for Medicaid.


"As you know Medicaid, for many women will expire six weeks postpartum ... Well, that's stupid because we could have been giving them birth control in the process. It's been proposed at the state level and it just hasn't gone very far, to have what's called inter-conception women's health care so that they can have access to birth control during that time ..."

AHPR: The first five years of being here. Is that what you are referring to?

Hunt: Right. They're not eligible for state-supported services. So we're doing all their prenatal care for free and then getting what's called Alien Emergency Medicaid at the time of delivery. It's a total money loser, and they could help support some of that. They could help support some of our perinatal coordination systems so that if they can't support those women directly, because the feds say they can't, they can help support some of our perinatal coordination so we can help get them drug treatment, we can get them medicines, we can do the homeless care coordination, or the HIV coordination for the prenatal care that they need. None of that stuff are we getting reimbursed for, or supported for, at the moment.

The state could provide funding for Denali KidCare, needless to say. And there's another one that's kind of innovative, which is to extend Medicaid. As you know Medicaid, for many women will expire six weeks postpartum. The kids will be supported by Medicaid longer but the women will often lose it--I'm not quite sure which women lose it--maybe it's just Denali KidCare that they lose. So six weeks postpartum they have no care for women's health until they're pregnant again. Well, that's stupid because we could have been giving them birth control in the process. It's been proposed at the state level and it just hasn't gone very far, to have what's called inter-conception women's health care so that they can have access to birth control during that time and thus, reduce the burden on the state for its pregnancies.


AHPR: This would be through Medicaid?

Hunt: it would be through Medicaid. Apparently some 13 other states do this already and we could do it. We just to get the political will to do it. So between case management and other funding things, I think we could do a lot. In recruiting, I think that they could help us through the Primary Care Association and through central recruiting offices and possibly through some relocation allowances. That would be really innovative, but good.

AHPR: What about the Municipality of Anchorage? Are there some specific things they could do to facilitate you seeing more patients [or] working better? It sounded like the possible issue of land and facility would be one way.

Hunt: Yes. That would be one way. The muni understands us, I think, quite well--certainly during the most recent administration. The muni has our best interests at heart. The muni is not per se set up as a health care entity. It is responsible for maintaining a public health presence. Therefore they need to have public health nurses, therefore they need something for those public health nurses to do pending the next epidemic or disaster, so part of the reason that the muni is involved in some of the reproductive health care at all is to keep their public health nurses occupied.

That said, they do have a STD [sexually transmitted diseases] and TB [tuberculosis] environmental control responsibility that they need to deal with. I mention that partly because by them having some sort of a healthcare presence, they've been sort of responsible for shipping those people off somewhere, and they often ship those people off to us. Ironically--I don't want to be critical of the administration--the cycle that ends up happening is that we could have gotten paid for some of that reproductive health stuff because there is breast and cervical care monies to support us to do that basic women's health stuff. They end up doing that and they end up shipping off that uncompensated medical stuff to us. They go do the paps and their reproductive health stuff, and then they find thyroid disease or neurosyphilis or back pain or heart problems for which they don't have the expertise nor the funding for, and they send that stuff to us. We could have been seeing that woman for wraparound services and getting paid for some of it and now we're just getting stuck with the uncompensated stuff.

What should the city do differently about that? Probably nothing. It's just the nature of the bad healthcare system that we've got, but could the muni do more for us? I don't think they're in a position to do much more for us--get us the land and the political support to build a good primary health care system. They really have been trying.


AHPR: It sounds like the possibility of getting land from the muni is still a distinct possibility.

Hunt: Yes, we're still working on it, and the board is largely responsible for making that happen. My job is to speak to the need.

AHPR: Somebody just handed you a sheaf of papers.

Hunt: Correct, and this is a rough sketch of our payer mix for prenatal care. Indeed, it looks like 58% are uninsured, 2% are covered by our homeless program so we pay ourselves for that grant. How are we to survive? The reason our OB practice is growing is that these are folks who in many cases have gone to other practices and been turned away for prenatal care.

AHPR: Because they couldn't pay for it?

Hunt: Because they couldn't pay for it.

"Fifty-eight percent of our pregnant ladies have no insurance. I would guess that a good chunk of that pool would have qualified for Denali KidCare. I wouldn't hazard a guess how many of them [but] a good chunk of them."

AHPR: Senate Bill 212 [Medical Assistance Eligibility] would have increased the federal poverty level to 200% from the current 175% in order to qualify for Denali KidCare. SB 212 didn't pass, but does the fact that it didn't pass have an impact on you, your clients, or your reimbursement?

Hunt: Well it does. These numbers reflect it. Fifty-eight percent of our pregnant ladies have no insurance. I would guess that a good chunk of that pool would have qualified for Denali KidCare. I wouldn't hazard a guess how many of them [but] a good chunk of them. They would have insurance. We're not seeing them necessarily for free, we're seeing them on a sliding fee. That may be as little as $10 a visit but they would have the confidence that they weren't incurring a huge debt, and we would have some extra income.

So the failure to pass that means that some chunk of these women are without health care today, and we're without that income today. So there's one. The other is in our pediatrics care, a little over half of the kids that we see, are uninsured--and same story. Many of those could and would be covered by Denali KidCare. I've seen the number that 1,200 people in the state were between 175 and 200%.


AHPR: Yes, 1,200 kids. Right.

Hunt: Which strikes me as low but somebody's got to have those numbers better than I, but a good chunk of those are ours--being in Alaska's most populous city dealing with a relatively low income population. So what it means to them is health care insecurity; and what it means to us is ongoing revenue insecurity. We're still going to provide that care. That's our mission to do that, but it means leaking ceilings for another five years.

"Community Health Centers are paid a flat fee per visit by Medicaid and Medicare--X dollars. It doesn't matter what we do as long as it's a face-to-face visit. It could be a very brief five minute, "Howdy, here's your refill of your blood pressure medicine," to an hour and a half long new intake for an HIV positive, pregnant, homeless lady--and everywhere in between, and they'll pay us the same amount of money."

AHPR: Can you talk about the Medicare situation? I've asked this question any number of times and everybody's always referring back to the Community Health Centers.

Hunt: I can explain some of this--and why they keep referring back to the Community Health Centers. The reason is that Community Health Centers are paid a flat fee per visit by Medicaid and Medicare--X dollars. It doesn't matter what we do as long as it's a face-to-face visit. It could be a very brief five minute, "Howdy, here's your refill of your blood pressure medicine," to an hour and a half long new intake for an HIV positive, pregnant, homeless lady--and everywhere in between, and they'll pay us the same amount of money. That amount of money is a little bit more than private docs' average visit would get from Medicare so it looks like we're paid better than a private doc for Medicare. And it's true--for the average visit. We lose money anyway, just like the average private doc loses money. For the average visit, he loses more than we lose. But we still lose.

If we do that 90-minute debacle for the new, complicated Medicare patient who somebody dumped, which is a daily experience, we still get that same rate. Whereas, if this guy does a 90-minute intake for a complicated patient, he bills more and that will go up. But they don't tend to think of it that way because the average reimbursement for the average visit is different. So it looks like a federally qualified health center, like [the Anchorage Neighborhood Health Center], is the solution to Medicare because we lose less money per visit but we still lose money per visit. It's differentially less, however. That may clarify some of the issues.


AHPR: But you continue to take them, whereas the for-profit private sector apparently doesn't based on just about everything I hear. The private sector, at least, here in Anchorage.

Hunt: Right. There are a few secretive primary care docs in town who are letting in the occasional Medicare patient but they don't tell anybody about it because, "it's my patient's mother who is now Medicare." They don't want to tell anybody about it because then they don't want to have to be in the position of saying, "No, I won't take any more." We're the only ones who are publicly saying, "Yes, we will continue to take them." Now, why do we do that, or why should we do that? The reason is that that's been our mission, to provide health care access for all.

The future, however, is that we may not be able to have an open door to Medicare either. That's not to say we wouldn't take new patients but we may have to control the flow because we're losing money. When half of our patients are uninsured, and the other 25% we're losing money on, we've got to control the gates, and it is within our charter and our by-laws and our funders' realm of legitimacy that we do control our gates. And we will. In the next year you'll see us having to take a harder line towards who we'll accept in, and collections at the front desk.


AHPR: So at that point, there's going to be less of a safety net.

Hunt: Right. Now, it comes around, however. If we aren't constantly floundering for money, we can better recruit and retain. And then if things are good, we can see the same number of low income and underinsured patients as we are currently. We're not going to reject anybody. We can continue to grow the practice but we just have to have some money to do it. The scope of our issue is that we're an eleven million dollar organization, a drop in the budget. Grants account for about three and a half million of that, so we have to earn our keep.

That's another thing the community doesn't understand about this Medicare thing. The [provider] community thinks we're paid X number of dollars per visit and that's better than they get. They think that we've got this sort of wide-open spigot from the feds to support this kind of care but it's only to the tune of about 34% of our overall budget, so we're in a death spiral. We're in this perfect storm where Medicare's going to get worse in July, the uninsured are [increasing], our health insurance will go up by another 30% on July 1, and I've got to pay my staff.

One of the ways out of this desperate spiral is to manage our payer mix, and we're not going to apologize about it because we can't afford to apologize about it. We're still going to do this work, [we] just can't do as much of it. I've got to figure out how to get these things paid for. And I've got to find out how I'm going to get my C-sections done and all that because I've got surgeons no longer willing to see them. What kind of public health crisis is that when I have to tell her, "Show up when you're in labor and the on-call guy will do your C-section"? That's terrible, but that's kind of where I am at the moment--I'm a little better than that, but to make the effect more dramatic. I lost my surgical backup for OB two weeks ago because they're tired of not getting paid.

I've got to go to the surgeons in town two weeks from now and beg to them, "Would you take our prenatal care referrals in rotation so we can all play nice and all share the burden?" I've got to find a place for these 20-30 C-sections that we're doing every year. If I can't get their cooperation, it's a public health crisis. Those are women who aren't going to get their sections in a timely fashion. Somebody's going to die. For every one of these, there's another Medicare patient with the same issue. The art and challenge of working in the safety net system is way more than just knowing medicine. Have I communicated that sufficiently?


"... we've got to see more paying patients. That makes me look really mercenary but it's not. It's just that we're going to lose money this year. Our fiscal year ends June 30. We're going to be a few hundred thousand dollars in the hole."

AHPR: Absolutely. Also, so many of the things that you can't control for, like you say, "the death spiral," are getting worse.

Hunt: It's getting worse, yes. So when it gets to recruitment and retention, I'm trying to keep my docs happy--I really am and sometimes they don't think so. It's just because we've got to see more patients, we've got to see more paying patients. That makes me look really mercenary but it's not. It's just that we're going to lose money this year. Our fiscal year ends June 30. We're going to be a few hundred thousand dollars in the hole.

AHPR: Are there any more issues you want to discuss for our readers or final comments? This is your opportunity to say whatever you think is important that we may not have covered.

Hunt: We haven't talked about Anchorage Community Mental Health Services and their closure, and that is huge. It's huge for us because they're not taking new patients now and we have porous boundaries that we would not like to take on. Do you know what I mean: CPSMI, chronic, persistent, severe mental illness? That's the population that they specialize in. They can't afford to do more but we don't have the expertise. We're family physicians for the most part. Although we stretch our boundaries way more than your average family physician will, we really shouldn't try to pretend that we can manage schizophrenics day in and day out, but that's what's coming our way now. We're really trying not to take that population on, and we're trying not to apologize about it. That said, they're getting appointments, we're trying not to, and some of them are getting in nonetheless. Then it gets awkward for us. The impact of their closure on us is sour.

AHPR: Was there a comparable impact from the closing of Clitheroe, or some other kind of impact?

Hunt: Only in that a good deal of our hospital business is in recycling substance abusers. "Recycling" expresses it well: you know, people who are on their 18th admission in the last two years for alcohol withdrawal. That said, even when Clitheroe was open, it didn't fully meet those people's needs. So no, Clitheroe had less of an impact on us. It's worth mentioning a new challenge for us here is that heroin's made a resurgence in Anchorage and Wasilla. Since I provide opiate treatment services, I'd rather that not be another thing because I'm getting overwhelmed with opiate treatment requests. With heroin's resurgence, there's a brand new demand for substance abuse treatment that wasn't there before--as if alcohol wasn't enough, now you've got this burgeoning opiate addiction problem in town and in the Valley. I happen to have a license to do that, and my waiting list is months long now to bring them in.

AHPR: I haven't heard about the resurgence of heroin.

Hunt: It is discouraging. Cocaine got expensive. The Taliban aren't in control. Then, Oxycontin happened. Oxycontin is too expensive and heroin is cheap. Another perfect storm. There are people dying, but not frequently. There's a huge surge in drug overdoses in the last year in town and more so in the Valley. Clitheroe wasn't really geared up great for opiates. Their specialty was alcohol but that said, it's 16 less beds or 23 less beds for that particular problem. Just more atmospheric disturbance for the perfect storm.

"Business as usual is going to kill us, so we are changing our ways. I'm not going to apologize. People will die because of it, and I'm sorry. I really am."

AHPR: Any other comments?

Hunt: I would say in closing, that we're very proud of what we do, and we do it at a high level of quality. We appreciate the community support but we would like more of it. It's a little-understood institution. You'll help me get the complexities out there. We are not a 100% federally funded institution, and we cannot survive with business as usual. I'm not being overly dramatic on that. Business as usual is going to kill us, so we are changing our ways. I'm not going to apologize. People will die because of it, and I'm sorry. I really am.

AHPR: Thank you.
 
AHPR Staff

Lawrence D. Weiss Ph.D., M.S.,
Editor

Jacqueline Yeagle,
Marketing and Communications Manager

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