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November 17, 2009 Vol 3, Issue 21

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Part 1: Alaska Native Medical Center Confronts Challenges
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Part 2: Nuka Model Developed Locally And Monitored Internationally
Part 3: Obsessive Listening, Workforce Development, Health Reform
AHPR Staff and Contributors
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Nuka Model of Care

Article: Nuka Model of Care

Evidence of Nuka Effectiveness

Nuka Concepts and Diagrams

PowerPoint: Nuka Model

Understanding The New SCF Space

From the Editor

Dear Reader,

We have in Alaska an extraordinary complex of Alaska Native health care institutions, which is unparalleled in the United States, and perhaps unparalleled in the world. For those of us who are not on staff in one of these institutions, or not otherwise significantly involved with their operations, how much do we know about these institutions? Probably not much, which is why I cornered Dr. Douglas Eby for an interview that turned out to be so comprehensive and informative it has completely filled this issue of Alaska Health Policy Review.  

Eby is a physician who has served as vice president of Medical Services for Southcentral Foundation since 1995. He is a big man with a commanding presence, a powerful voice, and an important story to tell. The interview lasted an hour and a half, and was followed by a tour of the recently built and opened new wing of the Anchorage Native Primary Care Center. Eby talked nearly non-stop the first hour, answering questions I did not have a chance to ask as well as questions I did not know to ask. During the entire conversation he was pulling out documents to demonstrate points, and operating two different computers to demonstrate additional points. The phrase "tour de force" comes to mind.

He is also a speaker and consultant, nationally and internationally, on healthcare system design and quality improvement. In his position as part of the leadership team for the Alaska Native Medical Center, Dr. Eby played a key role in the development of Southcentral Foundation's unique, innovative, and demonstrably effective nationally recognized primary care system.

I have added a number of resources, available in the left-hand side bar, which should be particularly useful to you to strengthen and broaden your understanding of the unique history and organization of the Alaska Native Medical Center and its widely dispersed components. Some of these documents are the very same ones Eby nudged in front of me as he was illustrating the new wing of the new building, or dozens of graphs and charts documenting clear improvement over time on critical measures.  

As always, I invite your comments on format and content, and your suggestions for future articles. Thanks for giving us the opportunity to collect, assess, and present this information to you.

Lawrence D. Weiss PhD, MS
editor, AHPR

Part 1: Alaska Native Medical Center Confronts Challenges

Doug EbyDr. Eby is a physician executive who has served as vice president of Medical Services for Southcentral Foundation since 1995. He is also a speaker and consultant, nationally and internationally, on healthcare system design and quality improvement. In his position as part of the leadership team for the Alaska Native Medical Center, Dr. Eby played a key role in the development of Southcentral Foundation's nationally recognized innovative primary care system. In this extraordinary, comprehensive, and exclusive tour de force, Dr. Eby discusses in detail the historical and philosophical origins of the Alaska Native Medical Center. Learn why this institution is absolutely unique, and why Dr. Eby and others from the Alaska Native Medical Center are invited all over the world to discuss their achievements. Dr. Eby was interviewed November 6, 2009. This interview has been edited for length and clarity.

Eby: The Alaska Native Medical Center [ANMC] has two owners: Southcentral Foundation, which employs 1,400 people, and half of those employees work at ANMC, and half of them don't. We run lots of other things that are not on the ANMC campus.  All of our residential treatment facilities for substance abuse and behavioral health are not on the ANMC campus. Our optometry and dental programs are not considered part of the ANMC campus. We run a medical clinic out in the Palmer-Wasilla area. We run clinics out in McGrath, and out in [garbled], lliamna, those areas, and they are not considered part of the Alaska Native Medical Center -- just the stuff that's on this immediate campus right here.
AHPR: But the Native hospital is a tertiary care center for the entire state, isn't that correct?
Eby: Correct, yes.
AHPR: But, is Southcentral Foundation also kind of a tertiary out-patient facility?
Eby: Well, ANMC has four levels of constituencies. So, the local population, they get everything here, from behavioral health to dental, to optometry, to community health, to primary care, all the way up through tertiary care. And then there are the CIRI [Cook Inlet Region Inc.] associated villages, or the nearest in villages, who have a little bit of service provided in their communities, but come here for most of it.

Then, there is what's called the Rural Anchorage Service Unit, which are 50 villages for whom this is their regional hub. Just like the villages around Bethel, their regional hub is Yukon-Kuskokwim. Same thing in Southeast -- the villages feed into Sitka as their regional hub.We are the regional hub for 50 villages that go from the Canadian border, the whole Copper River area, just south of Fairbanks, the McGrath area, all the way out through the Iliamna area, most of the Alaska Peninsula, the entire Aleutian chain, and the Pribilof islands out in the Bering Sea.

Now, the Aleutian chain and the Bering Sea are closer to Dillingham or Bethel, but the reason we're the regional hub, rather than them, is the airplanes fly between here [Anchorage] and there. The airplanes don't fly between St. Paul and Bethel or Unalaska and Dillingham. Even though it is closer, there is no air traffic. So, when you need to send people out to do work in the villages, or bring people in because they are sick, if you were sending them to Dillingham, they would have to fly to Anchorage then to Dillingham, and then if they needed a tertiary care level, you're flying them back to Anchorage.
That just made no sense, so Anchorage is the hub for this huge 2000 linear miles, end-to-end, massive swath of Alaska. So that's the hub function, regional hub, and then we are the referral tertiary care hub, for the entire state. So, the hospitals in Bethel, Barrow, Kotzebue, Nome, all those places, have family practice doctors, and maybe a pediatrician or an internist. They have no surgeons, or orthopedic surgeons, or neurosurgeons, or neurologists, or cardiologists, or any of those kind of people. They are all here, so the specialists here fly out to all of those clinics in all of those outlying areas, and then fly people in here for their surgeries and all of the other procedural things that they need to do.
So this is a community hospital, and a regional support hospital, and a statewide tertiary care hospital. Depending on where you live, it serves one, or various, of those functions for you.
So we have 1,400 employees, the [Alaska Native Tribal Health] Consortium has 1,800 employees. Their whole clinical activities are on the ANMC campus, except when they fly them out. And they are responsible for the inpatient nursing units, and the higher-end specialists. So, we employ all the family docs, pediatricians, OBGYNs, psychiatrists and so forth, they are all SCF [Southcentral Foundation]. But the cardiologists, neurologists, neurosurgeons, orthopedic surgeons, and those things which are statewide in their orientation are employed by the Consortium. But we try and run it as a single integrated operation, with one medical record, one medical staff structure, all that kind of stuff. In fact we share revenue, so all the money made on this campus goes into one big pot and then is split by a formula between the two companies. So again, it's part of keeping the place thinking and acting and running as one integrated health care system.
AHPR: Just for clarification: you talked about these four different kinds of the catchment areas, in a way. So, that was the hospital. But, what about Southcentral?  Does it share the same four catchment areas?
Eby: The four levels are shared between Southcentral and the Consortium. Together they are a joint operation, the Alaska Native Medical Center. The Alaska Native Medical Center is this building we are in, the [Southcentral Foundation] Primary Care Center, and the hospital together, are the Alaska Native Medical Center.
We then run these other things off-campus, which are residential treatment facilities for substance abuse, pregnant women, for troubled youth, or for chronic mentally ill, a home health agency, some halfway houses for troubled youth kind of stuff, all of that is not part of ANMC and is aimed at the local population. Does that make sense? It's confusing. It's confusing as all get out.

" ... the only people in the United States that are owed health care legally by the United States government are its indigenous people -- American Indian and Alaska Native people -- because they have treaties, nation to nation treaties guaranteeing such things."

AHPR: That was one of my first questions to ask you, to do exactly what you're doing, to figure out the relationships between all these different entities.
Eby: [Referring to a map of Alaska showing medical care referral patterns] This is all of Alaska, and here is Barrow, and then these villages feed into Barrow, and then for tertiary care, feeds into Anchorage. Southeast villages feed into the region and then into here. But, from Anchorage, you can see that the regional centers, this is Barrow, Kotzebue, Nome, Bethel, Dillingham, and Southeast, and Tanana Chiefs, all feed in here. But then there's all these little villages from the Canadian border, down to the Aleutian chain, and out in the Pribilofs, which also all feed in here as the regional hub. And in the color version of this, maybe you can kind of tell, this is a different color from these big lines. And so these are a different color from these big lines. Because these are secondary, to tertiary, community hospital, the referral center, whereas this is from community center to regional center, which also happens to be the referral center.
When the transition happened in '98-'99, the Consortium and SCF sat down and negotiated out who would run what, because this is technically on CIRI land, this is CIRI territory. There was an argument to be made that the whole thing should be run by SCF, but those folks out in the rest of the state said, "Well, if the local company runs it, then when times are tough, they will more look out for the local population and not for the statewide population. So we don't want them to run everything."

But SCF said if a consortium of tribes runs everything, they will pay most of the attention to the tertiary referral center stuff because they have their own primary care back home, and they'll short-change the local primary care. So they resolved the problem by splitting ANMC to two owners, and creating a consortium of tribes that pay attention to all the statewide support, and a local entity, SCF, that pays attention to the local services. So conceptually it works pretty well, except I have two boards, and two owners, jointly running the thing. No matter how well you get along, it is still two, so that tension we kind of live in all of the time.
AHPR:  Just another point of clarification. The funding from the IHS [Indian Health Service], is that 638 funding or some other thing entirely?
Eby: The way it works is, when you are Indian Health Service, it comes directly to you.  When you become tribally-owned, when you move from being federal to tribally owned, they call it 638 contracting. It's based on Public Law 93-638, which was something that was passed that said if American Indian and Alaska Native people could show the wherewithal to run their own programs, they should be allowed to run them.

Technically, 638 was, though, still tightly controlled by the government -- where it became Native-owned, but still government heavily regulated.  Native people said, "That's not really self-determination. We want more freedom to reprogram and run things how we want. If we want to redesign the thing, we want to be able to redesign the thing." The government said, "Fine." So, technically, we're not 638-contracted. Technically we're "compacted," which is called the All-Alaska Tribal Compact, which is a more mature relationship from 638, although people still use 638 as shorthand for everything, so it's confusing. But, that's where the term '638' comes from.

Funding-wise, though, the only people in the United States that are owed health care legally by the United States government are its indigenous people -- American Indian and Alaska Native people -- because they have treaties, nation to nation treaties guaranteeing such things. [There were] lots of treaties, though, so [it was] a little uneven, so the government eventually passed regulations that said, "here's what that means," and they sort of standardized them across the country, and then implemented Indian Health Service, and so forth from there.

The problem with this is that -- let me take a little detour -- if you're eligible for Medicaid or Medicare, you sign up, "I'm eligible," and then the government covers your costs for lists of services that the government provides to people who have Medicaid or Medicare. So, to the government, the more people that sign up, the more it costs them, right? And, the more health costs go up, the more it costs the government too. So Medicaid and Medicare have grown exponentially over time, because costs have gone up per person, per year, and the population covered by the programs have gone up over time.

Indian Health Service, on the other hand, is just a fixed line in a budget. It's not connected to how many people show up for services, or how much it costs per person, per year. So, while we should be getting 10-15 percent per person more, because that's what medical inflation has been running, and in Anchorage we should get 8 percent more on top of that, because 8 percent more of the population moves to Anchorage every year. Instead, we get nothing.

Our Indian Health Service money goes up by an average of 1.7 percent per year, year after year after year. I mean, it's a little more some years, a little less other years, but on the average, that's about how much -- despite a 10-15 percent per person, per year increase, and an 8 percent increase in the number of people, which means, Southcentral should be getting around 20-25 percent, probably around 20 percent more each year than they got before, in the year before, for Indian Health Services, instead we get 1.5 to 2 percent. So, we essentially have significantly less money per person, per year, each year, than we did the year before, which is a huge problem for us.

So, how do we survive? Well, we've gotten very aggressive about chasing down other ways of getting paid. The government, by their own admission, says they pay the Indian Health Service about 40-60 percent of what anybody reasonable would pay, to have basic primary care services provided. So, by the Government Accounting Office's own admission, they horribly underpay IHS, which then horribly underpays us. So to make up for it, they allow us to bill Medicaid, Medicare, private insurance, and so forth, without collecting any deductibles or co-pays, because indigenous people are entitled to health care without paying out of pocket.

So, here today, about 45 percent of our total budget, our revenue, comes from the Indian Health Service. Just under 50 percent comes from billing Medicaid, Medicare and private insurance for Alaska Native people who qualify for those programs. And then the remaining 5 to 8 percent is contracts, research money, philanthropy, all kinds of ways we chase getting a little bit of extra money in the door.
We are a private company providing services to a community, half of whom are uninsured, and the government gives us a block grant which stays flat no matter how many people are covered or what they cost from year to year, to essentially pay us for our uninsured care.

" ... we try not to use the word "patient" anymore. We use "customer/owners" because we think everyone who comes here for care is a customer/owner of the system, and it changes the whole power differential. ... "
AHPR: So the 45 percent of revenue from the Indian Health Service is shrinking each year?
Eby: The amount of money is holding steady, but the percent of what it takes to run this place has shrunk dramatically. Every year it goes down. About ten years ago it was about 80 percent of what this place ran on. Now it's about down to 45 percent because the population keeps going up, and we have gotten much better at helping people sign up. Most people sign up by themselves, of their own volition. They sign up to get Medicaid or Medicare, because otherwise they get a big bill that they have to pay. Well, not so here. Native people don't pay any out-of-pocket costs -- it's pre-paid. Their health care is pre-paid by land, and so forth, that was negotiated through a treaty with the government. It's not free, it's pre-paid, but they don't pay any out of pocket costs so we don't collect co-pays or deductibles, and only half of the people are eligible for Medicaid, Medicare and private insurance.
It's a big financial struggle for us to make all the ends meet, but we've done pretty well in playing the game. So, how do we do well in playing this game? Well, part of that story is -- and this is the real story, that to me, is of interest to other people -- when we at SCF, took things over, over ten years ago now, eleven, twelve years ago, in '98, essentially. We sat down with the community and said, "What do you want from a health care system?" For six months we just listened. We did written surveys, we held focus groups, we sat in waiting rooms with clipboards, we had one-on-one interviews with anyone who wanted them, we talked with every single one of our frontline staff, we talked to our new board of directors, who was taking over the system, and the CEO, and everybody else.

And at the end of the day, we produced a document that said, "[These are] the requirements for a health care system, from the perspective of the people getting the services, at ANMC."
So, the Native community basically told us, "This is what we like, this is what we don't like, and these are the requirements of a decent health care system." Those have evolved a little bit over time, but they are still what we call our "Operational Principles."  
We believe that we are in a complex, adaptive system environment, which basically says that you can't run it by a bunch of policies and procedures and power and control. You have to run it instead by principles that everyone can see, that are transparent, that every decision is made upon.
So, we have these fourteen principles, they spell out the word 'relationships,' R-E-L-A, you know, they start each line with one of those letters, because we think messy human relationships is the most important thing there is for changing health care [see slide 4 of this power point presentation about Nuka].
It's everywhere. So, big decisions, small decisions, everything pretty much. We have scoring papers, we score an idea against [the fourteen principles] ... Like if a patient has an idea, and by the way, we try not to use the word "patient" anymore. We use "customer/owners" because we think everyone who comes here for care is a customer/owner of the system, and it changes the whole power differential. So our customer/owners, if one of them have an idea, or a staff person has an idea, or if the CEO has an idea, it's scored against these principles. If it matches very high, we're going to try to do what we can to institute that idea. And if it scores very low, we're going to not use that idea.
I'll give you an example. The principles basically say that the relationship between the individual and their integrated care team is the most precious thing. The whole system is to be built around that. Let me take just a little detour -- so that's the main thing people told us, is they want to be in a deep personal relationship, longitudinally over time, walking a partnership where the medical professionals they interacted with knew them on a first-name basis, didn't have to get their history from them every time, and there's institutional memory. Personal relationships could be built over time where trust and accountability could be developed, and real change could happen in health decisions over time.
That's our fundamental, most core principle and premise of the system, and what that means in structure, is that since January of 2000, if you come here for care, you can choose your primary care provider. If you're unhappy, you can choose again, if you're unhappy, you can choose again. It's customer-driven, but we do try and roll you or panel you by whole household because one of our major key points is called "Family Wellness." We believe the family unit is the real place where health happens, rather than the individual, so we try and have the whole, extended family be connected by the same primary care provider, if possible.

Then, we support that primary care provider, every one of our primary care, mostly doctors -- there's a few NPs and PAs who are primary care providers. The primary care provider has some medical assistants that help move people in and out of rooms, who are coming for visits. And then they have their own, one-to-one ratio, nurse case manager, and they have their own case management support. So the doctor, nurse case manager and case manager support, together, are a team that are available to you, for anything you want, when you want it.
For every five of those teams, we have two behaviorists. We put the mind and body back together. And so you have your doctor, your case manager, and your behaviorist, are your primary clinical people you're relating to. For every five we also have a dietician and a pharmacist. So, as someone coming here for services, you should know your doctor on a first-name basis, your case manager. They have a case management support that you may not relate to a lot, but helps get all the work done. Your medical assistant is generally the same person every single time as well, and a behaviorist, which is the same person pretty much every time as well.
So, you don't have to repeat your history and all this stuff, and a relationship can build over time, and we guarantee you same-day access to them for anything you want, in person, or by phone or e-mail if you prefer, today. Guaranteed same-day access. We've sustained it for ten years. So, by putting the mind and body back together, and walking with you through a personal relationship that builds over time, supporting, encouraging, teaching and supporting you over time on your health journey, and coordinating your care and your issues across all the boundaries in the system. We're your companion, your expert advisor companion on your health journey with barriers to access removed. That's what has driven [emergency room] use down by 50 percent, specialty use down by 50 percent, etc.

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Part 2: Nuka Model Developed Locally, Monitored Internationally

" ... we try and get at the underlying issues, issues of family dynamics, and violence, and tobacco, and alcohol, and neglect, and abuse, and all of those things are where we're living a great deal of our time now for people who come here for services. ..."

AHPR: And is this what's known as the Nuka Model of Care?
Eby: Correct. We're called Southcentral Foundation, and when you hear those words, it doesn't mean Alaska, and it doesn't mean Native. You know, "Southcentral Foundation" could be in Missouri, or Mississippi, or Maine, or anywhere. So, as this has developed quite a national, international reputation over the last ten years, we decided to brand it with a little more Native-sounding name. So we call it the Nuka Model of Care. Nuka is not an acronym, it's a word. It's kind of a general, almost slang word that exists in both Inupiat and Yup'ik, and it refers to family members. It's also the name of a mountain in the bay right near Seldovia, where Katherine Gottlieb, our CEO, grew up, and it's got some other history. It's only four letters long, you can spell it, non-Native people can pronounce it and remember it. So if you're branding something, that is important. That's how we came up with the name. The philosophy and the structures and everything we've developed over the last ten years, we've kind of packaged it under this "brand" of the SCF Nuka Model of Care.
So, the core premise is that we are in a messy human relationship walking together longitudinally over time. If you're going to do that, barriers to access need to be removed because, if you can't get in for two or three weeks, like in your usual health care office, you're going to deflect a lot of the work off to the urgent care center or to the [emergency room], or whatever, and that's very undesirable for a whole lot of reasons -- cost being one of them, but quality, and consistency of purpose and all that  kind of stuff being another one.  
So, instead of doing just a lot of symptom treatment here -- "Oh, you have these symptoms, here's a pill. Oh, you have these symptoms, here's a different pill" -- we try and get at the underlying issues, issues of family dynamics, and violence, and tobacco, and alcohol, and neglect, and abuse, and all of those things are where we're living a great deal of our time now for people who come here for services. That's a very, very different thing to expect your medical staff to be dealing with, and for the people coming here for services to be getting from the clinical staff that they're interacting with. [This] is also partly why we've gone so heavily into the co-located, fully integrated behaviorist model, because an awful lot of what we're doing is behavioral modification and dealing with psychology sorts of issues.
So if you go back to our principals, relationship is to be optimized, locations are to be convenient to the people getting services, there's to be no duplication of services, no overlap, or redundancy in the system. We're to build on the assets that the Native person brings to the table. They are to be treated with respect. The cultural strengths of the Native people in the Native community are to be built on with intentionality in how we frame care and decisions, and so forth. That's more or less a summary of the principles we drive the system on.
One of them is also that we have to be population-oriented in our approach. So, you can't just do the best you can for the people in front of you, you have to think on a population-wide level. So, let me give you a couple of examples.
AHPR: So, you have the EpiCenter [The Alaska Native Epidemiology Center] here ...
Eby: There is an EpiCenter run by the Consortium, and we give them some business, and we get reports back from them. But, the most powerful thing we do for population management is actually something called the "data mall." We have a whole bunch of different clinical databases. We don't have a fully electronic health medical record yet. We have RPMS, which is a clinical information system. We have a billing system, we have a lab system, a radiology system. They are all different, we have 17 different electronic formats in which clinical information resides. It is all dumped into this great big huge data mall. And then we have four data extractors who pull this information out to a bunch of pre-determined reports that then allow us to manage the population very effectively.
There are something like 75 different measures now, like hemoglobin A1c for tracking diabetic control, and eye checks for diabetics, and foot checks for diabetics, and cholesterol management, I mean just all kinds of things we track. [We do] screening for domestic violence, tobacco use, and we screen everyone for depression at least once a year. We track all of these things through this data mall and then feed them back real-time. It's updated continuously, and then it feeds back to the clinical team that can pull this stuff up then and track their performance. It leads to "action lists," so as you go down through your performance measures, you get eventually to action list which tells you that these people are overdue for their mammography, these people are overdue for pap smears, these people are overdue for immunizations, or diabetic screening, or whatever.
Then the case managers and the case manager support can call them up, get a hold of them, get them to come in to take care of these things. Or, anytime you hit our system, we've taught all of our system to do what's called "max packing." So, if you're here for your sinuses, while you're here we're going to do everything we can think of that's possibly good for you, until you complain about how much we are doing. So, we are going to do your immunizations, your mam [mammogram], your pap, your colorectal screening, your hemoglobin check, your foot check, your eye check, all that stuff, while you think you're here just for your sinuses.
If we do it all at once you have to come in less often. We have to pull your chart, and greet you in the front, and bring you to the back, and take up a room less often. We are a lot more likely to get all of these prevention and wellness things taken care of, because most people don't say, "Hey, I think I'm going to go in to have my diabetic foot checked." They come in for other more urgent things, and we take care of all of that.
AHPR: So this "data mall," if I could just backtrack for a second. Is this kind of a canned program developed by somebody that sells it to HMOs?
Eby: A lot of HMOs do it. The technology it is built upon is industry-wide kind of technology, but the programming is all done locally because our particular mixture of what dumps into the data mall is different than someone else's particular mixture. So the data lives there, in different formats, depending on what your particular system is.

" ... All that routine stuff is now done by the behaviorist, because while they are doing that, they are watching the interaction and they're kind of assessing for parenting problems, and domestic violence problems, and nutritional problems, and all these other things that the behaviorists are particularly astute about doing. ..."

AHPR: And so the idea is, at the lowest level, it builds a record for an individual?
Eby: We've defined things we want to track. I can go in and look at it by system-level, or by provider team and how they are doing, or by individual person and how they are doing in like diabetic control and all that kind of stuff. If you were a customer/owner coming here, I could pull up your report card for you, and it would tell me everything about the things we are measuring. Now it wouldn't give me your full health history, but it would tell me what you are due for and overdue for, have you been screened for diet and depression in the last year, have you been screened for tobacco within the last three months or whatever, and is your hemoglobin A1c under control. It would tell me all of that stuff, but it wouldn't give me your full health history, which is why we are just weeks away from signing a contract with one of the big electronic health record vendors, because we want the fully robust environment.
When you come here then, we bring everything to you. So, [for example,] our behaviorists don't have their own schedules. You make an appointment to come here, and your appointment is with this particular integrated care team. We use the doctor's name because you have to have some label that says that this is the team that you're coming to, and the doctors are still the kind of peak in the peak of the pyramid of health care no matter how you slice it.

So, you make an appointment with Dr. Davis, but Dr. Davis has a case manager and a behaviorist and a dietitian and a pharmacist associated with them. While you are here you may primarily see the dietitian and the behaviorist or something like that. You may not even see the doctor at all, or you may just see them briefly, and then they may bring these other people in. So your visit may or may not be really with the doctor, but you make the appointment with them. And then all these other people are just there to come and an out of the rooms to help support whoever needs to be supported, in whatever way they need to be supported.  
We have our behaviorists doing more and more things. Like with children, all of the anticipatory guidance stuff, you know, your two-year-old ... here's what they should be doing developmentally, here's what you can expect developmentally in the next six months, here's some enriching things you can do with them to help them continue to develop. All that routine stuff is now done by the behaviorist, because while they are doing that, they are watching the interaction and they're kind of assessing for parenting problems, and domestic violence problems, and nutritional problems, and all these other things that the behaviorists are particularly astute about doing.
So here is just a brief demo. This is the actual, real data mall. It's live. So, it's actually live data, which is why I won't show you any individual patient's stuff. So, you got across here, behavioral health measures, cost, dental, finance, operations, and primary care and quality, and then these are performance measures. So, you have all of these different performance measure indicators you can look at. So if we go here, let's pick a real important one, which is the hemoglobin A1c annual screening. So, every year, if you're diabetic, you should have at least one hemoglobin A1c.

It's the HEDIS [Healthcare Effectiveness Data and Information Set]. HEDIS is the national benchmark to compare with. So, the 2008 Medicaid HEDIS percentiles, the 50th percentile performance is 79 percent. The 90th percentile performance is 88.81 percent, and our system-wide performance is 90.5 percent. So we are in, like, the 95th percentile performance as a whole system. And then we have six primary care clinics in this building, plus pediatrics, plus the Valley team out in Palmer-Wasilla. So there's eight of them, and this is how each of those different practices are doing.
So if we open up Three East then, Three East has these five integrated care teams for primary care providers. And it tells you the numerator, denominator, so if you look at Patty Co [?], she has 40 diabetics, and all 40 of them have their hemoglobin A1c on time. Dr. Corbin has 46, and 44 of them were on time. And so this is how each of them are doing. And then, if I go to Dr. Corbin, it will show me how he is doing for the last two years, month by month by month in his performance. And it will show me the HEDIS 50th and 90th percentile performance, and his trend over time.
AHPR: Well, there must be some element of electronic records, otherwise how would the data get in here?
Eby: We have data entry clerks hand-typing in all of the key staff that we want to track and follow. All of that's going to change once we get our electronic health record, but we have tons of data entry clerks because we need a lot of [them] for billing purposes, but some of [them] we just need because we want to be able to do population health, and individual health would be a good way, too.

" ... So at one glance, I can tell who the highest and lowest performers are on every single measure. And I can pull up a provider report card, so I can pull up Dr. Co, and look at her 75 different measures. ..."
AHPR: But it's very impressive, even at this aggregate level.
Eby: Well, one thing, if I were a provider, then I could click on my own name, and it will pull up my action lists for this. So it would tell me, if I were Corbin, it would tell me the two people ["patients"] and their contact information and everything, right out of this [data mall]. So the action lists are tied in to the performance measures, and so forth.  
It will also give me a grid with every single provider in the system and their dot, upper and lower control limits and benchmarkable 90th percentile performance. And for every measure in there it will do that. So at one glance, I can tell who the highest and lowest performers are on every single measure. And I can pull up a provider report card, so I can pull up Dr. Co, and look at her 75 different measures. And we have it programmed so it will show me red, green, and yellow. So green is hitting our expectations or above, yellow is teetering, and red is not hitting our expectations. And we can produce those for every single provider, every single day. And all of our managers, and physician leaders, and [everyone], have access to this. And we've now set up a physician job progression, with assistant medical directors and mentor physicians and mentor nurses defined, who sit down with you and go over your performance at least once a month
AHPR: And I'm assuming all of this is premised on the fact that you have one integrated system?
Eby: Right. We are one integrated system, from community health, to primary care, to specialty care, to inpatient care. If you don't have that, you can't do population health very well. And you can't control costs very well, because we are driving down all of our high-cost areas, and shifting some of that savings back into the front end because we share revenue with the whole campus. We think and act as one big integrated system. And here, at least so far, we do the right thing and then we figure out how to get as much money as we can for doing the right thing. We don't do what is financially advantageous to us.
Now, we have learned how to play the cost game pretty well. Most of health care just thinks "revenue, revenue, revenue -- how do I bring in more money?" Here, if I can drive total per person cost down by 30 percent, and lose 15 percent of revenue at the same time, I've still improved my margin, because I've lost 15 percent, but I've saved 30. That's still good. But most health care doesn't think that way, it's just "revenue, revenue, revenue, I want more money, I need to bring in more money," which is crazy. It's part of what ratchets health care costs up and up and up.
This is part of what drives us, is understanding this piece right here [referring to a simple graphic]. So, this is real simple. This is control on one axis, the vertical one. And acuity on the horizontal one. Right? So 100 percent here and high here. High acuity: I'm hit by a truck outside the street, I'm laying here unconscious, the EMS people come here they scoop me up, they take me to the ER, they do a bunch of stuff to me. They take me to the OR, they fix me, surgery, all kinds of stuff, they take me to the ICU. All on the way, I, the patient, or their family, have very low control. And the system has very high control.
And in a mechanical, linear environment, like a very high acuity operating room-type environment, that's okay with me. I want them to use best standards, protocols, and I want them to lean in Six Sigma and do everything smart, and drive out waste, improve quality, make it safe for me. And the only question there, is whether they should or shouldn't be doing it to me. You know, what's my life and my advance directives, and what are my values, and all that kind of stuff. Should you do it or not? But once you're going to do it, do it by a protocol and a standard. But I'm pretty passive and they are pretty active, okay?
But in health care, about 80 percent of the people, and about 70 percent of the money now, is not in that setting. It's in all of these long-term conditions and residential care, and all that kind of stuff. So nursing homes, assisted living, school clinics, outpatient primary care, outpatient specialty, home health, all these things, together, are now the majority of the costs in health care. And certainly, where the majority of the people work in health care.
And in those "sick" circumstances, the majority of the control of power lies in the patient and family's hands and not in the system's hands. It's not whether we want to give them power, it's that they already have it. So let's talk about primary care doctors office. Someone comes in, I do the medical model, right? Signs and symptoms, which leads me to a differential diagnosis, it could be this, it could be that, it could be the other thing. And then, we do a whole bunch of tests because we can, and there's no penalty in not doing them. And then you, there's no penalty to doing them. And then we say that you have a definitive diagnosis, you have diabetes, you have asthma, whatever. And then what do we do? We write a bunch of prescriptions, or give a bunch of pills, or give procedures to you.
So we act like it's a linear, mechanical process. Then once we are done seeing you, we ignore you until you show back up with us again, but, whether you pick up your pills after being prescribed, is under your control, not mine, and a lot of people don't pick them up. They can't afford them, not sure they're going to help, whatever. Whether you cut the pills in half so they last longer, because they can't afford them -- under their control. Whether you take them as prescribed -- under your control. Or, you quit taking them for three days because you feel better now, so you quit, or you feel worse from the side effects, so you quit -- under your control.
Whether you smoke, whether you drink too much, what your exercise habits are, what your sleep habits are, when you get frustrated, whether you lash out in violence -- all of these things are under the control of the patient and family. Those are the determinants that primarily drive whether you get sick and have a chronic condition in the first place, and how well you live with a chronic condition if you have it.
This is the truth, but yet we pretend that it's not. We pretend we are in control, the medical professionals. You come to us for appointments and we tell you what to do, and then how do we even judge what you do in between? We call you compliant, or non-compliant. Compliant patients, non-compliant patients. That term is so offensive. It's judgmental, paternalistic, condescending. "I am the all-knowing medical God, you come to me, I tell you to do this, take these pills, and then I judge you compliant or non-compliant."
It's insane, especially when this is true. And when they're not in our presence, out there in the community, they are hugely influenced by their friends, their neighbors, their church, their bartender, their hairdresser...

" ... that is a personalized kind of version of how this kind of stuff plays out, where messy human relationships and the messy human social fabric side is understood to be the most important variable whether or not your cholesterol is controlled or your blood sugar is controlled. ..."
AHPR: Television.
Eby: Oprah, Dr. Phil, have way more influence then the doctor's office does in how a lot of these people make decisions about their health, but we ignore it. You come to us to visit, you leave, we ignore you until you come back for another visit. Just dumb.
If you believe this graph, then you have to build your system like we've built it here, where you have same-day access guaranteed, for all of your questions and concerns, and so forth. Where I become your clinical expert advisor, partner with you on a journey over time, where relationship accountability and trust can develop, and we start to get to those underlying determinants that really drive your health outcomes, and quit relying on pills and procedures all the time to fix everything.
If you do that, prescription use goes down, visits to high-acuity areas go down, outcomes go up, less costs, better outcomes, happier people, because it's an intelligently designed system recognizing that this is reality, and that messy human relationship is really our primary fundamental base of our entire health system.
Here we talk about health care being split into four big buckets. The one bucket is the high-acuity, you know, operating room, ICU [intensive care unit], NICU [neonatal intensive care unit], PICU [pediatric intensive care unit], all those places. Next bucket is procedure people. So, replacing total hips, total knees, cataracts -- it's your surgical-mechanical people.
Then your third category are your cognitive specialists. These are all of your 'ologists,' you're endocrinologists, and the neurologists, and the pulmonologists, and the noninvasive cardiologists and so forth. That's bucket three. Bucket four is whatever part of the health system has a longitudinal relationship with you over time. So primary care, or the school clinic, or a nursing home, or assisted-living -- the infrastructure that works with you longitudinally over time. Those are the four buckets. The first two are mechanical and linear, where the patient is relatively passive and the system is relatively active. And in those circumstances, the medical model makes sense. Signs and symptoms, diagnosis, intervention.
But the problem is we think that that model applies to all of health care, so even in the third or fourth categories we do the same things: signs and symptoms, diagnosis, here's a pill, hope you're better. You are compliant, you're non-compliant. Really, if we're going to make a difference in the third and fourth category, we have to do a relationship where teaching, coaching, encouraging, and supporting can become our primary product.
At this point, I often illustrate this with a little story. Frank is 79 years old. Frank has congestive heart failure, he has COPD [chronic obstructive pulmonary disease], he has long-term chronic lung disease for smoking for a lot of years -- COPD congestive heart failure, diabetes. Frank lives alone, his wife has died, the rest of his family is still out in the village. He doesn't have a lot to do. He has a cardiologist, a pulmonologist, a diabetologist, a physical therapist, a home health nurse once in a while. And Frank has had seven admissions to the hospital in the last year, and has called 911 and been taken to the ER 11 times. He even keeps a little bag packed by his chair, so that he doesn't forget the things that he needs when he goes to the hospital. Frank is not unusual in American health care. Frank is very common in American health care.    

He has six or seven different providers who were all prescribing him different medications. There is no coordination across them. But the most fundamental problem isn't even that. The most fundamental problem is that Frank's number one medical diagnosis, clinically important diagnosis, is loneliness, isolation, dependency, and depression. Those are his main problems, and if you don't fix those, you are not going to make any progress in controlling his congestive heart failure, his diabetes, and all of the other stuff.    

In our system, our main intervention with Frank is to meet him where he is and get to know him and figure out what's important to him and how we can motivate him, and how we can get interest in life back up with him, and begin to become his friend and his partner. So, now he knows his doctor's name is "Mary," and his case manager's name is "Phil," and his behaviorist's name is "Suzy," and that he can get a hold of them today on the phone, or e-mail, or in person for anything he wants or needs. They are going to connect him with a home health nurse who comes by on a fairly regular basis and knows all of them on a first name basis and coordinates their care.    

Now we are not going to have him go to any of those specialists, or get any of the medications from those specialists, unless the primary care people decide that they need it to help support them manage these chronic conditions. And if so, the specialists are going to tell the primary care people, "Here's what I would do," and not do it themselves but have the primary care people do it. So all of his medications come from one place. He has a person who he can call anytime when he is feeling worse, and so forth. His care is coordinated, it is integrated, it's built on what is important to him, and it's with people he knows on a first name basis.  

Because we are connected to him at a personal level, we've got him now connected with Cook Inlet Tribal Council for some Elder lunches, and that kind of stuff, and Meals on Wheels. He goes to the Elders' group that we run, right down the street over here, where they play bingo, and they do beading, and they make food, and whatever. So he's not as socially isolated, he's got some friends, his care is coordinated, and he has access whenever he needs it and when he wants. Frank, on average, if you look at a bunch of these Franks in our system, would be admitted maybe once or twice a year now, instead of seven times, and would probably hardly ever set foot in the ER.    

So that is a personalized kind of version of how this kind of stuff plays out, where messy human relationships and the messy human social fabric side is understood to be the most important variable whether or not your cholesterol is controlled or your blood sugar is controlled. Because the only way we are going to get those things controlled, is if Frank starts to take responsibility for them himself, and the only way that is going to happen is if he actually enjoys life, looks forward to life, and takes some control over his situation because someone is helping him and advising him on how to do that.    

This is not what most people went to medical school or nursing school to do. It's not who we, the people we select to be doctors and nurses and so forth, we don't select by their ability to partner up with people and change their behaviors over time. We select them by how well they passed tests and can regurgitate science information, for Pete's sake. How stupid is that?    

So we hire, or we put the wrong people in the profession, but luckily for us, some good people happen to slip through for some reason and most of them go into primary care. So we try and find the right people that have an alignment with us, a philosophy, an approach. Then the rest of them we try and remediate, and teach differently when they come here. So as a system, we spend about five times as much in teaching and training, and developing our workforce, than the usual health system does. And we spent about five times as much in building infrastructure, and to do quality improvement and process improvement and redesign.    

In this division there's about 700 people. We have four improvement advisors and 15 improvement specialists who are spread out all through this division, doing work constantly with frontline staff on continually redesigning and improving and changing their work environments in alignment with our principles. As long as it's in line with our principles, you're not going to find people out in right field and left fields because they won't be doing this stuff. Because we essentially control all of these improvement advisors and specialists, with training and support and coordinating with them their activities, they don't tend to end up in the wrong places over time.    

AHPR: And how is your staff turnover?    

Eby: Interesting you should ask. I started down the line of the data here, but this is our 90 day staff turnover line. And it went from 17 percent to 3.4 percent. Pretty damned good, I would say. So, just to run through some more of this, I already told you that the population is exploding. It's like an 8 percent per year increase, without any increase in Indian Health Service money.    

[Referring to a series of graphs and charts] The emergency  room, urgent care utilization has dropped in half. This is from '97 on. This is a 60 percent drop in specialty visits. This is in admissions to the hospital, which are down about 40 percent. These are hospital data so it should be down about 35 percent. The primary care visits are down 20 percent, because we're "Max Packing." We do everything when you come in this time, and we do more by phone and e-mail all the time. So, in-person visits to primary care, down 20 percent. When you hit the system, you have about 80 percent chance of seeing the primary care provider that you have chosen. It's not 100 percent, because they don't work 365 days a year, or if you come in on the evenings, or Saturdays, or they are out in the villages, or whatever.    

This is the utilization in women's health services, which has dropped about 30 percent, because now, you get more of that taken care of in your primary care team. These are children with asthma under the age of 18. Their hospitalization rate has dropped to one quarter of where it used to be. HIV-positive individuals, one third of where they used to be. This is several measures of "perfect care" of HIV positive people ... went from about 40 percent of perfect, up to about 70, 80 percent perfect. And these tend to be kind of hard to reach, often they are drug addicts, and so forth.    

Childhood immunization rate -- we used to have three immunization nurses that went around sticking needles in everything that moved. We got rid of them and went to this whole person, whole family, integrated care approach and our immunization rates improved. Now we're running at about 93, 94 percent, which is extremely good. Smoking rates are starting to come down. Screening people for depression, we are now running just shy of 80 percent which is pretty darned impressive. Three quarters of our HEDIS comparison measures are running 75th percentile or higher, and this is in a Native, somewhat hard to reach population. Home health hospitalizations have dropped from 40 percent to 30 percent per caseload per year. Colorectal cancer screening, up significantly. Tobacco screening, very high, mid-80 percents.    

EPSDT [Early Periodic Screening, Diagnosis, and Treatment] is the very comprehensive child exam that Medicaid will pay you to do, but it takes a ton of time and energy to do it. We've increased from 29 percent to 62 percent of those being done on time, which is pretty darned good.    

" ... This is self-reported: "I can get an appointment when I want to get it," 89 percent.  Extremely good. "People are courteous when I come here for my visit," runs around 90 percent.  ..."

AHPR: Are these all Southcentral Foundation?    

Eby: Yes. It's the local 50,000 people. The biggest village in Alaska, by far, is here. They are now just shy of 50,000 people from between Girdwood and Houston. By 2015 there will be more people living in this area that are Alaska Natives than in the entire rest of the state combined. It is now about 42 percent of the Native population in the entire state live right here. Crazy, huh?  We have a behavioral health urgent response team that can go to the emergency room, or anywhere else in the system, to respond to behavioral health crisis kind of stuff. That has gone up, which is good, it's what you want.    

This is self-reported: "I can get an appointment when I want to get it," 89 percent.  Extremely good. "People are courteous when I come here for my visit," runs around 90 percent. Our revenue keeps going up because we keep playing the game better and better. This is our days and accounts receivable, it's another financial measure that have come way down. Our negative staff turnover, I already told you. Our network reliability is high, and I guess that's all we have in here. So it's just a sampling of some of the system measures. We are trying to get our reputation out and so forth. You know, we are mostly busy just running our system. We don't do real thorough self-evaluation and publication and research and all that kind of stuff because were just busy running a really good system.    

However, our reputation has started to become fairly widespread. Over the last number of years, Katherine Gottlieb [president and CEO of Southcentral Foundation], myself, and a few other people -- the demand for us to go out and give speeches, consult, and that kind of stuff is huge. We say no to 90 percent of it, but we do say yes to some of it. We've had a huge influence in a bunch of different places. There's this place called Care Oregon, which controls 40 percent of the Medicaid market in Oregon. They are based in Portland and they do Medicaid and dual-eligible Medicaid and Medicare. They have about 140,000 covered lives. They are a fiscal intermediary, they are the insurance company. The state pays them and then they manage the money with all of the different delivery systems.    

They pay primary practices, safety net clinics, and community health systems. They discovered us and decided as an insurance carrier they wanted to change the health care system that they paid for. They've come up with ways to incentivize all of the different places that they paid to deliver services. How to rebuild their systems is completely based upon us, so they've developed a training center where they bring people in. They've changed their payment methodology. They do active case management with themselves as the insurance company. They've shown pretty remarkable reduction in cost and improvement in satisfaction, and improvement in staff turnover at these kind of high burnout sort of practice levels. They found us about four years ago, and they've now got about 2 years of really good data. They pretty much directly cloned what we've done here. They're the best example of spreading what we've done.  

" ... We've had big influence in British Columbia. The entire province of British Columbia has changed their whole payment methodology in the last two years. ... they showed that for an investment of $50 million into infrastructure and payment support for picking up the most difficult of the patients, they've saved, in one years time, $125 million ..." 

AHPR: And are they working with a number of HMOs [health maintenance organizations], or are these private practices? Who are they able to do this with?    

Eby: Mostly community health centers, but some county health systems, and then they have some clients that go to HMOs or to private practices. We've also had a lot of influence [with] a lot of other people. Kaiser Permanente at a national level worked with us for a little while, and had us come to do some consulting and working with their teams. Eventually, they ended that relationship, mostly because they thought we were too demanding and too hard on their teams. We said this is really hard work and you have to dramatically think about how you're doing it. They were busy implementing their big electronic health record, and they get a lot of complaints from their teams that this was too hard and too demanding, or whatever. The Hawaii region actually kind of stuck with us, and the Hawaii region of Kaiser has done a pretty remarkable job of changing their whole primary care system based upon us.    

We've had big influence in British Columbia. The entire province of British Columbia has changed their whole payment methodology in the last two years. They just published an article about ten days ago where they showed that for an investment of $50 million into infrastructure and payment support for picking up the most difficult of the patients, they've saved, in one years time, $125 million in costs by essentially paying for this kind of service delivery system instead of what they were using. We've done a bunch of work in British Columbia, for the last four or five years, and some work in Saskatchewan and Alberta.    

A fair amount of work in New Zealand and Australia, particularly around their indigenous populations -- Maori and aboriginal folks. They don't listen very well, they're kind of arrogant countries when it comes to health policy, but we've had some influence there. We've done some work with the National Health System in England. I and a couple of folks spent a month traveling around, advising and consulting with all sorts of the NHS systems. One of our closest partners is a county in Sweden, called Jonkoping county, which is arguably the best health system in the entire world in terms of cost, outcome, and satisfaction. They are good partners. We exchange a bunch of information back and forth with them all the time.    

The Indian Health Service, at a national level, has had a 2 year project called, "Innovations and Planned Care," and we've been kind of the model they've been emulating. A number of our folks have worked as kind of faculty working with national leadership. The Institute for Health Care Improvement out in Boston -- who we are very connected with -- has been in existence for 22 years. Don Berwick is their CEO. He is very widely published, he's been on every national committee for health care, whatever.   

They've done a lot of work nationally and internationally, and are arguably the most powerful health care redesign engine in the world these days. Anyway, we are very connected to them. They pay SCF for 15 percent of my time. I am one of their senior faculty on medical home, primary care, health disparities, and whole system transformation. I do a bunch of work for them at an international level on a bunch of different projects. So that's kind of fun.    

If you go online to [Senator] Mark Begich's web site, he gave a speech yesterday [November 4, 2009] in the Senate -- six minutes long -- and four of the six minutes were about us and our program. So here you go, Mark Begich's web site, here you go, "Nuka Model: Health reform that works," Mark Begich. There he is right there making the speech. Anyway, you can watch it, it's a five minute and 23 second video. And it helps us. Very cool.  

Three weeks ago Newt Gingrich gave a major speech on health care policy. I don't know if you know that Newt has written a book on health care redesign which is actually not bad. I think he's an ass, but his book's not bad. He has become aware of us, and he gave a big speech to a whole bunch of health care CEOs in Boston about three weeks ago. He only mentioned one system by name in his entire speech, and that was us. He spent a few minutes kind of describing us, our system, what we do, and so forth, which was kind of cool.   

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Part 3: Obsessive Listening, Workforce Development, Health Reform

" ... We constantly, we obsessively listen to what's working and not working, what the customers want, and what they'd like to see different. So it's customer-designed, customer-driven, ...  that then drives pretty much every decision that we make. ..."

AHPR: Conceptually, how did Nuka arise? I mean, it sounds like you didn't grab it off the shelf from somewhere else.    

Eby: I guess I didn't really finish this stuff. So, in '98-'99, we did all of those interviews and came up with requirements for our health care system. Then we spent two more months writing up our transformational plan. We said, "Here is how we are going to change our health care infrastructure." We lined out, in the first month, we were going to do this, the second month, this, at 90 days, this, at 120 days, this. Basically we described the change towards choosing your own provider, creating these integrated care teams, heavily going in to case management, and guaranteeing same-day access. And we did that as one big fell swoop, between January of 2000 and December of 2000.    

AHPR: But the goals were based on the original interviews, and focus groups, and all that?    

Eby: Our system is customer-owned, customer-driven, customer-designed. And still today, we maintain at least ten different formal structured ways of listening to the voice of the customer at all times. So we have a whole bunch of advisory groups: we have a diabetes advisory group, we have a young mothers' advisory group, an Elders' advisory group, an advisory group from McGrath, another one from Iliamna [?], another one called the "Village Services Management Team" which are the leaders of all these villages we support.  

We do classic written surveys like every medical system does these days. We hold focus groups. We have customer service representatives that float around the building just helping people find their way and solve problems, but also collecting information and putting it in a database. We have an 800 number people can call. Our whole attitude just is, we want to hear every time something doesn't go well. So I tell everybody, "I am the VP, but you've got something to tell me about what's been going, well, you let me know." All of the board members and their relatives and everybody, believe me, they all let me know if it doesn't go right.    

We constantly, we obsessively listen to what's working and not working, what the customers want, and what they'd like to see different. So it's customer-designed, customer-driven, that we immortalize into these principles, that then drives pretty much every decision that we make. So [we] are principle-driven -- not what I want, or Katherine wants, or what the doctors want -- but these principles that are pretty well defined. And you build massive infrastructure in terms of data and feedback and tracking and population health capability, and then you put in place these improvement advisors and improvement specialists, and a job progression and mentoring system like I was describing earlier. You have invested in your workforce, you continue to be constant, to be consistently constant to your principles.    

You empower everyone to continually change and improve their environment, in support of the principles that we've laid out, and you change the power structure so that the customer/owner gets more and more and more of the power and the professionals have less and less. Those are the key critical elements to this whole thing. Way more invested in workforce, way more invested in improvement infrastructure, and so forth, consistent alignment with a particular philosophy, meeting people in very human, human terms. Making the system think and act as one great big system, rather than as individual practices making the professionals happy. And you've got a transformed health care system.    

AHPR: As you pointed out, your turnover has gone down, but a really big issue I hear, in all the other health care systems, is recruitment.    

Eby: It's a huge challenge for us. There is no medical school, no dental school, no pharmacy school, no lab tech school, no radiology tech school in this state. Recruiting is a huge problem. And you know, what we found is, once we get them here for a visit -- whether it's a pharmacist, or a doctor, or whatever -- we have about an 85 percent signing rate. Once they get here, they're like, "Wow, this place is pretty cool, it works, and you know, great practice and everything."  

The biggest impediment is Alaska. Most people don't wake up and say, "Hey I think I'll move to Alaska." Most people don't understand that we're on the south coast, there's a city, and life is not like Barrow, living in Anchorage. So we have to kind of talk people into the whole Alaska idea. And even when they do visit us and so forth, not everyone thinks that five months of winter is a great thing. So that's our single biggest impediment.   

But I'll tell you, we don't pay top dollar, and you work hard here, and you are dealing with all these really difficult hard to change things like violence and alcohol and tobacco and so forth. Because you're not just getting to skate across the top like most medical people are, you are down in the dirty stuff. Despite all of that, our retention is pretty good and our turnover is not too bad.  We are not full all of the time. I could use another three or four family docs right now, and we are actively looking for them. We lost three this year, but if you have 30 of them as we do, and they all stay for an average of 10 years, you're going to lose three a year. And ten [years] is long.  

You know what we really have, is about half of our staff stay 25 to 40 years. The other half come for two or three years and leave because Alaska wasn't for them, or they have kids, or their grandparents are back in Tennessee and, "You gotta bring those grandkids back here." Or they have kids, and a doctor is married to a doctor and one of them wants to stay home and raise them, and you know, just all those reasons. We generally will lose one doctor every two or three years because they are just unhappy with working here. Mostly that's not why we lose them -- it's grandparents, whatever.    

AHPR: Is it all personalized, or are there actual policy changes that would help the recruiting issues at the federal level, or particularly at the state level?    

Eby: Oh, absolutely! Are you kidding me? If [only] we could have loan repayment in a real aggressive way. A lot of people that we get are right out of training [and] they haven't already established themselves in Tennessee, or whatever. Especially doctors coming out of school now, have these massive debts. I really applaud that the state has doubled the number of people going into medical school from Alaska, which is fantastic.    

What we really need are more end-stage training programs. Having nurse internships, and pharmacy residencies, and dental residencies, and doctor residencies are really wonderful things because actually, where you go to medical school has a lot less to do with where you practice then where you go in your last stage of training whether you are a pharmacist, doctor, or an anything. Where you do your last stage of training is where you are most likely to end up putting down roots. So, supporting psychiatry residency, which is in conversation now, supporting pediatric residency, which is in conversation now, and supporting another one or two family practice residencies in addition to the one that already exists here -- for doctors that would be fantastic. For pharmacists, a residency thing. You know, all of those things would help tons.    

So yes, helping people from Alaska to get into the medical professions -- not just doctors, but any category -- then helping them come back, and especially helping them with those big debts they accumulate while in school would be [helpful]. Then the last stage of training, as much as the last stage of training could happen locally [would be effective].   

Here is the other legislative issue. For this state, it's the "Larry Plan."    

AHPR: [Laughter. Some weeks prior to this interview I gave a public presentation proposing a three-part health reform plan for Alaska: 1) greatly expand eligibility for Medicaid and Denali KidCare, 2) heavily subsidize the Community Health Centers, 3) significantly improve health insurance consumer protections. In jest I called this the "Larry Weiss Plan." -- ldw]    

Eby: I'm dead serious. If you take Medicaid eligibility from 150 percent of poverty, to 300 percent of poverty, which I think is the highest you can go ...   

AHPR: For reimbursement, for federal reimbursement. You can go higher.    

Eby: Oh, you can go as high as you want, but for federal reimbursement, yeah. Something like 40 percent of the Medicaid-eligible people in the state are Alaska Native. If they get seen in a Native environment, that's all federal money. The state doesn't contribute  at all. [It is] one hundred percent FMAP [Federal Medical Assistance Percentage], federal matching. So, for this state, if you just ratchet Medicaid up to twice where -- it's at 150 percent poverty, which is low compared to most states -- get it to 300 percent or 400 percent, I don't care. The more people you get in, the more federal money you bring in just in general, for everybody. But all the Native people who go to Native organizations for their care, the state doesn't pay a penny of that increased money. It's all federal money. What's not to like about that plan?    

About 60 percent of the community health centers in the state, now, are Native run, in rural Alaska, which is fantastic. Because now, Native and non-Native people can go to the Native system and have some support financially for their care, whether they're Native or non-Native, if they're poor, on a sliding fee scale like a community health center. This is another way to bolster the infrastructure of the state, to bolster the community health centers structure. It's the "Larry Plan." You do those two things and you transform what's possible in this state.    

AHPR: Specifically, what kind of policy would be beneficial in terms of the community health centers. What could the state do?    

Eby: Well, I've spent a lot less time thinking about community health center structure, than Medicaid structure or Medicare structure.    

AHPR: Is it cash?    

Eby: I think the biggest thing for community health centers -- but I don't know that it is the state requirements -- they have these crazy productivity requirements where you have to crank people through, you have to see so many a day or your funding starts to be put in jeopardy. Well, that's just dumb.  

" ... I think that the Denali Commission is supposed to be a federal-state partnership and it helps to build infrastructure, like clinics and water and sanitation in rural Alaska. The problem is, it's supposed to be this state-federal partnership, but all of the money in the Denali Commission is federal. ..."

AHPR: It's probably federal.    

Eby: I think it's federal. We have shown in our system, if you do a really good job, people come in less, and that's what you want. You want them to come in as often as they need to, not as often as the federal government says they have to come in. It's just dumb. So, community health centers are depressing because they've turned into these churning, churning, churning places, in order to meet their statistical goals in order to keep their funding. It's because people don't want to see their tax money wasted. They want to see these federally-funded places, publicly-funded places productive.    

Hold them accountable for health outcomes, the health of the population over time, satisfaction ratings, hemoglobin A1c's, that kind of stuff -- not for cranking bodies through like widgets. That's just dumb.    

At a state level, I think that the Denali Commission is supposed to be a federal-state partnership and it helps to build infrastructure, like clinics and water and sanitation in rural Alaska. The problem is, it's supposed to be this state-federal partnership, but all of the money in the Denali Commission is federal. So, I think this state, instead of giving people rebates, a year and a half ago, of $1,400 apiece or what ever the hell that was, it should have been pumped into infrastructure to sustain the state.  

One of the biggest ways is to put a whole ton of state money into the Denali Commission, combine the state and federal money, and have a vehicle for creating a sensible rural Alaska infrastructure. I think that's a big thing and that supports community health centers. If you have decent facilities and technology, which you can get through the Denali Commission, if it's well-funded, you can build a statewide infrastructure through the combined, integrated, Native and community health center monies; through the combined, integrated, Native-run community health center monies, through these Native-run community health centers.     

AHPR:  From a public health perspective I've always been very impressed with the ANTHC combination of water, sewage, and medical care. Could you talk a little bit about that? Is it all in completely different silos in ANTHC or is there some integration?    

Eby: Yes, no, and kind of. You know, they're run as separate divisions, but the senior leadership get together every week and collaborate. I can tell you from my own experience in the villages where I work, that the water, sanitation, and the local health facility in the villages are very connected. So that the community health aide structure and the facility manager really come together at the point of delivery, to a large degree. The same people in the villages are kind of paying attention to all of those pieces because they have that sort of contractual arrangement, if you will, with the Consortium, with SCF.    

At the implementation level, there is a huge impact of having clean water and sanitation on the health of the community. I think the fact that it is all under one umbrella is great, in terms of philosophy. It's primarily logistical, for water and sanitation. You are running pipes, you are insulating, and so forth. And so you just need engineering people who know how to do that kind of stuff. So I think it's cool that it's all under one umbrella, but functionally, mostly they are doing construction. It's the maintenance of it, then, in the village, where it starts to come together more, and it makes sense to be more coordinated.    

AHPR: I was thinking more like an epidemiology connection. People contract, for example, certain kinds of infections, and diseases are traced back to sewage or water, or that kind of thing.    

Eby: They do some of that, but that's all been proven to be true already. So, we don't need to keep proving it over and over, we just need to get the infrastructure built in the places where it doesn't exist. There's, you know, even H1N1. Some of the villages that are getting hit the hardest are the ones that don't have water and sanitation infrastructure. Now, it's primarily a respiratory-borne disease, so I'm not quite sure why the correlation, but there is a correlation.    

AHPR: Moving on to another question that's of great interest to me, and I think many of the readers -- the question of health reform at the state level, and health reform at the national level. Would any of this have any impact on the Consortium's health systems?    

Eby: Yes, it's what I mentioned before. Part of the proposal at a national level is to expand Medicaid coverage to be for all poor people. Right now, Medicaid just covers women and children and elderly. That's it. It's not really the "poor people's" program, it's the "poor women, children and elderly program." So one of the major cornerstones of the health legislation in conversation at the national level is making Medicaid really a program for all poor people -- the men and the women without children, and so forth, across the continuum.    

That would have a hugely, wonderful impact for us because even if it was kept at 150 percent of poverty, a bunch more Alaska Native people would be eligible for Medicaid, which would help our bottom line, which would help us sustain this onslaught of people from rural Alaska moving in to town that we don't get any more Indian Health Service money for. So that would be wonderful.    

The other thing is, there has been a lot of talk about, actually, the longer the health reform conversation goes at a national level, the better it becomes. At the beginning it was almost entirely about moving money around. The longer it goes, the more the conversation has become about the delivery system design, and paying for things that work. So for us, right now, this whole business of co-locating and integrating behaviorists and dietitians and so forth, in primary care -- we have a very expensive primary care model, and we don't get paid any differently than if we had a crappy, terrible primary care model.    

In fact, we get paid less because people come in less often now than they used to. So every financial incentive right now runs counter to our system. So yes, at a national level, if they could change and start to pay for population health, and start to connect across boundaries, financial responsibilities. So if you do a lousy job at primary care and your patients end up in the ER all the time, versus if they don't, there ought to be some financial consequence to you, or at least some financial benefit, if you're saving the government a whole bunch of money.    

" ... As long as health care remains all fragmented and piecemeal, every piece of the health care system is trying to maximize their financial well-being whether or not it creates havoc in some other piece of the health care system. ..."

AHPR: I just read that the state of Massachusetts, a commission there, has recommended global budgeting. I'm not quite sure how they could do it, because they don't really have a single-payer system, but that sounded pretty interesting to me.    

Eby: The other hot topic in health care literature, at least in some areas -- and a lot of it is coming out of Boston and Harvard, and such places -- is this issue of an accountable care organization, an ACO. Basically it's kind of like Care Oregon. Care Oregon is an accountable care organization where the payer pays an intermediary that takes responsibility for everything from emergency, to in-hospital, to specialty, to primary care, to community services. This umbrella organization may not directly deliver the services, but has responsibility across all of the boundaries for cost.    

I would love something like that because then you get rewarded for putting a bunch of money up front and saving a whole bunch of money on the back end. As long as health care remains all fragmented and piecemeal, every piece of the health care system is trying to maximize their financial well-being whether or not it creates havoc in some other piece of the health care system.     

AHPR: I brought up earlier the concept of the silos, the health care silos in Alaska. Is there some issue or some concern about relating to military health care, and private for-profit health care, and so forth, from the point of view of the Consortium?    

Eby: Well, one of our beefs -- and this is actually getting some attention now at a national level, in a good way -- has been that the government has a big military system here, and then when all these Alaskans who are in the military come back home their medical system, if they don't have private insurance, becomes the VA. But the VA is not an insurance company, it's a direct service provision entity.    

Most Alaska Native people have a stronger identity as a Native person than as a VA person. They can choose to go get their care at the VA or at the Alaska Native system, and they don't pay out of pocket costs whichever one they choose. Overwhelmingly, they choose to come to the Native system because they have a strong identity as a Native person. So we are, in effect, subsidizing the VA in Alaska because something like 30-35 percent of the vets in this state are Alaska Native. The VA is not supporting, financially, their medical costs because they all come to the Native system, so we would like some redress for that. If they just would pay decently for the Indian Health Service, then we wouldn't care.  

If they fully funded the Indian Health Services, then fine. Then the government is paying their obligation to these vets. But because they don't, and they only pay like 40-50 percent of what they should pay IHS, we end up being hurt by the fact that there's also money for these Alaska Native vets going into the VA system, in theory, that they're not tapping. We're trying to get the government to change that and allow there to be kind of an insurance company function to the VA so that if the vets choose to see us, we can bill the VA and get paid for doing it like we bill Medicaid and like we bill Medicare for Alaska Native people. But because they are a service provider and not an insurance company, they're not set up to do that, so we are having some arguments there.  

We have had a pretty collaborative relationship with the military, so some of the really hard to fill positions, like a perinatologist, for example, we've had a collaborative agreement. There is something called the "All Alaska Federal Partnership" [see: Alaska Federal Healthcare Partnership]. The All Alaska Federal Partnership has the VA, the military, and the coast guard, and the Native associated parts of the state, and we get together and figure out how we can help each other in hard to meet needs. Like high-end specialists and that kind of stuff.    

AHPR: It's specifically health related?    

Eby: It is primarily health-related. For example, the whole AFHCAN [Alaska Federal Health Care Access Network] telemedicine project was through the All Alaska Federal Partnership, and there's been some other things. It hasn't been as great of a thing as we were hoping it would be, but it has done some nice things. If there were a little more policy difference, like I was just describing between the VA and IHS, it would bolster this whole federal partnership idea in Alaska as well. It is a great vehicle, it is just the government thinks in silos, not comprehensively.   

" ... The gold standard nationally now is same-day access to primary care, which we do an extremely good job of. ... And the gold standard nationally for specialty access is three to five days. That's best practice. Well, in our system we think it should be three to five minutes ..."

AHPR: At this time I just wanted to ask if there is any closing statement you want to say, or any issue that we didn't cover that you thought we should cover?

Eby: Let me send you with just a couple more things. We went over this diagram that talks about the power and control [referring to a diagram entitled "Control: Who Really Makes the Decisions," in a document entitled "Appendix C - Key concepts/Diagrams from the SCF Nuka Model"].  

[Referring to a diagram titled, "Care Model - Improved" in "Key concepts/Diagrams ... "] This is, if you read health care literature much, about chronic disease, and so forth -- this is what used to be called the "chronic care model." If you are designing a system, you need to pay attention to community resources and policies, and then the health systems embedded in the community. This is a widely used, industry-used thing, and we have modified it to our own liking. 

We added workforce development. It's one of the most important things in health system organization design. We pushed together clinical formation systems and decisions support. They had them as two separate variables, but we think this is really one thing. We have redefined the work to be productive interactions through effective, asset-based partnering over time. This is our lingo. This is what we think we are primarily producing. We think we are a service industry, not a product industry.    

We think that a team connecting with the patient in the context of their family, it's "patient-driven," not "patient-centered." [We also think it is] coordinated, evidence-based, timely, and efficient. This is the IOM [Institute of Medicine] aims. It came out of their big study. The endpoint that we say it's all about is improved achievement of community goals, not our goals.     

This is our view of the entire health system, this is a little old, we need to update it [referring to a page with a diagram titled, "Southcentral Foundation Circle of Care." It has the customer family in the middle with the integrated team and relationship. We have these extending programs for high risk subunits of the population. So fragile Elders, at-risk youth, chronic mentally ill, and so forth, but they still get their main direction for their care out of the integrated care team. There's a few people, which are the hospice, very high-end, chronic mentally ill, some of the very fragile folks in nursing homes, where the medical home really becomes not us, but somewhere else.    

But for about 95 percent, it's us with these programs that get to high risk populations. So this is where everything should be partnered and coordinated longitudinally over time. The big change is where you have the specialists and inpatient care, and you see [on the diagram] a little tiny arrow coming down [from the "patient/family" circle to the specialists and inpatient circle] and a big arrow coming up, because we want to reduce this down to the very minimum that we can make it. And have a lot of the work pushed back up into here [primary care parts of the diagram]. The gold standard nationally now is same-day access to primary care, which we do an extremely good job of. We are probably the most wide open, longest-standing program in the country that we know of. We were on the front page of the New York Times in 2002 for this.    

And the gold standard nationally for specialty access is three to five days. That's best practice. Well, in our system we think it should be three to five minutes because the real job of the specialists is to support the primary care team, handling really complex issues, and partnership with the patient and the family -- not sending them off to a specialist for them to take control of the person. A lot of our specialists get this really well, some of our specialists we are still working on.  

And then the other part you have to have in the health system, is crisis response. There's a big arrow coming this way [from "Patient/Family" to "Crisis and Urgent Response"], and a small arrow going back. When you are in a car wreck, have a stroke or a heart attack, or you just got raped, you need to have an emergency room, and then we have this behavioral health urgent response team. That will take care of your crisis, and then puts you back into this integrated care environment as soon as you're stable and able to do it.    

So this is intelligent design of the entire health system, instead of each piece acting on their own self interests, which is how things really are. The centerpiece of it is the patient and family, longitudinally, with the hospitals and ancillary things off to the side -- not the big monster behemoth that's in the middle that everything else revolves around, which is unfortunately how medical care is often delivered.  

This is diagrams that show the difference in the internal processing with each patient [Referring to the first of two diagrams on a sheet of paper, "Traditional Methods of Managing Work Flow"]. It used to be that you would come in and then you would see the doctor who would then say, well, here are case managers, and so forth, can you help me with this? This person can only go as fast as they can go, which generally is between 20 and 25 visits a day. It is called a rate-limiting step. This system can only go as fast as this one piece [the health care provider, presumably a physician] goes.    

About 70-80 percent of what happens in primary care can be protocolized and ritualized, or done by somebody other than the doctor. If you can connect up the need directly with the definitive caregiver, only one of whom is the provider, you can start to put 70-80 patient touches a day through this system, whereas [before] you only had 20 to 25 a day through this system, using essentially the same resources.    

This is a little bit old also, but we still essentially do this [referring to a sheet of paper with a diagram on it titled, "Southcentral Foundation Functional Structure"]. This is our functional structure. We have a hierarchy. I'm a VP with a bunch of things under me, but the main way we do most of the work in this organization is through our functional committees. Most health care has operations and clinical quality. We said, if we are really going to be the thing that we want to be and radically change our system, we are going to need a lot more beefing up of our improvement capabilities.  

We created four ovals: operations, process improvement, clinical quality assurance, and clinical quality improvement. So, reporting to me, I am an operations director, a director of process improvement. A medical and nurse director of QI [quality improvement], and a different medical and nurse director of QA [quality assurance]. We have built robust expertise in each of these areas. We keep tension between these different things, and then all of our functional committees in the company report in to these broad category committees. This is really what ends up driving our system to a really big degree.    

So, for example, the HR [human resources] committee is made up of two HR people and eight frontline managers. The internal customers set policy and drive priority for the HR, for IT [information technology], for compliance, for everybody -- instead of being professional-centric. It's the same philosophy applied to our internal processes that we apply to our external stuff.    

We do a lot of radical things. Most of our large categories of hire, we do through a group hiring process. All of our CMAs [certified medical assistant], and admin support, and nurses, all go through a group hiring process. We do same-day hire, you drop your application off, you get an interview, you get a hire offer before the day is over, for the most part. Well, why not? Every other part of the hiring process is waste. It is dumb. We are competing with the other hospitals in town for hospital staff, we are competing with other clinics in town for clinic staff. We want the best. The only value added part of the hiring process is the application, the interview, and the job offer. Maybe checking references, although you rarely change your mind based on references. So why not? Why not do it all at once? It's just dumb to make it weeks long.    

This is the structure of our new building that we just opened 3 weeks ago [referring to one-page graphic titled, "Anchorage Primary Care Center New Wing" in a larger document entitled "Understanding the New Space - Fall 2009"] . It is a fairly dramatic redesign of the medical office. This is the public circulation area. There are six primary care clinics, two per floor. They are mirror images of each other. If you take this one and flip it like this, you get this one. So, standardization of structure and so forth. But mirror image because this is public circulation, the front desks are out here, the waiting areas are in the corners. This is public, and then it is semi-public down these hallways.    

All these rooms here, these six and these six, are what we call "talking rooms," that have been de-medicalized. There is no exam table in them. You sit like this with a computer screen, and you have a conversation -- equal power. Change that whole power, hierarchy differential stuff. Your information [can be viewed] on the computer, and we are going to be fully electronic before long. You can see it as much as I can see it. Everything is transparent, open, and I am here advising you instead of towering over you while you are naked in this semi-pretend paper thing that kinda, sorta covers you up, or whatever.  

So we have all these talking rooms. Since this is kind of like a semi-public corridor [where the talking rooms are located], and then you turn and the exam rooms, classic exam rooms, are on these private corridors. All of these procedure rooms, and the clean and dirty utility stuff is on the spine. So these are your more expensive, but less heavily utilized areas. [This layout reduces] the amount of footsteps it takes to do your work. These are high-volume, mid-volume, low-volume. Good efficiency planning.    

These are high costs, and therefore they are shared between the two clinics, instead of each clinic having to have their own set of these more expensive spaces. There is a large family room up here in the front, so that if you have a whole family with chickenpox, or tuberculosis exposure, or H1N1 flu, you can bring them in up the [nearby] elevators and in the back way, and back out again without contaminating all of these people.  

I forgot to mention there is a big stairway in the middle here. These are off to the side of the elevators, and they are really crappy, slow hydraulic things. We really want people walking up and down the stairs as much as possible. Physical fitness is built into our whole environment.    

This is the integrated care team space. There are three sections. In each one of them there is [a room with furniture]. So, you have your primary care provider, case manager, case manager support, your team here. And then along the outside here, are other seats, which is where your behaviorist, nutritionist, dietitian, and all those other kind of shared resources are. You have your integrated care team, your shared resources, right [by] the door into this hallway, so you can look [down the hall and see] flags and stuff, and it lets you know what's going on. The talking rooms are the closest things. There's outside windows and stuff for all of the teams to have lots of outside exposure. So, very healthy, wonderful, office scene, group office scene, where everyone can [come] over here and talk to everyone else about what is going on, because we want that team environment caring for people.    

This [area] is private. The patients don't come back in here because this is where all the HIPAA [Health Insurance Portability and Accountability Act] private conversations are happening. The manager's desk is right here. The manager does not have an office. We have de-officed all of our management people so that they are right in the messy mess of things that they are supposed to be managing. No hiding behind a closed door. The front desk supervisor sits right behind the front desk -- same idea. We have decentralized pharmacists so that they can help consult. When you are done with your visit you come here, see the pharmacist, a Vacu-tube delivers your medication, and you have that by the time you leave the clinic.     

This is a little narrative that talks about the design of the space ["Understanding the New Space -- Fall 2009"], a lot of the philosophy that went into the space, and then elements about the space. We think this is a pretty dramatically important contribution to our journey.      [I want to note what] you have to emphasize when talking about us, or excerpting things, or writing about us. Let me take just a little tangent.  

" ... So this story has to not be about Doug Eby, it has to be about the Native people owning, managing, designing, driving, and changing their own destiny and their own health system. ..." 

AHPR: Sure.    

Eby: Native people have been "done to" and "done for" for a very long time. Native leaders identify dependency issues as huge issues still in the Native community. Schools have made them dependent, health care has made them dependent, government programs of all sorts have made them dependent. So, to get to a healthy community and a healthy place they have to stand on their own two feet taking control of their own destiny. Part of that is having pride in the things that they do themselves. This place, and the transformation here in the world-class place this has become, happened when it moved from big, bureaucratic, federal ownership to local, Native ownership.    

All of this change and improvement has happened under the direction of a Native CEO, and a Native board. Sixty percent of our staff are Alaska Native, 76 percent of our leadership managers, and so forth are Alaska Native. So this story has to not be about Doug Eby, it has to be about the Native people owning, managing, designing, driving, and changing their own destiny and their own health system. Building beautiful places that were designed and built around the Native community requirements and expectations -- a program that was built around the Native community.    

I am just in the middle, a middle-man translator. I take the wishes and dream and hopes that are told to me of the Alaska Native people. [I take] their happiness, frustration, what they like and don't like about the system, and I translate it into these structural, operational things. But it is driven by what they want, what they need, what they see the health system ought to be, and that has to come through in the story. 

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AHPR Staff and Contributors

Lawrence D. Weiss, PhD, MS, Editor
Kelby Murphy, Senior Policy Analyst
Jacqueline Yeagle, Newsletter design and editing

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