In Alaska, a health care model for the nation


It takes about 30 seconds of walking around the campus of the Alaska Native Medical Center to see that this is what the Indian Health system should look like across the country. “No,” a friend corrected me, “this is what the U.S. health care system should look like.”

The Alaska Native Medical Center is two facilities in one. Essentially, there is an in-patient hospital and some statewide services managed by the Alaska Native Tribal Health Consortium. And outpatient services are administered by the Southcentral Foundation. The two management teams work closely together.

The Indian Self-Determination and Education Assistance Act of 1975 opened up contracting for tribal and native management of Indian Health Service programs. Southcentral (a non-profit affiliate of the Cook Inlet Region, Inc.) assumed some programs in 1987 and by 1999 ran the whole show. Today Southcentral serves some 55,000 people with 1,400 employees (including 10,000 in 55 remote villages).

“I believe that Alaska is the only state that has enacted Indian self-determination to the fullest extent of the law in assuming health care,” says Katherine Gottlieb, president and chief executive officer of the Southcentral Foundation. “We have taken what we had from the government and transformed it.”

So much so that Southcentral Foundation continually refers to its “customer/owners” as its foundation and inspiration.

Southcentral’s “Nuka” model of health care boils down to some basic ideas: That relationships are the key to health care; that patient care should be integrated, there should be same-day access to primary care; customer-owners are partners in their own health care and there should be given ample opportunity to offer advice and feedback. And to make all of this happen, there should be a culture where training and retraining is valued.

After contracting from the IHS, Southcentral Foundation made surveys and listening to customer/owners a key ingredient in its culture. “I think transparency is a key to success,” said Gottlieb. “Transparency in yourself and in everybody.”

The medical team approach is different too. The team sits together without hierarchy. Members include doctors, medical assistants, nurses, care coordinators and often a behaviorist. Customer-owners can choose their own team – and make changes if unhappy. The ideal is integrated care, so patients don’t have to make as many return visits.

Consider how most health care dollars are spent: Expenses increase at the end of a person’s life. What if that was reversed? What if dollars instead were invested early on prevention? That means treating the root causes of diseases before they surface as heart diseases, diabetes, depression or domestic violence.

The data backs up the Nuka model. There has been a 40 percent reduction in emergency room, urgent care. A 50 percent decrease in specialty care visits; a 20 percent decrease in primary care visits and a 35-plus percent decrease in admissions. “We have statistics that show a generational change,” Gottlieb said.

The Nuka model is not about money. “We still have a poorly-funded IHS system. We are not fully funded,” says Gottlieb. In fact she says the government has not fulfilled its treaty-trust obligations to American Indians and Alaska Natives. “Not yet.”

Southcentral’s system is about 45 percent funded by the Indian Health Service, 50 percent from “aggressive” billing of third party insurers or Medicaid and the remaining 5 percent from foundation or other government grants.

“You won’t find anything in Indian Country like this campus,” said Douglas Eby, the Alaska Native Medical Center’s vice president for medical services. There is less direct funding from IHS and this is by far the biggest, most sophisticated campus in the Indian health system that’s far better off than most for a variety of reasons ranging from leadership to the structure and resources of Alaska Native corporations.

“We were smart enough to say, we need to optimize revenue, and we’ve done very well at doing that,” Eby said. But the growth in population, people moving in from the villages, and flat funding from IHS, and health care being such a “wasteful” business drove a rethinking of business model. “Our real hope lies in controlling costs, doing things smarter, better and avoiding high care cost as much as possible.”

The same could be said about the entire U.S. health care system. And, it turns out, controlling costs also results in better health care outcomes.

Yes, this is exactly what America’s health care system should look like.

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment at

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