roviding essential services for a population of about 731,000 over roughly 663,000 square miles has forced the evolution of a healthcare ecosystem in Alaska that’s unlike any in the Lower 48.
“We operate on a scale here that no one else in the country, potentially the world, does,” says Jared Kosin, president and CEO of Alaska State Hospital and Nursing Home Association. “A big part of that is because of the way our beds and facilities are distributed.”
Alaska’s population is not connected by a continuous road system, resulting in isolated pocket markets that serve relatively small populations in rural parts of the state.
Kosin describes it as a hub-and-spoke model, with initial care for many starting in outlying rural facilities, such as critical access hospitals. Then, as patients need higher levels of care, they are moved to larger regional hospitals.
These hub-and-spoke healthcare services, provided by both Native and non-Native entities in Alaska, stretch across the state, with critical care hospitals in some of the most remote populated regions and highly specialized services in Anchorage and other urban hubs.
There are thirteen critical access hospitals, five sole community hospitals, three general acute care hospitals, and five specialty hospitals, including two military hospitals.
“The tribal system is extremely robust and comprehensive,” Kosin says.
Alaska Tribal Health System, representing 229 tribes and serving more than 175,000 Alaska Natives, is in charge of 8 of the 26 hospitals in the state. Alaska Tribal Health System additionally runs 36 health centers and 166 village clinics—many of which are off the state’s limited road system.
According to its website, Maniilaq Health Services’ “mission is to provide comprehensive healthcare to the people in our service area while promoting prevention, fitness, wellness, holistic strategies, and local traditions.”
One of the biggest challenges faced by the Maniilaq Association in providing healthcare is access.
“There isn’t a road system connecting communities,” Shroyer says. About 21 percent of all acute care beds in the state are inaccessible by road. “The main mode of transportation is by plane, so our travel is very dependent on the weather.”
A large part of the success of the Maniilaq Health Services falls on the shoulders of Community Health Aide/Practitioners (CHAPs) in remote villages, says Shroyer. The CHAP program was designed to help people in rural villages get the medical care they need. The program is unique to the State of Alaska.
“I think our CHAPs are so important to our services, and they definitely play a huge part in the health of our region,” Shroyer says. “We have a lot of programs that travel to the communities to help support the work of CHAPs in the region.”
As part of meeting the goals of its mission, the Maniilaq Association opened Utuqqanaat Inaat, a long-term care facility, in 2011. In line with progressive long-term care facilities elsewhere, Utuqqanaat Inaat was designed to have a homelike atmosphere for its up-to eighteen Elders.
Alaska has a dearth of nursing homes. It has the fewest nursing home beds per 1,000 persons 65 and older in the United States.
Nonetheless, Shroyer pointed toward a recent success for Utuqqanaat Inaat, which was the facility gaining approval from the Alaska Department of Environmental Conservation to serve traditional wild game, including giving Elders access to seal oil.
“The Traditional Foods Program has received national recognition as a unique and culturally sensitive service for our Elders,” the association’s website states.
Following the “spokes” of the healthcare system from the villages to Maniilaq Health Center and then to a regional hospital allows for more specialized care for patients.
“Community leaders at the time saw the need for additional healthcare services,” Craft says. “And that’s what the impetus for creating this hospital was.”
To meet present and future community needs, the team at Mat-Su Regional Medical Center analyzes the market, reviews databases about what services are being accessed and how they’re being accessed, and other data points to determine what specialty services the hospital should provide, Craft explains.
“Every year we put together a strategic plan… and we come up with models that project how many specialists we will need in a given field to serve our population,” Craft says. “When they physically positioned the hospital, they did it in such a way that was prime for the growth of the region.”
Craft points out that though the medical center is continuing to expand, growing its roster of specialists, it makes a point of recruiting professionals from outside the Last Frontier to prevent cannibalizing other regions’ services. The hospital also helps other medical practices in the region in their recruitment efforts. “It’s a collaborative process. We work to find the best fit for our community and our community medical providers.”
“At the time, the vision was to create a regional healthcare hub,” Craft says. “I would say that over the past seven or eight years or so the hospital has really grown into its regional garments and into its name: Mat-Su Regional Medical Center.”
The hospital started with seventy-four in-patient beds. A major campus expansion in 2018 added thirty-five more medical surgical beds, while 2020 saw an additional sixteen beds added for the center’s inpatient behavioral health unit.
“We serve the fastest growing population in the state of Alaska,” Craft says. “It is projected to continue that route into the near future.”
Though situated only about 30 minutes from Anchorage, the Mat-Su Regional Medical Center serves a regional population of about 113,000 and provided $20 million in community benefit in 2020.
“One of the tenets of quality healthcare is to provide the care as close to a patient’s home as possible,” Craft says. “If your support network is nearby and has easier access to help you get the services that you need, it’s far better for your health.”
Within the last seven years, the medical center has opened three urgent care facilities, a heart clinic, and an OB/GYN clinic. Additionally, it has added inpatient behavioral health services, which were nonexistent in the region and are lacking throughout the state, Craft says.
The Mat-Su Regional Medical Center offers a wide range of services for the community from critical care medicine and emergency services to joint replacements and orthopedic services. The medical center provided care for more than 138,000 patients in 2020. Staff handled nearly 28,000 ER patient visits, more than 7,000 surgeries, and assisted mothers in bringing 650 Alaskans into the world.
“This has always been a hot button issue, it is everywhere else as well,” Kosin says. “Healthcare is not really a commodity. It’s not the cheapest one wins, especially depending on where you are.
“Many of the services hospitals provide actually lose revenue, but it’s a hospital—it’s supposed to be there for the community and provide those services for our community.”
In general, hospitals lose money on essential critical care services and generate revenue to overcome those losses through imaging services and surgeries, Kosin explains.
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Kosin notes that because of how heavily subsidized healthcare is by the government from Medicaid and Medicare, it’s unreasonable to treat healthcare as a commodity moved solely by free market forces. But he does note that Alaska’s Certificate of Need legislation needs to be updated.
By focusing on the services, supply, and market, the Certificate of Need process attempts to find the right fit for the number of providers to meet the needs of the population, Kosin explains.
“There are some things that you do that are in the best interest of the patient regardless of the economic value it adds to your bottom line,” Craft says. “Sure, it’s a business, but it’s the business of caring for people.”
“You think about pediatric subspecialties that take millions of people to support, and we only have about 730,000 people in the entire state. So we subsidize those programs, and that’s part of our community benefit to the state,” Simmons says. “A lot of services are unique to Providence… if we didn’t provide them, they wouldn’t be offered in the state of Alaska.”
Providence, founded more than 175 years ago, has been serving Alaska since 1902—well before statehood. Most states, as part of their healthcare infrastructure, have state hospitals and healthcare services that cover the entire continuum of care, often partnering with teaching hospitals. That backstop service in Alaska is provided by Providence as it functions as the primary “hub” for the “spokes” of Alaska’s healthcare system.
In 2020, the hospital provided $70 million of community benefit, which comprises subsidized services and uncompensated Medicaid.
“We know it’s important to grow our own positions within Alaska,” Simmons says about the need to offer medical education opportunities in the state. “For example, the residency program that we run, which retains 80 to 90 percent of the graduates on average within Alaska—we subsidize that to several million dollars a year.”
Providence also boasts the highest level of trauma services in the state, as well as cardiothoracic surgery, neurology, neurosurgery, orthopedics, urology, and behavioral health, as well as other specialized services.
“We have critical care hospitals in Seward, Valdez, and Kodiak,” Simmons says. “We have the state’s only children’s hospital. We have the state’s only long-term, acute-care hospital.”
All in all, Providence has twenty-eight main business units running the gamut of healthcare needs in the state.
“One of the things that Providence has been doing—and it’s been a multiple year journey—is going from what I would consider more of an acute-centric organization to one that is a system-of-care,” Simmons says.
Simmons explains Providence has been working to change its economic model from fee-for-service, which rewards volume over quality, to value-based care, which rewards quality outcomes.
“We can serve more people at a lower cost by moving towards value-based care that works under a coordinated and system of care model,” Simmons says.
By looking at care systematically and making sure there is good access at the right levels of care, it strikes at the heart of the issue of people who lack access to primary care using the emergency department of a hospital for issues that are not critical.
“And that’s absolutely the wrong thing to do,” Simmons says. “It’s the most expensive area to receive care… what you want is for people to have good access to primary care.”
As part of its effort to provide more affordable care, Providence launched Providence Express. The service provides services and solutions for hundreds of issues or concerns for which a patient should never need access to an emergency department.
“Express Care is available starting at $149 per visit and $79 for virtual,” Simmons says. “And if you can’t be helped and need to be referred to a higher level of care, you won’t be charged.”
Both patients and healthcare providers save money when patients are given access to primary care or similar alternatives instead of visiting an emergency room.
“We brought down our visit volume for those low-level visits by considerable amounts, and that came out of our economics, but it was the right thing to do,” Simmons explains.
“It will improve the health of the population, but it also helps reduce and stabilize costs over time,” Simmons says. “We’re trying to be leaders in terms of that transformation. Another organization that does a really good job in terms of managing care is the Alaska Native Tribal Health Consortium.”
Many healthcare providers agree that the key to serving such a widely dispersed population in the rugged North is focusing on community wellness in addition to acute care and long-term care.
“I think all healthcare organizations are moving towards the wellness model, and certainly that’s something that we do,” Craft says.
The goal of focusing on wellness programs is to alleviate the costly pressure on emergency rooms and higher levels of care situations, Kosin explains. These benefits can be compounded by increasing access to primary care, creating a more contiguous continuum of care for Alaskans.
“What’s nice is [that] Alaskans work well together,” Simmons says. “While there’s competition, there’s also a ton of collaboration… I’m very optimistic that we’re gonna see some really positive changes over the next couple of years.”
Simply put, the better condition the “rims” of the system are, the less strain there is on the spokes and hubs. 