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Difficult delivery: Alaska's rural health care system copes with numerous obstacles.

Despite unforgiving geography, cruel climate and financial austerity, rural health care in Alaska has made dramatic headway against lethal diseases. Epidemics of infectious diseases virtually have been wiped out; life expectancy is up; infant mortality is down. One state health official says the improvement is the most miraculous of any population in the world.

Key to these successes are a dedicated corps of community health aides, supported by specialists in regional and urban medical facilities; advanced telecommunications; and strong, coherent political advocacy.

But despite these triumphs, the struggle to provide adequate health care to more than 65,000 Alaska Natives and nearly 60,000 non-Natives residing in rural areas is beset by several crises. Some experts worry that the system may be threatened by burgeoning new pressures.

Alaska Natives still experience higher rates of infant mortality and some of the highest rates of Sudden Infant Death Syndrome in the nation. Tuberculosis and other infectious diseases have been replaced by injuries -- many related to alcohol abuse -- as the leading cause of death among Alaska Natives. Cancer and heart disease death rates are climbing in the Native population as well.

In addition to new or recurrent health problems such as AIDS, alcoholism, hepatitis and deteriorating village water systems, Alaska's rural health care network will sooner or later have to face some of the same issues confronting health care delivery in the rest of the country.

"I feel we're providing better care than poor people living in inner city Chicago are receiving. I feel this state ought to be really proud that health care measures are as good as they are," says Richard Mandsager, a physician and director of the Alaska Native Medical Center in Anchorage.

"But I feel the community health aid system could be a house of cards that could come tumbling down with one malpractice case. I don't have a clue how we would provide care in rural Alaska if that were to happen. I fear it has incredible ramifications."

Mandsager also is concerned about recruiting doctors to fill rural positions. Government incentives, such as paying a medical student's $100,000 med school tuition in exchange for four years of service in poor areas, have dwindled or disappeared, in part because of a misperception that the supply of rural-bound doctors was plentiful. Also, the number of doctors reneging on the deal is rising, as many are lured to more lucrative positions or choose exotic specialties over basic family practice.

"Recruitment is a serious issue for the future," Mandsager warns. "Alaska is a tough sell when there's no job for the spouse and it's a small community and the cost of living is high. The cost of living in Nome is a whole lot different than the cost of living in Minneapolis."

Dealing with Differences. There are many reasons for the chronic discrepancies between the health care provided to rural and urban Alaskans, and they are tightly interwoven. The high cost of delivery to remote areas, many of which are marked by high levels of persistent poverty, is exacerbated by declining government aid. Furthermore, health among Alaska Natives has been a barometer of cultural upheaval dating from the turn of the century. Cultural change has exacted, and continues to take, a high human toll in physical and mental health.

Throughout all of Indian Country in America, health care problems are similar. In Alaska as well as Outside, sufficient funding is not available.

According to the Indian Health Service (IHS), Alaska Native health care is funded at 70 percent of need. Comparably, the service reports that care in the Albuquerque, N.M., area is funded at 76 percent of need, and in the Oklahoma area, funding is at 60 percent of need.

Having evolved over three decades of tremendous social and economic change, the Indian Health Service system is considered by many to be a model for attaining cost efficiencies without sacrificing quality of care. Although the system is largely defined and fiscally driven by the federal trust relationship established by Congress through the offices of the Indian Health Service with Alaska Natives, it serves both Natives and non-Natives.

A distinct subsystem has become discernible. Operated by privately and publicly owned enterprises, providers offer services in rural or semi-rural areas, such as the Matanuska-Susitna Valley, Sitka or Cordova, that are not otherwise covered by Native health care contractors operating under Indian Health Service auspices.

The IHS system has three main components: primary, secondary and tertiary care. Primary care includes routine health maintenance and treatment of common or minor illnesses. The care at this level is provided by community health aides residing in the villages, or by physicians, physicians' assistants, dentists, nurses or others who either visit villages on rotation or work out of regional hospitals or health centers.

Secondary care includes routine hospital admissions for common illnesses or injuries, specialist outpatient care and minor surgical conditions or pregnancy. These services are occasionally rendered in the village, but more typically in regional hospitals or at the Alaska Native Medical Center.

Tertiary care involves special services for serious or life-threatening illnesses or injuries. It is provided under immediate direction of a specialist and on an inpatient basis. It often involves major surgery or complex diagnostic procedures.

Although the care at this level primarily is delivered through the Alaska Native Medical Center, private facilities, such as Providence or Humana hospitals, also deliver the care and are reimbursed by IHS. Under the IHS system, Native patient costs are covered by the federal government; non-Natives reimburse IHS for their care.

Catalysts for Change. Another feature of this system is that tribal groups -- from single villages and village consortiums to regional non-profit associations -- are eligible to contract with IHS to administer federally mandated health care. As a result, local people are empowered to manage health care policies more closely tailored to local conditions.

Altogether, 24 Native organizations contract with IHS to deliver health services in both urban, rural and semirural areas. In recent years, many have begun to contract with state agencies to provide services in their areas as well. In all, the IHS/Native contract system operates 7 hospitals and 183 outpatient facilities, 173 of which are village clinics operated under contract by local or regional Native corporations.

The other part of the rural health system largely revolves around 11 regional hospitals in communities ranging from Ketchikan, Wrangell and Sitka to Cordova, Valdez and Palmer/Wasilla. As do many of the IHS or Native-operated facilities, these hospitals refer more critical medical problems to urban hospitals.

Last fall, a rural health conference was hosted by Valley Hospital of Palmer, intended in large measure to increase the dialogue between all sectors of the rural health care delivery system. According to Mandsager, the conference provided an opportunity for rural health workers and administrators to identify common problems. He notes it also helped people learn how the IHS/Native-contracted system has achieved such longevity and generally acknowledged success.

In 1974, when Paul Sherry joined the Tanana Chiefs Conference (TCC) in Fairbanks, the IHS system was still rudimentary in many respects. Many villages didn't have clinics at all. Of those that did, some, though not all, were linked by shortwave radio rather than by telephone to backup doctors.

"In 1975, we didn't have telephones in the villages to conduct medical consultations between health aides and doctors. You can't imagine the degree of difference that telephones make. We had no resources for patient transport," he recalls.

Sherry, now health director for TCC, which serves 40 villages in the huge, remote interior region of the state, says the most profound change in rural health care delivery has been the achievement of local and regional self-determination brought about through contracting to deliver the IHS services. "There are tremendous changes in 15 years. It was the will of the people to make change happen. It provides greater flexibility in using resources. It gives more ownership to communities that are served and brings the decisions on priorities closer to home," he says.

Another important accomplishment has been developing the secondary level of care, largely by providing resources in support of community health aides closer to the villages. The result is a continuum of care stretching from village to city that is able to evaluate and cost-efficiently address many medical needs.

This system has evolved in response to problems that most urban Alaskans don't have to worry about. Says the Alaska Native Medical Center's Mandsager, "I don't think people in urban areas understand what happens when a person in St. Paul gets sick and has to decide whether to travel. That person has to pay $600 air fare just to get started with treatment. That would make a person sit up and take notice. Our financial support for travel has really atrophied over the last few years."

Some patients are able to obtain funds from alternative sources, such as family or charitable organizations, or occasionally loans from local or regional health workers. Those who obtain funds for travel one-way to obtain treatment sometimes find it difficult or impossible to return home.

Compounding the problem has been the reluctance of many air carriers, which cite collection problems, to transport patients who can't pay in advance. As a result, many rural Alaskans defer care, despite a doctor's recommendation to obtain treatment.

A 1991 report by the Alaska Native Health Board, made up of representatives from throughout the state who advise government on health needs, says the "unmet need" for patient travel expenses totaled $4.9 million for fiscal year 1990. The study, which only documented basic and necessary health care services, says 40 percent of patients who need to travel for further assistance are currently deferring treatment because they can't afford the cost of travel.

In addition to the patient travel cost issue, the Alaska Native Health Board has identified a number of high priorities for its 1992 state and federal legislative agendas. Those priorities include replacing the aging Native hospital in Anchorage, increasing and more efficiently administrating funds, addressing a growing rate of turnover in the vital community health aide program and tapping more support for workers in mental health, youth treatment, and behavioral health programs. The board also is seeking additional resources for prevention programs, a route seen as a cornerstone for future health care cost-containment strategies.

Health Issues. One of the most critical problems is village safe water, an issue that graphically illustrates the recurring nature of many rural health dilemmas. In its current report to the Alaska Legislature, the Alaska Native Health Board notes: "Despite advances in arctic construction technology, considerable investment on the part of state and federal agencies in village sanitation projects, and significant improvements in rural water and sewer systems in the last 30 years, the majority of Alaskan villages still have substandard sanitation systems."

According to a health board survey, only 61 out of 140 villages surveyed have adequate household plumbing, as defined by the U.S. Census Bureau; another 66 were served only by washeterias, with residents hauling water to and waste from their homes. Even more alarming, the board reports a survey of 164 (of the total 173) village health clinics shows that 22 require complete replacement, while 47 require major renovations or additions to meet community needs. According to the survey, 24 clinics have inadequate water or sewer systems.

Given the link between contaminated water and diseases such as hepatitis, these kinds of statistics are enough to make the heartiest health planner or practitioner ill. But to veterans such as TCC's Sherry, this is nothing new. The needs always have been acute, and the resources never have been sufficient to get ahead.

"Despite the amount of money that was invested in building facilities in the late 1970s, those investments never fully met the need in the first place. Now, the unmet need figure is staggering, nearly a billion dollars," says Sherry.

And that's just for construction. The high cost of operation and maintenance has made some village water and sewer systems a casualty of recession, as declining revenue-sharing dollars and chronic local poverty made it difficult for local governments to keep systems going.

While medical costs are high all over, they are significantly higher for rural Alaska, regardless of who's paying. Reliable statistics comparing urban and rural health care delivery costs are not available, but professionals familiar with both urban and rural infrastructures offer rough estimates.

"In rural areas, overall costs are much, much higher than in a place like Anchorage. The cost is substantially more, sometimes 100 percent more for comparable services," says David Schraer, a physician and director of patient care standards for the Alaska Area Native Health Service in Anchorage. Schraer says this is equally true of the very remote areas of Western and Arctic Alaska, as well as those communities, such as Sitka, that are relatively closer to population centers.

Business Impact. While health care takes a lot out of the economy, it does put something back, and this is no less true of rural health care. Rural health care services generate business and public payrolls and purchasing in remote communities, as well as in the state's urban centers.

"We buy a lot of health care, as well as provide it," says Sherry. He estimates Tanana Chiefs Conference last year paid $2.51 million in reimbursement to Fairbanks Memorial Hospital for care provided to the organization's constituents; another million dollars was paid to Fairbanks doctors.

In Anchorage, Mandsager says Alaska Native Medical Center last year directly reimbursed local health providers for overflow and specialized services not available through Indian Health Service. He is encouraged that a venerable but vital part of the rural health care system -- the old Native hospital -- will be replaced in the next three years. But Mandsager worries about the potential for malpractice lawsuits and the problem of meeting the letter of medical facility regulations in clinics still operating under relatively primitive conditions.

A source of hope is the potential for health care providers in the established IHS/Native contract system to network more with counterparts in larger, predominantly non-Native communities, and thereby to benefit from decades of dedicated experience. "We've all got things to learn from each other," Mandsager says. "We're too small a state and too fragile a system not to talk."
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Title Annotation:Rural Health Care Report
Author:Richardson, Jeffrey
Publication:Alaska Business Monthly
Date:Mar 1, 1992
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