How the Nuka System of Care has improved the quality of medical care (and lives) of Alaska Natives

Much of what you read here is about the parts of our health care system that cause so much pain–physically, mentally and financially–for millions of Americans every day. We write about the greed that drives so many business practices and the need for lawmakers, regulators, employers and unions to address them in meaningful ways. Most of what we weigh in on pertains to Washington, D.C., but that certainly is not where all the action is. 

Going forward, you will find reports and commentaries from across America–what is happening at state and even local levels you should know about, including what employers are doing to free themselves from the shackles of big, for-profit insurers and their pharmacy benefit managers. So in a very real sense, it will be the fulfillment of our commitment to solutions journalism. 

This first piece, by veteran journalist Bob Hetherington, fits perfectly in the solutions journalism framework. He’ll take you to Alaska to report on a continuing success story that is improving access to care while also lowering costs and enhancing the quality of care and life for thousands of Alaska Natives.

— Wendell Potter

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Health outcomes among Alaska Natives once ranked among the world’s worst. The widespread population includes Anchorage, its surrounding area and 55 rural villages scattered across a service area the size of Sweden.

But health and care have changed so dramatically there since the 1990s that providers and policymakers from around the world are studying Anchorage and the nonprofit Southcentral Foundation (SCF), whose Nuka System of Care delivers highly rated outcomes for a high-risk population at roughly half the average per-person cost of systems across Alaska and the United States of America.

“We have radically, dramatically reduced cost as we produced way better outcomes. The happiness of people using the system and working in the system are both very high,” SCF’s executive vice president Dr. Doug Edy explained during a podcast for a Swedish audience. “So, happier people on both sides of the equation, and dramatically better outcomes at lower costs. It’s kind of what people have been looking for in health care and modern medicine.”

The community-based Nuka System is among initiatives that are remaking America’s health-care system from the ground up, said Dave Chase, co-founder and CEO of Health Rosetta, a nonprofit dedicated to accelerating the pace of transformational change.

“The Nuka model produces stunning outcomes. And from Singapore to Sweden, health care and policy experts visit what many consider the best health-care system in the world,” Chase said.

The Southcentral Foundation is the only U.S. health-care concern to receive the nation’s top award for excellence, the Malcolm Baldrige Quality Award, two times, once in 2011 and again in 2017. And in July 2023, the foundation was named to the Mac Baldrige Society, whose members serve as trustees of the Baldrige Foundation’s Institute for Performance Excellence.

SCF executives assumed responsibility for the health-care system formerly run by the federal government through the Indian Health Service in the late 1990s, when the system employed just one Alaska Native.  

They kept the best practices of modern medicine. And they literally changed everything else, integrating those best practices with Alaska Native’s values and the wisdom of the elders.

“Modern medicine is a pretty paternalistic, professional-centric enterprise, for the most part,” Eby said. “You have diagnosis, labs, X-rays, pharmaceuticals, and treatment plans. Then Medicine thinks it has done its part and it is up to the individual to implement. And when they fail, we call them non-compliant. 

“We turned all that on its head.” 

He explained:

“Instead of calling the people receiving care ‘patients’, we call them ‘customer-owners’. We believe, deeply, they own their own health journeys. They control the variables. They control whether to take the pills. They control what they eat. Whether they use alcohol, tobacco or drugs. What their sleep habits are. How they exercise, handle frustrations and any conditions….

“Our value proposition in business terms is by establishing personal, effective and trusting long-term relationships and by becoming very good at coaching, advising, mentoring, encouraging, cheerleading and cajoling them to make changes for better health.”

The Nuka System is now four times larger than the previous health system and provides care to more than 70,000 Alaska Natives and others across a sprawling area and an additional 30,000-plus statewide. 

It operates on a no-excuses model to serve remote villages without on-site medical professionals. For example, all their members had access to Covid vaccines via plane, boat or sled (in the Alaska winter) by the end of January 2021.

And now, about half of its 2,700-person workforce are Alaska Natives.

Over time, the Nuka System has reduced emergency room and urgent care visits by 50% and hospital admissions by 53%.

At the same time, the Nuka System has provided childhood immunizations 93% systemwide, and customer and employee satisfaction now ranks above 90%.

“One of the statistics, which is true in pretty much every developed country in the world, is that 5 to 10% of the population drives about 50% of the cost,” Eby explained. “And our system is at its most effective with the most fragile individuals and most complicated of health cases.”

The Nuka System focuses on understanding everyone’s unique story, values and influences, according to the foundation, which provides core training to the entire staff in Alaska Native storytelling culture.

Customer-owners use stories to relate to their health and their treatments. They make care decisions with their families and their care  teams, which include social workers and behavioral specialists. 

This focus on individual history, self-image and relationships helps care team members identify and address social determinants of health, such as access to housing, food and safe neighborhoods.

The foundation’s approach enabled it to reach the 95 percentile in national standards of diabetes care, for example, and to achieve an overall 98% patient satisfaction rate.

So far, representatives from nearly 900 organizations and 33 countries have studied the Nuka system for best practices.

Bob Hetherington writes about health care change agents. He is an MBA-equipped communications consultant and a national award-winning business journalist, who has contributed to The New York Times, USA Today and others.