Re-Release: The Nuka Blueprint (feat. April Kyle & Dr. Doug Eby)

TRANSCRIPT

Click here to listen to the episode published on August 4, 2026.

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APRIL [INTRO]: What does it look like to question how healthcare operates, who its drivers are, who's in charge — and if you flip that and decide that families know what families need, and we're going to give families the keys to the car and let them be the drivers, what do you end up with? 

DOUG [INTRO]: We're walking with, we're partnering with, we're supporting. We're not doing things to people, we're not doing things for people — that puts us in power and them on the dependent side of the equation.

APRIL [INTRO]: So the control sits with community, and we're asking for our healthcare institution and the people who work in it to rebalance to a role of shared responsibility and partnership.

DOUG [INTRO]: What we've done is take the best known practices from literally all over the country and the world, pull them all into a single system that aligns with our principles, and execute them at full scale with obsession for 25 years.

JOHN: Thanks for joining us for another episode of Moving to Value Unscripted. My name is Dr. John Rodis, and I'm a recovering ex-hospital president and the president of Moving to Value Alliance. Our mission is to advocate for a value-based healthcare ecosystem with the highest quality outcomes at a reasonable cost for our communities. I want to thank our members who make this podcast possible. We'd like to give special recognition today to our trade member, Connecticut Joint Replacement Surgeons. We're joined today by my fellow board members, Lisa Trumble and Dr. Steve Schutzer. Lisa is the CEO of Southern New England Healthcare Organization, a physician-led, clinically integrated delivery system in Connecticut and Massachusetts. Steve, a nationally renowned arthroplasty surgeon, is one of the founders of MTVA and co-founder of Upswing Health. We are thrilled to be joined today by two very special guests who have an amazing story we're eager to share. Welcome to Moving to Value Unscripted, Dr. Doug Eby and April Kyle.

APRIL: Hi, John. Happy to be here.

JOHN: Thank you, April.

DOUG: Good to see you.

JOHN: Thank you, Doug. Thank you so much — I can't tell you how excited we are to have you here. Daryl Moon has been talking about you guys, and of course I've been hearing about it, as we all have: the Nuka System and the South Central Foundation, in Alaska. Everyone says it's one of the best health systems in the world, and I know people all over the world come to visit. Our listeners are dying to hear the story. So maybe, Doug, if you want to just start — give us a little bit of your journey, how you got from finishing residency in family medicine to somehow ending up in Alaska in the first place. And then transition into a little bit on Nuka — how it got started, what it was like before, and what it's like now.

DOUG: So I had the usual medical training of a physician in the U.S., and came to Alaska in 1990 — 35 years ago now. At the time, the Alaska Native Medical Center was run by the Indian Health Service, by the government. I was a family practice doctor, but I was put to work in what was called the emergency room, which was essentially where everyone went — a big, huge walk-in clinic, everything from heart attacks to earaches. Not really much of a system design, and pretty much no acknowledgment of the fact that there were tens of thousands of people living locally, in addition to it being a hub for the whole state. So within a few years, we'd done a lot of work to redesign the whole outpatient area, create actual primary care, redo emergency services, and so forth — a lot of good work using something called TQM and CQI. Then in the mid-90s, it became apparent that the whole system was going to move from federal management to tribal ownership and management, as permitted under federal legislation. And that started the journey of transitioning from looking internally for answers to instead following the lead of the people for whom the system exists — what we call customer-owners, the Alaska Native people, who took actual formal ownership but also, in our case, became the teachers and leaders of how we designed and recreated things from there. I'll turn it to you, April.

APRIL: My name is April, and I'm serving as our president and CEO — I've been here for 22 years. I am Alaska Native; my family's from the native village of Nanwalek. While Doug was working in that ER, my family was using that old health system, the hospital run by the federal government. It wasn't the best place in Anchorage to go — it was underfunded, there weren't ways to access care other than through the emergency department. And we had this great opportunity to decide, as a community, that we wanted to own and operate our own healthcare system, which came from the Indian Self-Determination Act, passed in the '70s. All across the nation, Alaska Native people and American Indian people were thinking, maybe we want to do this differently — what would it look like if we operated our own services? We're a product of that. It's sort of a grand experiment: what does it look like for a community to lead, operate, run, design, and imagine what they would want their healthcare to be? We're just a part of that in Alaska — there's a whole tribal health system, a regionalized system, and we're one of the regions, the one based in Anchorage, so we're the region with the biggest population. We provide the local and regional services and cooperate with our tribal partners across the state. What people come to learn from us about is whole-system transformation — what does it look like to be willing to really question how healthcare operates, what it's based on, who its drivers are, who's in charge? And if you flip that and decide that families know what families need, and we're going to give families the keys to the car and let them be the drivers — what do you end up with? That's the journey we've been on for decades.

LISA: What a unique opportunity, to be able to take a community and work with the community to design a health system. Can you talk about what that experience was like for you all — how you went about it, what kind of ideas came out of it, and a little more on the journey to where you are today?

DOUG: I was hired by the CEO at the time, Katherine, around '94, '95 — several years ahead of the actual transfer, which happened mostly in the later '90s. So by the time the transfer of ownership happened, I was chomping at the bit to get going. Katherine and I, and the community, had lots of conversations — we pretty well knew what sorts of things we were going to do. But Katherine was very wise, and said the first thing we were going to do was a very extensive listening process. For six months we didn't change anything. We did tens of thousands of surveys, thousands of people in focus groups, a thousand one-on-one interviews with anyone who wanted one — four months of a very thorough listening process, then two months collating the millions of data points we got. Out of that came something called operational principles, which we created in the late '90s from all of that input, and that's still how we run the company today. If things people want to do align with the principles, we're likely to do them; if they don't, we're not likely to do them. They're detailed enough that you can take an idea and score it against them — 13 or 14 points, describing in detail exactly what people said would work and wouldn't work for a system: relationship-based, immediate access, continuity, based in story, building on strengths, easily accessible, measured and accountable, coordinated, no duplication, and built around what's best for the people using the system rather than the people staffing it. A powerful process and a powerful product that's driven pretty much everything we've done for the last 25 years. When people ask us what they should do first, we often tell that story and say: first, listen longly and deeply and thoroughly to the people for whom you exist — that's not your staff, that's the people receiving services. It's important to listen to your staff too — the people other than the community who know best are the people directly interacting with the community all day, every day, generally not the executives in the executive suite. So a lot of staff input as well, but at the end of the day, primarily the voice of the community.

STEVE: Just a follow-up question — was that fortuitous, that the government just said, "let's transform from federally managed"? What was the incentive for them to do that?

APRIL: Yeah, Steve, the history is that it's hard in a podcast to really talk about the harms that came to Alaska Native and Native American people on this continent at the hands of our government. There was an opportunity historically for tribes to interact with the U.S. government through treaties, and one of those treaties said Alaska Native and Native American people would receive healthcare — so the government has a treaty obligation to provide healthcare to many people. They created this branch of government called the Indian Health Service. The reality is the government's never fully met that treaty obligation or fully funded the IHS, and there was a lot of criticism about how those services looked. Congress looked at that, and the congressional findings in the '70s acknowledged that the underfunded IHS system was causing harm rather than creating wellness for Native people. It opined that perhaps if the community receiving those services had a voice, or even better could lead those services, they could create systems that would really improve the well-being of their own people. So it was a really unique opportunity in the '70s, but it came out of the federal government never meeting its responsibility to indigenous people.

STEVE: And this was a national transition from federal?

APRIL: Right — the Indian Health Service was operating across the U.S., in places where Alaska Native and Native American people are, and the Indian Self-Determination Act gave tribes and tribal organizations the opportunity, if they wanted, to contract or compact in order to receive those federal dollars and design their own healthcare system. It played out differently in different places. In Alaska, Alaska Native people said, "we want to do that — let's figure out how." And we decided to do it collaboratively as a community. In the beginning, that base funding, the IHS money that came to us, was the majority of how we operated. Over time that's been flat-funded, and we've grown and are funded more like everybody else — Medicare, Medicaid, third-party payers — so we're really interested in what's happening at a federal level with Medicaid and changes to how people are paid. We operate more and more like anybody else in the healthcare market. Our difference is that we consider our driver, our voice, our leader, to be community — everything we do, change, or try is based on what people and families need. And the question is: how has that worked? When you look at the primary care system we've developed and the outcomes we've created, that's why people like you reach out to us and say, let's talk — what have you done? 

DOUG: There's a number of people in the U.S. who have the idea that if we could just move to a single-payer system, or to community-driven healthcare, all the problems would magically be solved. That's just not true. In our case, we're vertically integrated, all our money is under our control across all the different pieces, and we're community-owned and community-driven — but the real secret sauce is what you do with that. It creates possibilities that don't otherwise exist, but it's not magic in itself. Most tribally operated places and most community health centers, FQHCs, are in control of their own destiny and locally governed, and they don't all magically produce the results we have, because the culture and ethic of modern medicine is also very dominant. Pretty much everyone who works in healthcare has been trained in the modern medical model, and that model is incredibly institution-centric, professional-centric, negativistic, and judgmental — we've moved away from all of that. Even if you get community ownership, vertical integration, and single-payer, if the medical model remains dominant, you still have huge problems. I'm a doctor — I sometimes joke that from the beginning of my training to the end, it was basically how to take a two-and-a-half-hour history and physical and put it into ten minutes. That's only half joking, because that's essentially what you're taught: how to take the human out and put the technical in. So a process in an exam room looks like — first, I can't even talk to you if I'm not in an exam room, which is ridiculous. Second, you come in, we don't know each other, in a few minutes I get what I need, I tell you your diagnosis, then I tell you what you're going to do: take these pills, change your life this way, come back and we'll see how you're doing. And when you show back up and haven't done exactly what I told you, I call you "non-compliant" in a condescending, judgmental, arrogant, institution-centric way — which is horrible. Instead, for us, it's a journey. People live their lives in context over time. We make it so they can always see the same people, and we've guaranteed same-day access for over 25 years. Now we've moved on to the concept of immediacy — if we're not in contact with you within a few seconds, you'll give up on us and do something else, because we live in a culture of immediacy, so we need to respond to that: phone, text, email, video, or in person, they drive how they interact with us, and we accommodate them — 70 to 80%, even before COVID, was being done virtually and essentially asynchronously, because they control how they connect, and we guarantee access whenever and however they want, to the people who know them. So every conversation is part of a single story over time. What we've done is take best proven practices from literally all over and put them into this philosophy, run on principles, not rules — and then we've executed. That's a big part of our story: actually having done what a lot of other people just talk about, and pulling it together into one system that actually works, based on the philosophy April's articulated, that our entire system is built on.

JOHN: You remind me a little of — I was just listening to Dr. Chen, who started ChenMed. His two sons, you may know, wrote a book called "The Calling." When Dr. Chen started his company, his idea was: how many patients can I see in a day? I'm not suggesting this is your model, but he said, "I think I could see 20 patients a day," and then, "but I want to see them every month" — so if I see a patient every month, how many patients can I have in my panel? The math worked out to 450, so he started with 450 patients and saw them every month, because his idea was to help people build trust and get to behavior modification, which needs that relationship over time. After four or five, six months, patients get that — you've got my interest in mind — and hence his company, ChenMed. So let's put a little meat on the bones of what the model actually looks like — who's the provider? Doug, to your point — I've said this on other podcasts too — most of us learn diagnosis and treatment in medical school. We don't talk about prevention, we don't learn about nutrition, sleep, stress, the continuum of disease — just diagnosis. I say diabetes, you say metformin. I say hypertension, you say ACE inhibitors or beta blockers. We're taught diagnose-and-treat, not the continuum. And listen, I learned in medical school that Native Alaskans have a lot of health problems — prone to diabetes, obesity, suicide, alcoholism, the dark winters. So you guys didn't exactly start with a healthy population. Tell me about what the model really looks like — the nucleus of care. I get immediate access, people contact you, they call you, they get in quickly, or they communicate by text or phone. How did you get them out of the emergency department to this model?

APRIL: I'm going to tackle that, John — I'll start a little broad, and then we'll dive into what our current clinical service delivery model looks like in this longitudinal relationship primary care model. Doug, I'll ask you to fill in some of the details too. But I just want to comment that what we know is that communities, families, and peoples are very good at understanding what their needs are and at designing solutions — our people have been doing that for generations. So there's this idea that if you empower communities and ask them, "what's happening for you in your life, what do you need, what if we could be your partner?" — it requires that the competency you build as an institution is the competency of being in relationship. Those relationships happen at many levels. First, you can't just say you're community-owned — what does that mean practically, how do you be led by your community? That macro-level ownership matters, and you have to acknowledge there's no single right clinical service delivery model, because the needs of your community are forever evolving. So the relationships are what let you continually hear what your community needs — how our community interacts with us is going to change, we're interacting by cell phone more than phone calls now, so how will our healthcare system meet what our community needs in the future? The answer is, A, creating the way to be in relationship to hear from community, and B, innovating based on that direction. It's very hard in the U.S. when the pressures driving you are all the regulations, accreditation, how you're paid, risk of litigation — we manage all of that risk too, we're just not letting it be our driver. So that macro-level relationship matters, and so does the competency of being in relationship at a micro level — how we think about a family and who they interact with in our system, and how we create touch points so that story can be shared and that relationship can be built, so we can walk in somebody's journey with them in a positive way. We've invested a ton in how we do that within the primary care model. So if we can dive down into primary care, Doug, do you want to take a bit of that?

DOUG: Yeah — the core competency needs to be trust, coaching, influence, and partnering with people. That's not how I was chosen to go to medical school, and it's not what I was taught in my clinical training, including my family medicine residency. So we have to own training and teaching that competency to all of our staff, which we do in a very sophisticated way — we don't replace clinical competencies, we add to them, in a different package. Our teams today have 40 to 70 touches per day, but only 10 to 12 of them are in person on any given day, because we've built a system off of how they want to connect with us, and it turns out they don't really want to come to our exam room most of the time — and if we've known them forever, we don't need them to. Our panels run around 900 to 1,000 — we think that's too big, ideally 700 or 800, but that's what we can afford; our per-capita spend is well below the national average. From the beginning we created panels, case management, care coordination — every provider had a full-time nurse case manager from day one — and we moved, over six months, from weeks of waiting to guaranteed same-day access, five days a week, to your primary care provider and case manager. We've done that for 25 years. Then we pulled in additional resources over time. The next thing we added was behaviorists — not co-located psychotherapists, but behaviorists doing cognitive behavioral therapy, short-term practical problem-solving; if you want psychotherapy, we have behavioral health clinics we send you to. By moving to that basic underpinning, you drive down the need for specialists, ER and hospital use, lab, pharmacy, and X-ray — but you drive way up behavioral health. We have arguably the biggest, most sophisticated behavioral health system, with programs from residential to crisis, addictions to psychotherapy, family therapy — the whole range, at maybe five times the usual scale — because when you go deeper, there's no "here's a symptom, here's a pill" anymore. We're deep into generational trauma, depression, anxiety, parenting, marital stuff — the deep stuff that drives health outcomes for practically everybody. That's where we live, and our people have to be skilled at it. But total cost goes way down and health outcomes go way up. Earlier on, our whole population was in the bottom fifth percentile for pretty much every HEDIS outcome measure — screening, prevention, chronic disease management. I went to the board and said I wanted to set the 50th percentile as our goal, which is ridiculously high from where we were. The board said, "so you want to be average?" I said yes, because we're nowhere close. They said, "we don't want to be average" — so for 25 years, the goal has been the 75th percentile. After all this time, we're achieving that, with maybe two measures where we're not quite there — we've reached the 75th to 90th percentile on pretty much every chronic disease, prevention, and screening measure, about 75 measures we benchmark to. We've moved an entire population from the bottom fifth to the 75th to 90th percentile while driving down total cost, with satisfaction ratings at 96, 97, 98% positive — even asking things like whether their culture was valued, whether they're an active participant, whether they own their own health journey, things most health systems don't even ask. Staff retention and positive feedback run about 95%, turnover well below industry averages. Happier people on both sides of the encounter, less total cost, very expensive primary care but way less total system cost, better retention, dramatically improved outcomes. It actually works better, and while our story is specific to us and some things are culturally specific to Alaska Native people, these basic principles and approaches work anywhere in the world there's a healthcare system. It solves many of the evils of the modern medical system. April, anything to add?

APRIL: No, I'll just say the experience from the perspective of community has really been night and day. In a system where we used to access the ER and the hospital, we've decreased ER utilization and hospital stays and lengths of stay. We're redefining what "primary" really means. Our vision is a Native community that enjoys physical, mental, emotional, and spiritual wellness. We think far too often the medical model focuses just on physical wellness, and we know our wellness is multidimensional — it's no longer okay to say, "don't worry, we have behavioral health, it's in that other building over there, for that one uncle in your family." Instead we're saying what's primary is really your whole self — and not only your whole self, but that we journey in life with others, and our wellness is impacted by others. So we're thinking about wellness for people, for families, and for communities, and our interventions look like intervening individually, involving family, and being part of the fabric of community. When we think about what our Nuka System is, it's really beyond just healthcare — it's about how people live, and what our role can be in helping people live with more balanced, multidimensional wellness.

DOUG: Right. We've evolved this over 25 years, and where we started is no longer where we are. The first big addition was all those behaviorists, and they continue to be completely fundamental. Primary care is primary care for medical, for mental, for social services, all in the same place — you call the same number, which is your team, by the way, you don't even call the front desk, you connect directly to your team. The case manager has what's called a case management support person, one for every team, and they're the traffic cop — all the phone, email, text goes to that person, who sits right by the nurse and the provider, and they decide together who to pull in for what. Over time we decided to start pulling expertise into the hub instead of sending people all over the place. After 25 years of evolving this, we think we've reached the proper balance — you can't co-locate everything, eventually it becomes unwieldy. But we pulled in the high-volume, high-frustration stuff, and we right-sized all our clinics — we used to have big monster clinics, and we broke them up. The sociology of the workplace tells you that you can run on family dynamics up to about 15 staff, team dynamics up to 70; over 70 you become a bureaucracy by definition. So all our clinics are 60 to 70 people — five or six primary care teams plus associated staff. In our main building in Anchorage, we have nine identical primary care clinics in one building — you always go to the same place, always see the same people, so as far as you're concerned there's one clinic, but there are actually nine, all identical. In every clinic there are five or six teams of four people: the provider, the nurse, the case management support person, and a CMA who helps move people in and out of rooms.

JOHN: And Doug, let me interrupt for a second, just so I'm clear — the provider is a family medicine physician, a nurse practitioner, or internal medicine trained?

DOUG: About 80% are family physicians. We have one or two general internists, and several very high-end PAs or nurse practitioners who started with us in other roles, turned out to be superstars, and now manage a panel just like the physicians do. We also support over 60 remote villages — we can come back to that as another topic; delivering healthcare to rural and remote locations is a worldwide challenge, and we're world-class at that too. In every clinic there are four or five teams. Ideally there'd be a behaviorist for every team, but we haven't figured out how to afford that yet, so we're at about a two-to-one ratio — two or three behaviorists per clinic, two or three midwives, since pregnancy is a primary care condition here — all pregnancy up through moderate risk is handled in primary care, with midwives helping the teams. All ages are seen — children, elders, women's health, everything — so there's a pediatrician in every clinic, one for every 5,000 to 6,000 total population, who helps with complex children and helps the generalists catch developmental delay or autism early, because catching it early can completely change a child's trajectory. There's a dietitian in every clinic, a PharmD-level clinical pharmacist in every clinic — by mandate, every elder on five or more medications gets a pharmacist review, because polypharmacy in elders is a massive but generally resolvable problem if we get smarter. Pharmacists are tremendously underutilized in healthcare generally, but not here. There's also a structural social worker in every clinic — not a clinical social worker, but a logistics social worker handling placement and logistics for frail people. And our behaviorists — we started out thinking we'd hire a bunch of psychologists, but it turns out clinical social workers are the best behaviorists, because they're willing to do short, practical work instead of long-term psychotherapy, though we do have some psychologists and family therapists too. Shared across the nine clinics, there are four psychiatrists — by having psychiatrists help generalists manage psychiatric issues, they can triple the caseload they can handle, and you never have enough psychiatrists, so it's hugely impactful to put psychiatry right into primary care. There's a fellowship-trained pain doctor with ten years of experience, a very high-end pain specialist who does diagnostic workups, and a psychologist with 30 years of chronic pain experience helping generalists manage people living with pain for life — massively impactful. We've also put addiction expertise into primary care, and we have home visitors — teams in every clinic who extend the primary care team into homes, rather than a separate standalone home health agency, with a particular emphasis on high-risk families with newborns and children under two. We've taken on parenting as part of what we teach everybody, because society sucks at parenting.

JOHN: Most important job we all have, with the least education.

DOUG: Yeah — the idea is we're taking responsibility for everything that matters to healthy families and healthy multi-generational realities, and pulling all these experts physically into primary care. All the other "-ologists" — cardiologists, pulmonologists, gastroenterologists, dermatologists — are somewhere else, but they support the whole tribal system, which means they're used to doing phone and video consults for generalists, and they respond quickly, which cuts in half the people referred to them and keeps the work in primary care through phone and video connectivity. I think AI is going to make a big difference here too, helping generalists get to specialized knowledge when they need it. We refer to specialists 65% less than we used to, and the whole thing works as a network, pulling information, people, and support toward where you are.

JOHN: And those specialists aren't — if I gathered what you said, it sounds like they're "separate." Do you mean they're also not employed by the Southcentral Foundation?

DOUG: The ones physically in our space — psychiatrists, pain, and so on — are salaried the same as everyone else. The others are primarily employed by our sister company, which operates the in-hospital, adult surgical, and medical subspecialty services. They're on the same campus, but half a mile away or so, and they support us virtually — we can send people to them if need be, but because they work in a system, they cooperate with us, and everybody's on salary. I in particular, but our system as a whole, think individual pay-for-performance is evil, corrupting, and deprofessionalizes people, and it needs to be avoided at all costs. Let me take a breath there — see what April wants to add, and what questions you have.

APRIL: I'll just add that there's a tension between how much to integrate into primary care, how big any one primary care clinic should be, how to sit in relationship within a clinic, and when the right time is to refer to a specialist — that's a tension we've played in for a long time, figuring out the right balance. There's a whole bunch we can do when we bring expertise to a generalist team, and that generalist team is expert in the relationship — the relationship is what's most important. There are times you're going to need to see a cardiologist, so the relationship between the primary care practice and the cardiology practice matters — a service-level agreement where the two sides talk about what's expected, what happens before the referral, what it will include, and how the person gets pulled back into primary care afterward, where that longitudinal relationship sits. We haven't hit as hard on how we think about relationships structurally across parts of our system — that's been an important, if imperfect, part of our journey, something we've worked really hard at.

JOHN: Over time, of course, your primary care providers are getting smarter through that relationship with specialists — and as Doug said, I think AI might start accelerating that even more.

APRIL: If we use psychiatry as an example — we began by co-locating psychiatrists, physically working in the primary care clinic but with their own caseload. Then we piloted integrating them differently: instead of psychiatrists delivering care directly, their customer group became the primary care teams, and they provided consult services and case reviews to primary care. What you find is that a primary care provider in good relationship with a family can manage a certain amount of complexity, try a certain number of depression medications independently — but with a colleague in the practice to confer with, the level of complexity they can manage is much better. And you don't lose people to what we call "the stairs" — you don't refer them somewhere else in the system they never actually get to, because you've brought that expertise into that environment. The expertise that exists in primary care, whether through those providers or their colleagues, really improves the delivery of care. It leads people to look at our system and ask, how could you ever afford that? And the answer is: think about what it would look like to have really robust, strong primary care, and how you'd save money in other parts of the system. There's a lot of talk about what that could look like — very few places you can actually see it, in practice, over decades.

LISA: Yeah — it's just tremendous what you all have built over time, embracing the core concepts of whole-person care and integrating everything into primary care. I believe completely in what you're saying about behavioral health — if you don't have access to those resources, you can't attack the medical conditions as well. I come from a previous system where we had integrated behavioral health, and we were fortunate — it's remarkable what can be done with primary care and behavioral health together. But as I was listening to you describe what you've built — do you think your model is portable to other places in the country?

DOUG: This is portable literally everywhere, especially everywhere the medical model exists, which is like 90% of the earth. We just had our big international health conference that we throw every summer — people came from Singapore, Sweden, Australia, New Zealand, all over Canada and the U.S. for a deep dive with us for a week. Singapore is arguably the most efficient, cost-effective system in the world, and starting 15 years ago, their primary care system for complex individuals became a pretty much exact clone of ours after spending a lot of time with us. So it's definitely portable anywhere. The problem is most of the powers that be in modern medicine don't like us — we use less pharmacy, less lab, less X-ray, less specialists, less ER, less hospital, and at least in the U.S., that's not financially popular with anybody. Part of the reason we have a positive margin every year is that we decrease cost by more than we give up in revenue — we probably give up 20 to 30% of the revenue we could make if we forced everything into visits, but we save 30 to 40% of per-capita spend by driving down all the expensive stuff. So our margins are great, but because of decreasing cost. Healthcare doesn't really understand this — it says it does, but it just keeps trying to increase market share and throughput, use Six Sigma to drive out waste, which is fine, but that's not the core problem. The core problem is the wrong model.

LISA: How did you pivot economically to be able to afford the level of resources you have in primary care and behavioral health? And what's it like to recruit the right talent into your model?

APRIL: I think it required us to be willing to imagine a different model, to grab onto the principles that were going to matter, and to give up other things that existed in the system. We had, you know, nurses who were "the specialist" of this or that, and we did away with a lot of that — which was hard for people, because those were their babies. We put all our eggs in the primary care basket. And you asked, so what does it mean to hire people into that? I think even before that is: how do you walk with your current employees who are transitioning into that new way of thinking? Doug was part of that — it took a lot of strength. And then we got really good at figuring out our core workforce competencies, our values. I hope what you're hearing is we're pushing against the hierarchy of modern medicine, where the healthcare system is in control and people and families are patiently waiting to be recipients of something. We want that control to shift — the control sits with community, and we're asking our healthcare institution and the people in it to rebalance to a role of shared responsibility and partnership, bringing your expertise but valuing equally the expertise the family brings to that relationship. So we had to get good at figuring out who's aligned with that way of thinking. It doesn't mean if you like to golf, you take Fridays off — this isn't a provider-centric model. Even when you join us, what we're doing goes against how you were trained, how you learned to practice before, so we help you onboard into the system. We spend a lot of time intentionally walking with people, thinking about how we sit in relationship with each other. There are no physician lounges, no doctor's offices — you are a partner with the community member and the case management support person on your team. What does it look like to be in relationship with that person? That's a lot of the work I do that I really enjoy — we're investing in that workforce being ready for it. If I can add one thing — it's a task to change the culture of healthcare into this Nuka system of care. It takes intentionality, and we work at it every day. But that's actually easier than reorienting a community to its relationship with an institution of healthcare — that orientation happens generationally, over time, as people feel that sense of ownership and responsibility, that they're in the driver's seat, that they have voice, that they can tell us what they want out of their healthcare system. It's exciting to see us increasingly achieving that different relationship between community and system. 

DOUG: We didn't leave that to chance — for 10 years after we took over, we very directly used newspapers, radio, websites, every kind of way to message that the role of the individual, family, and community was different in this system, and staff had to learn what was different too. Everyone had to relearn the system — it took a decade.

JOHN: Yeah — you changed the paradigm. You changed the whole model.

DOUG: It took 10 years. There was a bit of a generational thing too — if you were under 30, you were like, "well, finally, about time."

JOHN: That's what my kids say.

DOUG: If you were over 50, you kind of said, "this is not what going to the doctor's like, I don't like this." The other thing we haven't emphasized much — April's alluded to it a couple of times — is the massive infrastructure underneath all this. We spend five to ten times more on primary care than the usual system, and ten times more on workforce development and training — we have a whole building dedicated to it, over 150 courses we formally teach. Everyone goes through a three-day core concepts training, which April directly leads as CEO every single time — it doesn't happen if she's not available. Then pretty much everybody takes coaching courses, motivational interviewing, and tons of technical courses, including a whole infrastructure around using computers and electronic health records optimally, which is massively underdone in healthcare generally. We have about ten times the usual amount of improvement staff — about 45 full-time improvement advisors and specialists across the system, supporting four to seven different projects at any time, which means somewhere between 75 and 100 major improvement projects happening across the company at once, even 25 years into this. About 15 years ago we bumped into the Baldrige framework, which was really important — healthcare thinks if you do operations well and measure and give feedback, the rest takes care of itself, which isn't true, and Baldrige makes that very visibly not true. It expects you to put as much energy into leadership, strategy, customer voice, corporate culture, data, workforce, and knowledge management as into operations — healthcare doesn't understand that; even an IHI conference is 90% operational design, safety, and measurement. So starting 15 years ago we beefed up the areas we weren't as strong in. We're still the only healthcare organization in the entire United States to win the National Presidential Award in Baldrige twice — we were a finalist last year too, almost won it a third time, didn't apply this year, we'll apply again next year. They don't hand it out for being cute and interesting from Alaska.

JOHN: Yeah — for our listeners, and having thought about it, Steve was being humble earlier, but the joint replacement program he started was 99% outpatient, and included patient-reported outcomes for a year after surgery. I thought about Baldrige for that unit specifically. For listeners who aren't familiar — not only did you guys win it twice, nobody wins the Baldrige twice, I think maybe the Ritz-Carlton has. It's an unbelievable accomplishment. I want to segue for a moment to the hospital — I'm a hospital guy, I ran a hospital. I remember when we interviewed someone who had a great primary care practice, and the hospital in town bought them, and soon after shut the operation down because they were so good — they were reducing hospitalizations, costing the hospital money. You guys did the opposite — you ended up essentially owning a hospital, though you didn't own the hospital from the beginning. Tell me about the hospital piece — it's got to be a little different than what we've talked about so far.

APRIL: Because we were designing a tribal health system to serve Alaska Native and Native American people living across the state, our model was to create regional tribal health organizations — we're one of those, where the local community owns and leads the development of services and decides priorities. But some regions have very small populations and don't have the economies of scale for a full continuum of services — some have small hospitals, but every region refers into the statewide hospital, and that statewide hub is in Anchorage, same as our hub. So rather than a big regional hospital and a separate statewide hospital, we put the two together — we're on the Alaska Native Medical Center campus. Our partner there, ANTHC, operates the statewide services, and we operate some of the statewide services plus all the primary care — and their board of directors is made up of all the regions. So rather than a corporate hospital system running the little things, you have the regional community system running the big hospital — it's really the opposite. We think the individual services we deliver matter, but so does the relationship between services and how we think about continuum planning.

DOUG: Just to follow April — part of the maturation of our system over time has been increased, conscious investment in leadership development, workforce, coaching, training, improvement capability, and also deepening our capabilities around very high-complexity, high-risk subpopulations. We've built out what I believe is one of the top five pediatric and adolescent neurodevelopmental clinics in the U.S. — for autism, brain injury, fetal alcohol, we have a whole integrated multidisciplinary team, in addition to your primary care provider, with a lot of in-home and in-school capability built in. We have something called intensive case management, using bachelor's-level clinical social work to come alongside people with long-term mental health challenges who'll never live fully independently — very small caseloads, and again, they don't replace primary care, they deepen the support available to help people navigate life. These are people who'd otherwise often be homeless or in emergency rooms — very expensive to the health system — and we've dramatically reduced their total cost by doing this. Traumatic brain injury is a whole under-recognized, under-treated, massively expensive category we have a whole approach for. We've quadrupled the size of rehab — PT, OT, exercise physiology — and added chiropractic, massage, and acupuncture, so we build in complementary and alternative medicine. We provide reviewed and approved vitamins and supplements. We have tribal doctors and traditional healers who work with people who don't have so much physical findings as they are, in a sense, "soul sick" — not classic mental health — and they're expert at partnering with that subgroup of people. We've got all the usual stuff too — maternal-fetal medicine, gynecology, oncology. Our OB-GYNs are mostly gynecologists who do a little high-risk OB; actual labor and delivery is pretty much midwife-dominated, we're very midwife-centric, with 70 to 80% of pregnancy happening in primary care and only the really high-risk stuff going to OB or maternal-fetal medicine.

JOHN: Unlike the lower 48. You have a low C-section rate, I'm guessing.

DOUG: We have close to the lowest in the United States — around 11, 12%. It's low, but we don't want to be dangerously low — it's one of the things we track and worry about, because our staff take pride in not doing sections, to the point where sometimes it might be a little risky. So our problem is worrying about too low a C-section rate, not the other way around. A couple other things — we de-officed everyone about 15 years ago: no doctor's offices, no offices for executives or managers, everyone's right in the mix of the work. If you can't see, feel, and hear the work in real time, I don't know how you manage or supervise it — seems obvious, but it's lost on most places. As April mentioned, we eliminated disease-specific clinics and disease-specific nurses, because we can't afford them — we put all our eggs in the everything-for-everybody, whole-person, whole-family bucket, because most healthcare runs three parallel primary care systems in the same system: disease-specific, whole-person, and home visiting. We can't afford three paradigms, so we're all in on one. The principle-based approach to management is sometimes called "tight-loose-tight" — we obsess about philosophy and principles, that's the high tight, and we obsess about outcomes, that's the low tight, but so long as you produce the outcomes and stay philosophically consistent, we're loose about how you organize your team, handle your work, structure your day. You get a tremendous amount of freedom, which re-professionalizes the professionals — sometimes called complex adaptive systems theory, and we're pretty expert in all of that, which goes back to running on principles rather than rules. For example, staff often want a rule like "more than 10 minutes late, you get rescheduled instead of seen" — that's stupid, because it's the people who have the hardest time showing up on time who most need us. We also changed the words — "customer-owner," because they own their health journey and make choices like a customer. We hate the words "compliant" and "non-compliant," unless we're talking about whether staff is compliant with the wishes of the person receiving care. We try to eliminate words like "caring for" — modern medicine talks about caring for people all the time; we're walking with, partnering with, supporting. We're not doing things to people or for people — that puts us in power and them on the dependent side. Modern medicine is rampant with negativity and paternalism, and we're trying our best to eliminate it, because they're in control, they're in charge — we're guests at their table, offering safe and reasonable alternatives, support, and cheerleading. But they own their journey. Guests at their table — that is not "caring for" or "doing to" people.

JOHN: You should start a medical school.

DOUG: Well, the Institute for Healthcare Improvement asked me 15 years ago to write a white paper on the future of medical school education — they asked about 20 faculty to write these, hoping to attract more academic medical centers to the IHI club. I wrote mine, thought it was completely brilliant, but the title was "Why Medical Education as It Currently Exists Should Be Abolished," which was not very good for attracting academic medical centers, so they didn't use it but I thought it was completely brilliant.

JOHN: I'm sure it was. Doug, I want to finish one thing you mentioned earlier about Alaska, for us lower-48 types — I'm in Connecticut, a tiny state, but if I have it right, Texas can fit twice in Alaska. So even though you're in the "South Central" region, it's still a pretty large, spread-out geography, and you have villages that can't easily get into the hub, into Anchorage. How do you manage those?

APRIL: The answer is that we partner with the local community — they establish a health council representing various families in different parts of the community, which becomes our on-the-ground governance for their clinic. We work with them on the budget, the type of employees, clinic hours, all the things around how it operates. At a macro level, we as leaders spend a lot of time sitting with and listening to community — the investment in listening and being with community as executives is way more than I've found among any of our peers. And we have a modified model — we're not going to have family physicians in 55 villages in our region, so it depends on the size of the village. In a sub-regional clinic we might have advanced practitioners; in a very small community, we have what are called community health aides — community members who've decided they want to become their local healthcare providers. We've created a training program, across the whole tribal system, not just us, where somebody can start as a trainee, get training and clinically supervised hours and experience, work under a certain amount of autonomy based on that training, and be the primary care delivery system. Our smallest communities have maybe 48 or 55 people, accessible only by plane. So it's a matter of working with community on what they think healthcare delivery could look like for them locally, being responsive to their ideas, and designing a very small healthcare system connected to that sub-regional hub and to Anchorage. About 60% of our primary care teams in Anchorage are connected to a village, and they're the everyday connection to the community health aide there — an appointment might surface a red flag, and the aide reaches out to their Anchorage team about it. Decisions get made about whether that person comes into the sub-regional hub or into Anchorage, based on complexity, and we also notice the frequency with which a community might need someone to travel in — so we'll run specialty clinics with Anchorage-based folks coming in for a three- or four-day trip. That's how we deliver dental services, for example — we don't have full-time dental providers out there, so they do community trips throughout the year. We haven't talked a lot about rural and remote, but I think remote in Alaska is a whole new category — traveling in a tiny plane with a lot of heavy dental equipment.

DOUG: All around the world, governments struggle with getting healthcare to rural and remote locations, and their favorite answer is to bribe doctors, nurses, and pharmacists to go live somewhere they don't want to live. That model fails all the time, everywhere, and yet it keeps getting perpetuated — you go to conferences on rural and remote healthcare and everyone's trying to figure out how to bribe providers into living where they don't want to live. It's not sustainable, it's failed for decades. Instead, you do what April described — find people who already live there and want to live there, who are willing to be trained up, and then you support them. The urban healthcare system has to take on, as part of its obligation, the support of rural and remote healthcare. Almost all of our primary care providers have one, two, or three villages, and all day, every day, those villages get same-day access to them — but the people on the ground, even brand-new health aides, are the actual primary care providers, and our urban people are the support. Health aides have five levels of certification — by the fifth level you're basically at physician-assistant level, but the early levels are simpler and need all-day, every-day phone and video support, which our urban people understand is part of their job. We also do telepharmacy, which is pretty cool — every village has a bulletproof vending machine stocked with medications. The health aide sees the person, enters the needed medication into the computer, the physician in Anchorage concurs, the pharmacist in Anchorage remotely controls the machine, which drops the medication and label, the health aide puts the label on in video view of the pharmacist, shows the pharmacist the meds, and hands them to the person — with the Anchorage pharmacist managing that inventory remotely from up to a thousand miles away, with support from the physicians. It works extremely well. That's the answer to rural and remote care everywhere — find people who already live there and want to, and figure out how to support them delivering the service, with the urban system on the hook for making it happen. Especially today, connected through cell towers — it changes the whole landscape.

JOHN: But we're still trying to do it the old-fashioned way in some ways.

DOUG: Most of our villages, we can do X-rays, take pictures of eyeball funduses and eardrums and skin, listen to breath and heart sounds, all through phone and video connectivity. My favorite village story — we have these carts with all this technology, built to be plug-and-play components, because when something fails you just unplug it and send in a new one, since we can't afford to send repair people a thousand miles into the villages all the time. We learned that early on. But my favorite story: a brand-new clinic was built way down the Aleutian chain, and it got super cold — way below zero — and the brand-new furnace quit, six months into a new clinic. It needed warranty work or you'd lose the warranty, so people were panicking, thinking the whole clinic would freeze and break. The husband of the health aide said, "I'm kind of a know-it-all, do-it-all handyman — how about you get the technician in Anchorage on the video cart?" So the health aide wheeled the video cart into the furnace room, used the camera we normally use for ears and throats, and her husband took instruction from the certified repair person in Anchorage and got the furnace running again — saved the whole clinic.

JOHN: Robotic surgery from afar. I love it, I love it — that's a great story. Listen, we've taken a lot of your time, guys — by tradition, I'm going to let Steve ask the final question. Steve?

STEVE: You know what, I'm going to take my prerogative here and just ask one burning question I've had for the last hour. I think this is an important message for our listeners — one of the goals of these podcasts, even when we're talking about problems, is to be inspirational, to inspire young people and old people to do something positive. The message over the past hour has been very inspirational, but this has been burning in my mind: you folks were given an opportunity in the '90s, during the transition from federal to tribal ownership, but not everybody did what you did — there's only one Nuka. I have kind of a founder's mentality, and I want to understand the DNA, the thought process of the founders. As Seneca said, luck is when opportunity meets preparation — it's not totally luck, but you were given some latitude to build something. From the founder's perspective, what inspired that vision 30 years ago?

APRIL: Steve, that's a really good question, because the easier thing to do is replicate what you already know healthcare to be — the harder thing is to imagine something different. I think what happened was embracing the idea that community, that people, that families should really inform how we redesign the system, that we're going to listen to their voice. Doug described this listening process — and I hate to call it a "community needs assessment," because that's something a grant tells you to check a box on; this was really going out and understanding from people what they need out of a healthcare system. When we did that, community told us their priorities were domestic violence, child abuse, neglect, addictions — things that had nothing to do with the old medical model. It forced us to think differently about how we were going to interact with community, and it's important that that learning from community became the way we do business — continually asking and listening, redesigning and innovating based on how communities are experiencing their lives and wellness, and understanding how we can be welcomed as a partner in their story. If we do that, it means everything Doug described about our current clinical service delivery model is amazing, but more important than that is our willingness not to be the experts who know exactly what healthcare should be, but to be expert in listening to community and letting community drive what we do. That should mean if you don't come back to Alaska for 10 years and then you do, you'll see the system has changed — we've improved and changed the service delivery model because our community's needs have changed, but the principles are the same: that customers own the system, that we hear their voice because we invest in relationship at a micro to macro level, that we check the boxes that keep us accredited and avoid litigation risk, but the driver is what the people tell us to do. We're flipping the idea that we're the experts who'll judge in 15 minutes whether you're compliant — we're asking community to give us direction, showing them what we did with it, and asking, did we get it right, were we compliant with your direction? And the answer is always "not quite, keep working on it, this is what we need" — that's our forever journey of relationship and improvement with community.

STEVE: That's something in your collective DNA that may not be innate everywhere, because not everybody's done what you folks have done — kudos to you and your vision. We do have a tradition as we wrap these up, where we usually ask what your vision is for the next three to five years in U.S. healthcare — but for you folks, I want to tweak that a little. If the IHI really gave you the latitude to redesign U.S. healthcare, informed by everything you've learned over the last 25, 30 years, where would you start, and what would you do?

APRIL: I think we have to ask ourselves whether we're fundamentally willing to change how we see our role as executives, leaders, and policymakers in healthcare — whether we think our job is to have the expertise to design the system, or whether we're ready to walk away from our own perspective in order to understand the perspective of community, to really understand how communities receive our system, because until we do that, we can't redesign it to meet their needs. I don't know if we're ready to think that big as a country, but I'd sure like to be part of that conversation if we are.

DOUG: I just want to echo April — the core question is, for whom does this system exist? It does not exist for universities and medical schools, it does not exist for the doctors and nurses — it exists for the people who receive services from the system. Baldrige says no matter what your product is, it's product-ignorant — you say what you're trying to accomplish, and it tells you all the elements you have to pay attention to in order to succeed, and core to that is obsessing about what the customer wants, no matter what you're producing. In our case, we're trying to produce services that support people on their health journey, which requires obsessing over what they want, what they need, what they determine as their own goals and aspirations, and how we use all of our training and expertise to support them on that journey. What we've done is take the best known practices from literally all over the country and the world, pull them into a single system that aligns with our principles, and execute them at full scale, with obsession, for 25 years.

JOHN: Amazing. Doug and April, I can't thank you both enough for joining MTVA — and on a broader scale, for what you've done over all these years, showing us that there's a better way to do this. Down here in the lower 48 and around the world, I've seen people from New Zealand, Australia, Iceland come see you, rave about it, and try to bring it back to their own countries — and I wish we could just do it here. It sounds like we could, but it takes that determination, that obsession, and most importantly, a focus on the communities we serve — well, "serve" is even the wrong way to say it. I'm getting it.

DOUG: Who we are accountable to.

JOHN: I'm getting it. Thank you so much for joining us.

STEVE: We really appreciate it — we'll be seeing you soon.

JOHN: Yeah, absolutely — we're going up there. Not to fish, we want to get an orientation. Road trip.

STEVE: Road trip.

APRIL: Come to our conference, we'd love to have you

JOHN: It's every summer, right?

APRIL: It's every summer, we do it in June. The material's fun, but what's really fun is the cohort of people who choose to come — the cool, innovative thinkers who show up make it a great conference, even though it's a small one.

DOUG: Yeah, but our daughter and a couple of her friends and I caught 104 fish on Saturday, so there's a little bit of fishing too. 

JOHN: That's great. Thank you guys, thank you so much.

JOHN: To learn more about MTVA and how to join our community, visit our website, movingtovalue.org. If you enjoyed this conversation, please follow us and leave a review on Spotify or Apple Podcasts. Thanks again for listening and for being part of this important movement.

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