The All Alaska Pediatric Partnership, a coalition of providers and state health officials, on July 1 released a study more than two years in the making spelling out the state's top needs and a way forward to meet them by coordinating care, Outside contracts and physician recruitment to keep kids and their families closer to home.

The $250,000 study performed by medical consulting company Kurt Salmon Associates identified 12 strategic recommendations the AAPP is now moving to implement.

The top early priorities are improving infrastructure to keep expanding telemedicine capability, jointly recruiting and interviewing pediatric subspecialists by Providence Alaska Medical Center and the Alaska Native Medical Center, and reviewing relationships with Outside providers to find the best combination of outcomes and cost-effectiveness.

State and hospital officials said pediatric subspecialty care is not a profitable enterprise in Alaska, making cooperation on cost-sharing between Providence and ANMC crucial.

"It has to be supported by both institutions," said Dr. Matt Hirschfeld, inpatient pediatrics director at ANMC, who is working closely with Providence CEO and pediatrician Dr. Dick Mandsager.

Mandsager has been practicing in Alaska since 1985; he was director of ANMC from 2000 to 2004, the state director of health from 2004 to 2006 and the director of Providence children's hospital from 2006 to August 2009, when he became CEO.

"There's always levels of competition," Hirschfeld said. "The big change in the last five years is that collaboration aspects have improved significantly. That has gotten better since Dr. Mandsager has been at Providence. Around pediatric subspecialties, it is very strong. We both see the needs to work together and make it sustainable and viable."

According to the AAPP study, Alaska now has 247 physicians providing pediatric care, with 125 in primary care and 122 in pediatric subspecialties such as cardiology, pulmonology, psychiatry and endocrinology. Eight of the state's 24 hospitals provide pediatric care; 90 percent are served in Anchorage.

Currently about 200,000 Alaskans are younger than 18 years old, according to census data. That number is projected to grow by roughly 20,000 and reach 28 percent of the state total by 2020, according to the study, which reported Alaska needs between 140 and 180 subspecialists to meet its needs.

The study broke down subspecialist needs into immediate (within the next three years), short-term and long-term categories, and proposed a combination of centralized care, outreach and decentralized care based on specialty with hubs in Anchorage, Juneau and Fairbanks.

Mandsager said the study, designed to assess current services, forecast future needs and offer strategies to improve availability, "was helpful was to educate the other partners to a common level of understanding about reasonableness, hopes and dreams and aspirations, and how the future population affects this."

Stephanie Birch, manager of the family health section of the state Department of Health and Social Services, helped start the AAPP 17 years ago while at Providence and will chair a monthly meeting among providers to coordinate subspecialist, nurse practitioner and physician assistant recruitment.

"That is brand new," Hirschfeld said. "We've always kind of known what each other is doing, but now we're dually interviewing people so we can make sure they can function in both systems. The collaboration, whatever that turns into, will really make the recruiting stronger."

Birch will also begin looking at the contracts for Outside provider care to see if cost savings can be achieved. Providence contracts with Seattle Children's Hospital for subspecialty care not available in Alaska, while ANMC usually works with Oregon Health and Science University in Portland.

"We're likely not getting the best bang for our buck," said Birch. "We need to log who has contracts for what and what are we paying. We need to figure out if we can come together and put out a (request for proposals) for everyone and see if we can't get a provider who's really interested or if we can get it for a better price."

Some pediatric care, such as cardiac and cancer surgical specialties, will never be practical in Alaska because of the low volume of patients, but tremendous savings in travel costs could be achieved in other care segments, according to AAPP.

Reduced travel and housing costs could allow for keeping Medicaid reimbursement rates high enough to successfully recruit subspecialists, who are in short supply nationwide.

"That's the theory," Mandsager said. "If we can send a doctor to Fairbanks and save 10 families from coming to Anchorage, those are the conversations we have with the state."

Birch said the state has an "excellent" relationship with Medicaid, which covers 39 percent of Alaska's children, compared to the national average of 27 percent. Counting the 9,000 available for Denali KidCare, nearly half the children in Alaska — about 87,000 — are covered by some form of government funding.

"Medicaid has been a partner in this to decrease the flights, air travel and expenses of having families go Outside," Birch said. "They have also tried to support the physician decision if a child needs to be sent Outside. They're not second-guessing the provider."

Two other important keys to subspecialist recruitment are creating opportunities for medical research in Alaska and developing a pediatric residency program in conjunction with Seattle Children's. University-based medical research is still no more than an idea, but the residency program will begin in summer 2011 with the goal to start residents practicing in Alaska in 2012.

Hirschfeld said studies have shown that half of doctors will practice in the state where they went to medical school at some point, but residency programs can retain 80 percent.

"That is huge for recruitment," he said.

Birch said the AAPP is going for the "low-hanging fruit" in the early stages of implementing the plan to better utilize existing funding from the state and providers. Additional state funding could be needed at some point to fund urgent subspecialty needs, but another strategy recommended by the AAPP study was to establish a fundraising organization to help providers pay the costs.

"Philanthropy is a better source than state grants," Mandsager said. "We're trying to do more of that. We're hoping as we build this network that it will remain stable. We don't want to depend more on the state."

Hirschfeld said staying close to home is the top response when ANMC's surveys its patients on pediatric care, and with continued support from the state and collaboration among providers, meeting the 2020 needs is a realistic goal.