Alaska
She received chemo in two states. Why did it cost so much more in Alaska?
Ash Adams/KFF Health News
Emily Gebel was trying to figure out why she was having trouble breastfeeding. That’s when she felt a lump.
Gebel, a mother of two children, went to her primary care doctor in Juneau, Alaska, who referred her for testing, she said.
Her 9-month-old was asleep in her arms when she got the results.
“I got the call from my primary care nurse telling me it was cancer. And I remember I just sat there for probably at least another half an hour or so and cried,” Gebel said.
Juneau, the state capital, has about 31,700 residents, who are served by the city-owned Bartlett Regional Hospital. But Gebel said she has several friends who have also had cancer, all of whom recommended she seek treatment out of town because they felt bigger cities would have better care.
Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
She opted for treatment in Seattle, the closest major American city to Alaska. She underwent surgery at Virginia Mason Medical Center in September 2022. In January, she began chemotherapy at Lifespring Cancer Treatment Center, a stand-alone clinic that she said she selected because it offers a lower-dose chemotherapy.
During chemo, she learned she had stage 4 breast cancer, she said.
Commuting to Seattle for chemo every week — nonstop flights last as long as two hours and 45 minutes — became tiring. So Gebel began treatment at Bartlett Regional Hospital after her Seattle doctor taught hospital staffers there how to administer her chemo regimen.
Then the bill came.
The patient: Emily Gebel, 37, insured through her husband’s employer by Premera Blue Cross. She was previously covered by Moda Health.
Medical service: One round of metronomic chemotherapy, which involves regular infusions at lower but more frequent doses and over a longer period than traditional chemotherapy.
Service provider: Bartlett Regional Hospital and Lifespring Cancer Treatment Center. The hospital is a tax-exempt facility owned by the city and borough of Juneau, though most of its revenue comes from the services it provides, according to hospital officials. Lifespring is a stand-alone, doctor-owned cancer clinic in Seattle.
Total bill: The prices for Emily’s chemo infusions at Bartlett Regional Hospital varied week to week. A hospital bill showed one infusion in July was listed at $5,077.28 — more than three times the price for a similar mix of drugs at the Seattle clinic, $1,611.24.
What gives: In the United States, the price for the same medical service can vary based on where it is received. And for those living in remote areas like Alaska, the price difference can put care further out of reach.
Emily’s firsthand experience with this disparity began after her husband, Jered, requested a cost estimate from Bartlett Regional Hospital. It said Emily’s chemo would cost around $7,500 per weekly infusion, more than 4½ times what she had been charged in Seattle.
“The email came through with the bill estimate, and it’s like, ‘Oh my goodness, this has to be wrong,’” Jered said.
Jered said Emily had met her annual out-of-pocket maximum, meaning her insurance would cover the costs of her treatment, but from the start, the disparity just bothered him.
When Emily received a bill for a few rounds of her weekly chemo treatments, it showed that the hospital charged more than triple what the Seattle clinic did for a round of chemo, asking higher prices for every related service and medication she received that week.
The hospital charged about $1,000 for the first hour of chemo infusion, which is more than twice the rate at the Seattle clinic. One of Emily’s drugs cost $714, more than three times the price at the clinic.
It was even the tiniest things: The hospital charged $19.15 for Benadryl, about 22 times the clinic’s price of 87 cents.
Staff at Lifespring Cancer Treatment Center, the Seattle clinic, did not reply to requests for comment.
Sam Muse, the hospital’s former chief financial officer who no longer works there, said Bartlett Regional Hospital officials determined prices by looking at average wholesale prices and what other facilities in the region charge. Muse said the hospital had to account for high operating costs.
“Anything that we charge certainly has to take into consideration … the cost of just supplying healthcare in a rural setting like Juneau,” Muse said. “We’re not accessible by road at all, only ferry or plane.”
Juneau’s isolated geography makes reaching many resources a challenge. The city is part of the Alaska Panhandle, a narrow, island-speckled sliver of the state wedged between Canada, the Pacific Ocean, and Glacier Bay National Park & Preserve. Neither Anchorage nor Vancouver, its nearest major cities, is close by.
The hospital — the only one in the city and largest in the panhandle — treats a small number of cancer patients, at least a few hundred last year, Muse said. Its two oncologists live outside the city and fly into Juneau six times a month, said Erin Hardin, a hospital spokesperson.
Bartlett spent nearly $11 million last year to pay and fly in nurses, doctors, and other staffers who live outside the city, Muse said.
We’re “trying to find that happy medium between keeping care here and keeping costs down and how do we do that in a sustainable way for the long term,” Muse said.
Even though research shows Alaskans seek emergency care and are admitted to the hospital less often than many Americans, they had the third-highest health care expenditures per capita in 2020.
“Alaska is special in that it’s small, it’s remote, therefore it’s more expensive,” said Mouhcine Guettabi, an associate professor of economics at the University of North Carolina-Wilmington who studied health care costs in Alaska when he taught there.
Guettabi said hospitals often need to offer higher wages to recruit doctors and nurses willing to live in Alaska, which has a higher cost of living than most states.
Towns or entire regions may have few specialists and only one hospital, creating a dearth of competition that may drive up costs, Guettabi said. It’s also more expensive to ship items there, including medical supplies.
But Alaska’s costs are higher even when taking all those factors into account, Guettabi said. In Anchorage, for instance, prices for medical items increased nearly three times faster from 1991 through 2017 than prices overall.
Alaska also has a unique policy that may be increasing prices. Its “80th percentile rule” was enacted in 2004 to limit the amount of money patients pay when treated by providers outside their health insurers’ network. But like many experiments meant to rein in costs, the rule has instead been increasing health care spending, according to a study by Guettabi.
“Critics think the rule may be adding to that soaring spending, partly because over time providers could increase their charges — and insurance payments would have to keep pace,” the study noted.
The resolution: Emily received a bill from the hospital in September, more than five months after beginning treatment there.
It said Emily owed about $3,100 even though a previous explanation of benefits said she’d met her out-of-pocket limit.
Jered said he contacted hospital billing officials, who discovered that a medicine had been incorrectly coded and told Jered that Emily’s charge was zero.
“We know how hard it is to pay these ridiculous medical bills,” Jered said. “If I’m able to push back a little bit against this massive system, well, hey, maybe other people can, too. And who knows, maybe eventually health care prices can come down.”
Emily said she’s glad Jered knows how to handle the financial aspects of her care. Like many Americans, she could have just paid or ignored the incorrect bills, risking being sent to collections.
“I can’t imagine the amount of time I would have to spend on it while juggling parenting and also dealing with completing treatment, going through the sickness that goes along with that, and just generally feeling very run down,” she said.
The takeaway: Alaska government officials, nonprofits, and experts have suggested methods to lower the cost of health care. The state is considering repealing the 80th percentile rule and implementing value-based care, which emphasizes paying providers based on health outcomes.
But what should Alaskans and other patients do in the meantime? If you live in a high-cost state, you might check out prices at a health care system in a state next door.
In any case, get ready to advocate for yourself.
Jered learned about medical billing by following the Bill of the Month series and reading “Never Pay the First Bill,” a book by Marshall Allen, a former ProPublica reporter.
Request itemized bills and make sure the codes match the services you received, Jered said. Note any prices that seem outrageous. If you have concerns, arrange an in-person meeting with an official in the provider’s finance department. If that’s not possible, a phone call is better than email. Make sure to document all conversations, so you have a record.
Come prepared with your documents and evidence, including the rate paid by Medicare, the federal insurance system for those 65 and older. Ask the official to explain the reasons for the codes and pricing before contesting anything. You can sometimes negotiate high-priced services down. And remember that the person you’re speaking with isn’t to blame for your health care costs.
“Don’t come at them angry, don’t come at them as viewing them as the enemy — because they’re not,” Jered said. “They are working within the same broken system.”
Emmarie Huetteman of KFF Health News edited the digital story, and Taunya English of KFF Health News edited the audio story. NPR’s Will Stone edited the audio and digital story.
KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
Alaska
Alaska Judge’s Sex Scandal Brings Scrutiny to US Attorney Tucker
The sexual misconduct findings that toppled a federal judge in Alaska will prompt fresh scrutiny of the Biden-appointed US attorney there, according to two of her predecessors in the post and lawyers experienced in similar inquiries.
S. Lane Tucker, the Anchorage-based US attorney since 2022, wasn’t mentioned by name in a judicial panel’s July report that concluded Judge Joshua Kindred had inappropriately sexualized relationships with two Alaska prosecutors, forcing him to resign.
But defense lawyers are preparing to challenge dozens of cases involving Kindred and those prosecutors. Tucker also faces separate complaints to investigative agencies that raise questions about how the office leadership responded to the allegations.
In one, to the independent US Office of Special Counsel, Kindred’s former law clerk claims Tucker and other top managers retaliated against her after she reported the judge’s behavior to them. In the other, public defenders asked the Justice Department’s inspector general to investigate alleged ethical breaches at the prosecutors’ office.
The IG has referred that complaint to Justice’s Office of Professional Responsibility, which reviews attorney misconduct allegations, according to an Aug. 2 letter obtained by Bloomberg Law.
Robert Bundy and Karen Loeffler, Alaska’s US attorneys during the last two Democratic administrations, expect OPR to probe the office, which they said would inevitably include an examination of what Tucker knew, when she knew it, and how she responded.
“It goes to what the US attorney was doing to ensure that her office was following the appropriate rules of professional responsibility and the obligations in the Justice Manual,” Bundy said.
Spokespersons from both investigative agencies declined to comment or acknowledge their inquiries.
A spokeswoman for the Alaska US attorney’s office declined a request to interview Tucker and declined to comment in response to a detailed list of questions.
Xochitl Hinojosa, the Justice Department’s chief spokesperson, also declined to comment for this story.
Kindred’s resignation capped an 18-month inquiry in which the Ninth Circuit judicial panel found he created a hostile work environment, sexually harassed his clerk, and received nude photos from a senior Alaska federal prosecutor.
Both the US attorney’s office and federal public defenders launched internal reviews after he stepped down to identify cases where the judge or the prosecutors failed to disclose or act on obvious conflicts. Prosecutors disclosed at least 43 cases so far, and defense lawyers, poring over past cases, say they’re preparing to seek relief in many more.
That raises the prospect that leadership in the US attorney’s office missed or ignored red flags and now could be forced to reopen dozens of closed cases.
“There obviously was nobody steering the ship,” said Rich Curtner, the longtime former chief federal defender in Alaska, who retired in 2020.
‘Prompt Response’
In a staff-wide July 12 email obtained by Bloomberg Law, Tucker touted her office’s “prompt response” after the former law clerk, whom she had hired as a line prosecutor, first reported in fall 2022 that Kindred had sexually harassed her.
Tucker and her top deputy, Kathryn Vogel, quickly referred the allegations—including the claim about the other prosecutor’s nude photos—to the Ninth Circuit and OPR, according to internal administrative proceeding records viewed by Bloomberg Law.
The office has never publicly said it undertook its own internal review after learning of Kindred’s claim that the senior prosecutor, Karen Vandergaw, sent him nude photos. Tucker later promoted Vandergaw to an advisory role in September 2023.
The judicial panel substantiated that Vandergaw sent the photos and had a “flirtatious rapport” with Kindred in its July report. She was effectively demoted shortly after the report’s publication.
Tucker also initially declined to approve the former clerk’s request to be reassigned out of the district, according to the clerk’s whistleblower complaint with OSC. In a separate filing in the internal administrative proceeding, Tucker said that she viewed the former law clerk as spreading gossip by discussing the nude photos allegedly sent to the judge.
Three legal ethics professors told Bloomberg Law that such a serious allegation should’ve compelled Tucker to initiate her own review within her office, while waiting for OPR to complete its process.
“This is not a situation in which the US attorney should be taking a hands-off attitude,” said John Strait, a professor emeritus at Seattle University School of Law who has run ethics training for the Alaska US attorney’s office.
Of particular concern, given the potential conflicts of interest, was Tucker’s decision to elevate Vandergaw into a role with oversight of more cases during the pendency of the Ninth Circuit probe.
In response to a convicted cyberstalker’s motion for a new trial due to Kindred’s failure to recuse, prosecutors Sept. 3 argued the guilty verdict must stand because Vandergaw “played only a minor advisory role.”
Bloomberg Law’s analysis of the 43 potentially conflicted Kindred matters flagged by the US attorney’s office shows Vandergaw was involved in nearly three dozen of them. Neither Kindred nor Vandergaw have commented publicly since the judicial panel released its findings.
Loeffler, the US attorney in Alaska from 2009 to 2017, said the public attention on Kindred’s misconduct should have turned the ethics problems into a “a nonstop daily issue” for that office’s leadership. “You have to be there every day dealing with the fallout,” she said.
Tucker waited nearly a month after Kindred’s resignation to call an in-person, all-staff meeting to discuss it, said current and former staffers who requested anonymity to discuss internal operations.
A detached leadership style and out-of-state absences have become hallmarks of her two-year tenure, according to interviews with nine current and former employees of the office and three lawyers and law enforcement officials who have business there.
Tucker left Alaska for roughly a third of weekdays in her first year on the job, according to an analysis of travel documents obtained by Bloomberg Law.
“That’s just unheard of,” Loeffler said.
On July 12, four days after the public release of the judicial report about Kindred, Tucker sent a staff-wide email. “It is important for you all to know how proud I am of the ethical compass of our office and the work we do on behalf of our community,” she wrote.
Nine days later, Tucker left the state to attend the Ninth Circuit’s judicial conference in Sacramento. She had initially scheduled to spend an extra eight days of personal time in Palm Springs after the conference, the documents show. It’s unclear if she kept those plans.
Warning Letter
Tucker grew up in Sarasota, Florida, and graduated from law school at the University of Utah. She moved to Alaska in 2002 after working as a government attorney in Washington. She served as an assistant US attorney and then civil chief in the office before moving to private practice at two prominent law firms in Alaska—Perkins Coie and Stoel Rives.
Both firms declined to comment for this article.
Cecy Graf, the former chief financial officer at Stoel Rives, said Tucker was a “force to be reckoned with” and was considered whenever there was a “major decision to be made.”
When she was under consideration for the US attorney’s job, two former prosecutors in the office shared a letter they’d drafted for the Biden transition team with Tucker. The letter urged Alaska’s next top federal prosecutor to prioritize addressing what they characterized as the office’s pattern of discrimination complaints from women attorneys.
They also highlighted a November 2020 decision from DOJ’s internal complaint adjudication office, reviewed by Bloomberg Law, which found “there is evidence that a discriminatory and retaliatory culture existed within the” Alaska US attorney’s office.
One of the letter’s authors, former Alaska federal prosecutor Kimberly Sayers-Fay, said Tucker never responded to her message.
Tucker was confirmed by the Senate in May 2022 to lead the office, a staff of around 50 to 60 tucked inside a tight-knit legal community. Her resume lists 15 years of Justice Department experience—all as a civil attorney, without referencing criminal cases. She discussed her inexperience in criminal law openly with staff after taking over as US attorney, employees said.
Faced with multiple veteran departures, Tucker turned to James Klugman, who had four years of federal prosecution experience, to helm the criminal division at the start of 2023.
Tucker delegated wide-ranging authority to him, while rarely attending criminal meetings herself, said multiple people with direct knowledge of the office’s operations. Klugman was reassigned back to regular line attorney around a year later.
“It sounds like a perfect storm,” said Mark Yancey, a former US attorney who later ran DOJ’s national training academy for prosecutors. “You really need strong leadership in your criminal division.”
Yancey added that his former division, DOJ’s Executive Office for United States Attorneys, could also look into leadership’s response to the Kindred scandal.
Judicial Application
Tucker has already set her sights on her next career move: one of the district’s open judgeships.
In a 2023 letter to Sen. Lisa Murkowski (R-Alaska) expressing interest in the vacancy, Tucker wrote: “I have developed a balanced perspective that allows me to recognize the validity of disparate viewpoints and arguments, treat all with dignity and respect, and resolve problems with fairness and efficiency.”
The Alaska Bar Association rated Tucker as one of the four most qualified applicants for the judgeship.
Murkowski, who had previously praised President Joe Biden’s choice of Tucker for US attorney, declined to say if she also recommended Tucker as a finalist for the previous court vacancy—which is still awaiting a White House nomination.
Both she and the state’s other Republican senator, Dan Sullivan, have called on the Justice Department to investigate the US attorney’s office in light of the scandal.
Alaska
Inmate running for U.S. House seat calls Alaska's News Source from federal prison to talk about candidacy, ballot lawsuit
Alaska
Alaska Permanent adds 26 PE funds to ‘impaired’ list
Alaska Permanent Fund believes 26 private equity funds in its portfolio will fail to return carrying costs, with the system writing down about $147 million in value, according to meeting documents.
The write-down will not impact Alaska Permanent’s private equity strategy, a spokesperson told Buyouts. The system has no plans to shop the funds on the secondaries market.
“To reflect the impairment in statutory net income and fund balance classifications, $147 million of unrealized losses were realized through a write-down of cost to fair value,” Alaska Permanent Fund’s meeting materials read. “These impairments have no impact on the carrying value of investments or on the net increase in the fair value of private credit investments.”
Meeting documents from the pension fund’s September 5 meeting indicated that 26 private equity funds, along with four private credit and two infrastructure funds, would “more than likely” fail to return on the carrying cost over the remaining estimated holding period of the assets.
This is a continuation of a trend that Alaska Permanent Fund saw last year, when 19 private equity funds in the portfolio were determined to be impaired. An undisclosed portion of the 19 private equity funds from last year carried over to the 26 funds identified in 2024, according to a spokesperson for Alaska Permanent Fund.
The impaired funds make up around 0.07% of the Alaska Permanent Fund’s value, according to the permanent fund. A spokesperson told Buyouts that the pension fund will be retaining its existing relationships with the funds and the LP’s categorization of the funds as impaired will not impact their standings.
In its meeting materials, the Alaska Permanent Fund highlighted that it had future funding commitments of $4.2 billion for private equity, along with $1.4 billion for private credit.
The pension fund also reported unrealized gains of $4.9 billion from its private equity assets, after making an additional $35 million worth of investments in the private equity sector compared to last year.
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