Looking at a map of north Alabama, it is hard to find a county untouched by Huntsville Hospital.

The large, not-for-profit health care provider owns or manages the majority of the hospitals in the Tennessee Valley. David Spillers, CEO of the system, said that isn't by accident.

"If you ask any health care consultant in the nation, they will tell you the health-care systems that are going to be successful in the future are going to be larger, not smaller," Spillers said.

The system's affiliates now include Huntsville Hospital, Madison Hospital, Decatur General, Parkway Medical Center in Decatur, Lawrence Medical Center in Moulton, Helen Keller Hospital in Sheffield, Red Bay Hospital, and Occupational Health Group, which has facilities in Decatur, Huntsville and Madison. The agreements with those facilities range from out-right ownership to management and lease agreements that vary in their terms.

But the intentions of the Huntsville system have been questioned by some. Officials with RegionalCare Hospital Partners have called the expansion a monopoly on health care in north Alabama.

RegionalCare owns Eliza Coffee Memorial Hospital in Florence and Shoals Hospital in Muscle Shoals. It also operates five other facilities scattered across the United States. Those are in Ottumwa, Iowa, Paris, Texas, Sharon, Conn., Waynesburg, Penn., and Wilmington, Ohio.

RegionalCare has proposed a 300-bed, $250 million replacement hospital for ECM in Florence. In September, the company announced it had signed contracts to acquire all of the land needed to build the facility at its first-choice site in east Florence.

But standing in the way of that construction are four Huntsville system-affiliated hospitals that have challenged the certificate of need application for the new hospital. Officials at those facilities contend, according to their letters of opposition filed with the state, that a new hospital could have a negative impact on existing providers.

RegionalCare recently proposed a management agreement with Lawrence Medical Center in Moulton, but ultimately the governing board of that hospital chose Huntsville Hospital. At the time, a RegionalCare official said Huntsville would begin shutting down services at the small, rural hospital.

"Fundamentally, we believe health care is best when it is delivered close to home," said Jeff Atwood, vice president of communication with RegionalCare. "It is important that people are able to receive the care they need close to home and not have to drive 50,60 or 70 miles to get it."

Members of the Huntsville system said when they signed on with Huntsville, they weren't handing over the keys.

Helen Keller Hospital CEO Doug Arnold said since signing the management agreement with Huntsville Hospital in October 2010, the hospital has not lost any services.

"In fact we have expanded services to include open MRI, which was secured through Huntsville," Arnold said. He said Helen Keller Hospital can now "make available certain premium heart implant devices."

That doesn't mean trips to Huntsville or other large health-care centers will be eliminated. There is a place in the health care landscape for those, he said.

Spillers said specialists need a "critical mass" to maintain a high-level of expertise. That means they can't be at every facility, he said.

"Our relationships through these outlying communities allow us to enhance our services and be better at what we do," Spillers said.

"We believe being part of the Huntsville Hospital System allows us access to patient services not regularly available in smaller metros," Arnold said. He listed those services as some heart procedures, trauma services and speciality children's services.

There are services not available anywhere in the Huntsville system, which is intentional, Spillers said.

"We don't do pediatric heart surgery," he said. "I don't believe you should cannibalize other people to the point that they can't be good at something. We have no ego when it comes to sending patients to other facilities. We like to support those facilities because we want them to be good at it when we do have a patient that needs that service."

Spillers said what Huntsville has is far from a monopoly.

"We don't have anywhere near a monopoly in the services in health care that actually make money," he said. "Primarily the areas that make money in health care are surgery, imaging and physical therapy. You can look across north Alabama and see surgery centers, imaging centers and physical therapy centers everywhere."

Arnold said being aligned with a larger systems provides for more efficiency. That is particularly true in the business side of health care.

"We have taken advantage of (Huntsville Hospital) network services such as cash cycle management, contract audits that saved $200,000 this year, purchasing of joint implants, saving $650,000, decision expertise, legal services, shared laundry and the ability to recruit executives, nurses and physicians to the Shoals area," Arnold said.

Huntsville Hospital Health System has built a large distribution center in Huntsville. In it are rows and rows of supplies that can be trucked across north Alabama when needed.

"Buying in bulk saves everyone in the system financially," Spillers said. "We've also found savings opportunities in the business office side of health care by consolidating some billing and collection services. We have been able to concentrate expertise in those areas that you likely wouldn't be able to do in a single, smaller hospital."

That is important as reimbursements from Medicare, Medicaid and private insurers decrease in Alabama, he said.

The benefits of purchasing in bulk and the stability associated with being part of a larger entity are not being questioned by RegionalCare, Atwood said. Instead, he said, he worries about accessibility at the local level.

"There is a greater value in people having a choice in health care," he said. "I think anytime anyone tries to control all of the care in an area, that will impact the level of services available."

Spillers said it is not their goal to eliminate services. He said he believes more services will be offered in smaller facilities as technology advances.

"As technology changes, more services will be located out in those facilities," Spillers said. "The newer procedures may be concentrated here."

As for where Huntsville Hospital Health System will go next, Spillers said there are no deals currently in the works. He said the hospital has a few informal relationships with facilities in north Alabama that might lend themselves to a more-defined agreement down the road.

"Almost every market we have gone into, we have been invited in," he said. "I think that happens because the community looks at what we've done — we've treated everyone that has walked into the doors and offer services they can't get elsewhere — and invite us in to see if we can help them."

Jennifer Edwards can be reached at 256-740-5754 or jennifer.edwards@TimesDaily.com.