Legislature(2009 - 2010)CAPITOL 106

03/30/2009 08:00 AM EDUCATION

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
Moved CSHB 58(EDC) Out of Committee
+ Bills Previously Heard/Scheduled TELECONFERENCED
HB 204-POSTSECONDARY MEDICAL EDUC. PROG.                                                                                      
8:04:50 AM                                                                                                                    
CHAIR SEATON announced that the  first order of business would be                                                               
HOUSE BILL  NO. 204,  "An Act increasing  the number  of students                                                               
pursuing  a  medical  education who  are  provided  postsecondary                                                               
educational  services   and  programs;   and  providing   for  an                                                               
effective date."                                                                                                                
8:05:16 AM                                                                                                                    
SAMUEL  DIX,  Staff  to Representative  Nancy  Dahlstrom,  Alaska                                                               
State  Legislature,  informed  the committee  that  the  Wyoming,                                                               
Washington,  Alaska,  Montana,  and  Idaho  (WWAMI)  program  has                                                               
evolved  to provide  three out  of four  years of  medical school                                                               
education within  Alaska.  According  to a 2006  Alaska Physician                                                               
Supply  Task Force,  Alaska ranks  17   lowest in  the nation  in                                                               
terms  of physician-to-population  ratio.   The  task force  also                                                               
estimates that  Alaska has 375  fewer doctors than needed.   This                                                               
shortage  is likely  to worsen  as Alaska's  population increases                                                               
and ages.   Furthermore, one-third of the  state's physicians are                                                               
likely to retire  within the next 10-15 years.   Mr. Dix told the                                                               
committee that at this time 50  percent of Alaskans who enter the                                                               
WWAMI  program  ultimately  practice   within  the  state.    The                                                               
aforementioned  percentage increases  to almost  90 percent  when                                                               
WWAMI graduates from other states are included.                                                                                 
MR.  DIX  explained that  during  the  first  year of  the  WWAMI                                                               
program  students study  at the  University of  Alaska Anchorage,                                                               
whereas in  the second year  students from all five  WWAMI states                                                               
study at  the University  of Washington's  School of  Medicine in                                                               
Seattle.    The  third  and  fourth years  of  study  consist  of                                                               
clinical  clerkship   and  rotations   in  the   various  medical                                                               
specialty areas.  He noted that  these clerkships can be taken in                                                               
any  of  the  five  WWAMI  states.   However,  the  Alaska  track                                                               
provides students the  ability to complete nearly  all third- and                                                               
fourth-year clerkships  in the  state.  Mr.  Dix stated  that the                                                               
overall  goal of  the program  is to  incrementally increase  the                                                               
amount of students to 30.   At this time, only an additional four                                                               
seats are being asked for  because that's all that the University                                                               
of Alaska  Anchorage can handle  with its current  facilities and                                                               
8:07:09 AM                                                                                                                    
REPRESENTATIVE  GARDNER noted  that she  was a  supporter of  the                                                               
past legislation that  doubled the number of  students allowed in                                                               
the WWAMI program.  However,  the House Finance University Budget                                                               
Subcommittee discussed  that the  strongest indicator of  where a                                                               
student will practice  medicine is the location  of the student's                                                               
residency.   Therefore,  the real  impediment  to increasing  the                                                               
number of  new physicians  in Alaska  is having  enough residency                                                               
spots in Alaska.   She asked if the sponsor  has explored what it                                                               
would take to simply offer more spots for residency.                                                                            
MR.  DIX pointed  out that  three out  of the  four years  of the                                                               
WWAMI  program are  spent in  Alaska.   He then  highlighted that                                                               
since  the  inception  of  the   WWAMI  program,  the  number  of                                                               
physicians practicing in Alaska has increased.                                                                                  
8:09:09 AM                                                                                                                    
SUZANNE  TRICK, Regional  Program Director,  School of  Medicine,                                                               
University  of  Washington,  stated  support for  HB  204.    She                                                               
informed the committee that prior  to doubling the class size for                                                               
the Alaska  WWAMI program,  Alaska ranked last  in the  nation in                                                               
the number of  medical school seats per person.   Although Alaska                                                               
isn't  at the  bottom, the  state still  ranks low  and thus  the                                                               
state has  a need  for more  medical school  slots in  the state.                                                               
Ms. Trick  then noted  her agreement  with the  earlier mentioned                                                               
notion that students practice where  they receive the majority of                                                               
their  training.    She  pointed  out  that  Alaska  only  has  a                                                               
residency program  in family medicine  and thus there are  only a                                                               
few types of  residents that can be captured for  training in the                                                               
state.  Therefore,  the state needs physicians  in more specialty                                                               
areas than  family medicine.   Ms.  Trick informed  the committee                                                               
that  she is  working on  a residency  program in  pediatrics and                                                               
psychiatry,  as well  as rotations  in internal  medicine.   Many                                                               
WWAMI residency students  rotate in Alaska in  order to determine                                                               
whether Alaska  is a site at  which they would like  to practice.                                                               
The WWAMI  return rate of nearly  9 out of 10  physicians is very                                                               
high.   In  fact,  it probably  exceeds  most residency  training                                                               
programs that place physicians on the ground.                                                                                   
8:12:26 AM                                                                                                                    
MS. TRICK, in response to  Representative Gardner, clarified that                                                               
for  every 10  physicians the  WWAMI program  pays for  about 8.8                                                               
initiate  their  practice  in  Alaska.     Of  those,  5  of  the                                                               
physicians are from Alaska and 3.8 start in another WWAMI state.                                                                
8:12:47 AM                                                                                                                    
REPRESENTATIVE GARDNER asked if  there are impediments that could                                                               
be removed to improve the residency numbers.                                                                                    
MS. TRICK  said that there are  three areas of barriers.   First,                                                               
the  ways  in  which  residency   programs  are  financed.    She                                                               
explained  that  residency  programs are  usually  financed  with                                                               
federal  funds as  well  as funds  from the  state  in which  the                                                               
program  is  located.   However,  since  the federal  funding  is                                                               
capped,  the  program  is constantly  working  with  the  federal                                                               
government  regarding the  number  of residents  they will  fund.                                                               
Second,  there  have  to  be  enough  physicians  and  volume  of                                                               
patients  for  residents  to  receive  adequate  training.    The                                                               
aforementioned  is  particularly true  in  specialty  areas.   In                                                               
areas such  as internal medicine,  there aren't enough  people to                                                               
train  residents.   The  third  barrier  is technical  assistance                                                               
residency  programs  take   a  long  time  to   develop  and  the                                                               
accreditation process  takes a  year after  the site  and faculty                                                               
are identified.   Ms. Trick  said that  at this point  she didn't                                                               
see anything that she would recommend changing.                                                                                 
8:14:43 AM                                                                                                                    
MS.  TRICK,  in response  to  Chair  Seaton, explained  that  the                                                               
family practice designation  once was similar to  being a general                                                               
practitioner.    She explained  that  family  practitioners do  a                                                               
three-year    residency    training   program    while    general                                                               
practitioners generally don't.  She  noted, "We don't really have                                                               
general  practitioners much  anymore."   In  further response  to                                                               
Chair Seaton,  Ms. Trick informed  the committee that  [the WWAMI                                                               
program] is training  in primary care, which is  needed the most.                                                               
Furthermore, [the  WWAMI] program  is training "the  most primary                                                               
of primary  physicians."  In  response to  Representative Wilson,                                                               
Ms.  Trick  clarified that  family  medicine  is a  primary  care                                                               
8:17:22 AM                                                                                                                    
REPRESENTATIVE EDGMON  inquired as  to where the  physicians that                                                               
don't initiate a practice in Alaska go.                                                                                         
MS. TRICK deferred to Mr. Valenzeno.                                                                                            
8:17:51 AM                                                                                                                    
DENNIS  VALENZENO,  Director,  Alaska  WWAMI  Program;  Associate                                                               
Dean,  Medical  and Pre  Medical  Program,  University of  Alaska                                                               
Anchorage,  informed the  committee that  Alaska WWAMI  graduates                                                               
who don't practice in Alaska  may practice anywhere in the United                                                               
States, although there  may be a higher  percentage practicing in                                                               
WWAMI states.  He noted his  agreement that the primary factor in                                                               
determining where  medical students  practice is the  location of                                                               
the  student's residency.   However,  the  second most  important                                                               
factor  is where  the medical  student  attended medical  school.                                                               
Therefore,  he indicated  the need  to capitalize  on the  second                                                               
8:20:24 AM                                                                                                                    
REPRESENTATIVE  KELLER  related  his understanding  that  HB  204                                                               
would cover four  students.  He inquired as to  the percentage of                                                               
the total tuition cost covered by HB 204.                                                                                       
MR. VALENZENO explained:                                                                                                        
     The budget for  WWAMI is a two-part budget.   The first                                                                    
     year is  at the  University of  Alaska Anchorage.   The                                                                    
     normal cost  for a medical  school nationwide  is about                                                                    
     $75,000  per year  per  student.   In  the first  year,                                                                    
     because of  some economies of  scale at this  point, we                                                                    
     will  be able  to  increase  to 24  just  based on  the                                                                    
     tuition  that  our  students   pay  as  our  additional                                                                    
     compensation.    That's  about  $20,000  per  year  per                                                                    
     student.    Years two  through  four,  the budget  runs                                                                    
     through   the  University   of  Washington   School  of                                                                    
8:21:46 AM                                                                                                                    
MS. TRICK then explained:                                                                                                       
     For  years two  through  four, the  cost  that you  pay                                                                    
     represent  the  state  support for  medical  education.                                                                    
     It's about  $56,000 per  year per student.   On  top of                                                                    
     that the students pay tuition of about $20,000.                                                                            
8:22:11 AM                                                                                                                    
REPRESENTATIVE  KELLER  related   his  understanding  that  those                                                               
students who  do not  return to  Alaska receive  this money  as a                                                               
loan, and therefore have to repay the state in full.                                                                            
MS. TRICK  clarified that 50  percent of state support  becomes a                                                               
loan that  would have to  be repaid  if the student  practices in                                                               
another state.                                                                                                                  
CHAIR SEATON  surmised then  that in years  two through  four the                                                               
state support is  in the amount of $56,000 per  student per year.                                                               
Fifty percent  of that amount is  a loan, which would  have to be                                                               
repaid  if the  student doesn't  [practice]  in Alaska.   If  the                                                               
student  returns  to Alaska,  the  complete  loan forgiveness  is                                                               
three years for  those who [practice] in an  urban setting versus                                                               
five years in a rural setting.                                                                                                  
MS. TRICK stated her agreement.                                                                                                 
8:24:08 AM                                                                                                                    
SHELLY HUGHES,  Alaska Primary  Care Association,  stated support                                                               
for  HB  204,   primarily  based  on  the   shortage  of  medical                                                               
professionals that exist  in Alaska.  She opined  that if nothing                                                               
is done  to reverse the  trend, certain  areas of the  state will                                                               
face a  public health  crisis.  Therefore,  the provisions  in HB
204 that get WWAMI graduates in  some of the harder to fill spots                                                               
are something the Alaska Primary  Care Association supports.  Ms.                                                               
Hughes  informed  the  committee  that the  Alaska  Primary  Care                                                               
Association  represents  primary  care providers  throughout  the                                                               
state, particularly  watching out  for those  who are  safety net                                                               
providers.  In  the last three weeks, there has  been turnover in                                                               
about  28 of  the 32  physicians in  the community  health center                                                               
system.   In  fact, there  are currently  about 22  vacancies for                                                               
physicians.  The incentive to stay,  to pay off an obligation, is                                                               
very  favorable.   Furthermore,  the  longer  a  person is  in  a                                                               
community,  the  more  likely  he/she  will  stay.    Ms.  Hughes                                                               
characterized HB 204 as a step  in the right direction.  However,                                                               
the shortage of  physicians means that the state  should not only                                                               
look to  grow its  own physicians  but also  to import  them from                                                               
Outside.  The  physicians in the safety net  health center system                                                               
makeup  about   2  percent  of  the   physicians  statewide,  but                                                               
represent 10 percent  of the vacancies.  She  highlighted that it                                                               
takes health centers  one year to eighteen months to  fill one of                                                               
these  vacancies.    Furthermore,  the  patient  load  in  health                                                               
centers  has increased  by 57  percent [between  2000 and  2006].                                                               
She  informed the  committee that  statewide the  vacancies range                                                               
from 11-27  percent, with  the lower vacancy  range in  the urban                                                               
areas while  the highest vacancy  rate is in the  tribal clinics.                                                               
Some  of  the health  centers,  she  mentioned, are  also  tribal                                                               
clinics.  She  highlighted the cost of recruiting,  which is over                                                               
$100,000.    Therefore, cultivating  WWAMI  graduates  is a  cost                                                               
savings to  the health  care system.   In conclusion,  Ms. Hughes                                                               
reiterated support for HB 204.                                                                                                  
8:28:21 AM                                                                                                                    
CHAIR SEATON asked whether WWAMI  graduates currently work in the                                                               
health  clinics.   He  also  asked  if  the Alaska  Primary  Care                                                               
Association specifically recruits WWAMI program graduates.                                                                      
MS.  HUGHES  related  her  understanding  that  there  are  WWAMI                                                               
graduates working in [the health care centers).                                                                                 
8:28:55 AM                                                                                                                    
REPRESENTATIVE  GARDNER  inquired as  why  the  patient load  has                                                               
increased by 57 percent in the last six years.                                                                                  
MS. HUGHES  attributed part  of the increase  to the  increase in                                                               
the  number of  health care  centers.   Furthermore, health  care                                                               
centers  accept patients  regardless of  the patient's  insurance                                                               
status.   Ms. Hughes  predicted that even  more people  will seek                                                               
care at health care centers  due to the current national economic                                                               
situation.   In further response  to Representative  Gardner, Ms.                                                               
Hughes  related  that  the  most   cost  effective  ways  to  get                                                               
physicians and other  health care providers into the  state is to                                                               
provide loan  repayment program.   Loan repayment is  included in                                                               
HB 206, in  a sense, because the obligation is  reduced.  An even                                                               
better  incentive is  in  the  form of  cash,  which would  reach                                                               
beyond the  pool of graduates  to experienced graduates  and thus                                                               
increase  the  pool  of  physicians.   The  Alaska  Primary  Care                                                               
Association  is  supporting  another piece  of  legislation  that                                                               
utilizes the direct incentive of cash.                                                                                          
8:31:58 AM                                                                                                                    
REPRESENTATIVE WILSON  recalled that  in her district  there used                                                               
to  be an  intern program  for  family practice.   However,  that                                                               
program is no  longer due to the lack of  population in the area.                                                               
She asked if such a program is happening elsewhere in the state.                                                                
MS. HUGHES  answered that she  wasn't aware of any  such program.                                                               
She  informed   the  committee  of  a   federal  Student/Resident                                                               
Experiences and  Rotations in  Community Health  program (SERCH),                                                               
not  to be  confused with  the Southeast  Alaska Regional  Health                                                               
Consortium, which brings students in  their second and third year                                                               
to Alaska for a four-week  rotation.  Although the aforementioned                                                               
program was  terminated last year, she  related her understanding                                                               
that it  will be  in place again.   This program  has had  a good                                                               
return rate.                                                                                                                    
8:33:20 AM                                                                                                                    
REPRESENTATIVE   KELLER,  referring   to  Ms.   Hughes'  comments                                                               
regarding  direct  grants,  requested  more  information  on  the                                                               
legislation to which she referred.                                                                                              
MS. HUGHES explained that the  proposed legislation would provide                                                               
higher  direct  payments  to   providers  who  take  hard-to-fill                                                               
positions,  which would  be defined  based  on criteria  directly                                                               
related  to  the situation.    This  would  be used  in  employer                                                               
situations,  such  as with  health  centers  as well  as  private                                                               
practices in a community with a known health provider shortage.                                                                 
8:35:13 AM                                                                                                                    
CHAIR SEATON informed the committee  that HB 204 will be referred                                                               
to  the House  Finance Committee,  following being  reported from                                                               
this committee.                                                                                                                 
8:35:47 AM                                                                                                                    
REPRESENTATIVE  KELLER   expressed  interest  in   the  incentive                                                               
options available.                                                                                                              
MS.  HUGHES  informed  the  committee  that  the  other  proposed                                                               
legislation  would allow  a  WWAMI student  to  be eligible  [for                                                               
direct  payments],  as an  additional  incentive  for him/her  to                                                               
practice in Alaska.                                                                                                             
8:37:34 AM                                                                                                                    
PAT LUBY, Advocacy Director, AARP  Alaska, provided the following                                                               
     As you  well know, the  entire country has  a physician                                                                    
     shortage.   In Alaska,  it is acute,  especially access                                                                    
     to   physicians  who   will   see  Medicare   patients.                                                                    
     Certainly   one  of   the  most   helpful  things   the                                                                    
     legislature has  done in the  recent past has  been the                                                                    
     expansion of the WWAMI program  from 10 to 20 slots for                                                                    
     Alaska medical students.   HB 204 will  give us another                                                                    
     four slots for Alaskans who  want to attend med school.                                                                    
     Will it solve our physician  access problem?  No.  Will                                                                    
     it help?  Yes.  AARP encourages you to pass HB 204.                                                                        
8:38:51 AM                                                                                                                    
KATHLEEN TODD, Family Physician,  informed the committee that her                                                               
daughter is participating in the  WWAMI program.  "The thing that                                                               
a lot  of people  don't understand  is that if  you don't  have a                                                               
state,  your chances  of  getting into  medical  school are  much                                                               
lower," she  opined.  She  explained that other states  only take                                                               
their in-state  residents.  Without  slots in the  WWAMI program,                                                               
Alaskans can only  attend private medical schools.   As an aside,                                                               
Dr.  Todd related  the need  for  the legislature  to review  the                                                               
regulations regarding who is an Alaskan  and who isn't.  Dr. Todd                                                               
mentioned that  the state needs  primary care physicians  as well                                                               
as family  practitioners who can perform  surgeries, orthopedics,                                                               
emergency  room service,  and obstetrics.    She highlighted  the                                                               
need to participate  to the maximum extent possible  in the WWAMI                                                               
8:42:23 AM                                                                                                                    
CHAIR SEATON,  upon determining  no one  else wished  to testify,                                                               
closed public testimony.                                                                                                        
8:42:33 AM                                                                                                                    
CHAIR  SEATON reminded  the committee  that HB  204 would  not be                                                               
referred  to  the  House  Health  and  Social  Services  Standing                                                               
Committee and announced that HB 204 would be held over.                                                                         
8:43:15 AM                                                                                                                    
REPRESENTATIVE WILSON  opined that  it is  obvious that  the need                                                               
exists  and no  testimony  [in  opposition to  HB  204] has  been                                                               
heard.     Therefore,  she  related   her  desire  to   move  the                                                               
legislation from committee today.                                                                                               
8:43:59 AM                                                                                                                    
CHAIR SEATON reiterated  that HB 204 would be held  over in order                                                               
that there be a second hearing  that provides time for the public                                                               
to comment.                                                                                                                     

Document Name Date/Time Subjects
HB 204 information.pdf HEDC 3/30/2009 8:00:00 AM
HEDC 4/1/2009 8:00:00 AM
HEDC 4/3/2009 8:00:00 AM
HB 204
AmendingCSHB58 verP3 28.pdf HEDC 3/30/2009 8:00:00 AM
HB 58
HB 58 material.pdf HEDC 3/30/2009 8:00:00 AM
HB 58
HB 58 fiscal note.pdf HEDC 3/30/2009 8:00:00 AM
HB 58
HB 58 amendment.pdf HEDC 3/30/2009 8:00:00 AM
HB 58
HB58EduAmendPacket.pdf HEDC 3/30/2009 8:00:00 AM
HB 58