Legislature(2009 - 2010)BUTROVICH 205
03/25/2009 01:30 PM HEALTH & SOCIAL SERVICES
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SB 139-INCENTIVES FOR CERTAIN MEDICAL PROVIDERS 1:31:34 PM CHAIR DAVIS announced consideration of SB 139. 1:31:57 PM SENATOR OLSON, sponsor of SB 139, said it establishes a loan repayment and incentive program that is essential to induce people to come to Alaska to serve as health care professionals. Two years ago the Health Commission estimated that over 400 more medical doctors are needed to provide the same level of care as is available elsewhere in the country. SB 139 will play an important role in the overall solution by establishing this program now. Forty-four states already have a similar loan program, so competition is fierce. Alaska offers unique lifestyle opportunities, but a program such as this will make us competitive with other areas. Rural Alaska faces an acute shortage of doctors. 1:34:28 PM KENDRI CESAR, staff to Senator Olson, said SB 139 establishes the Health Care Profession's Loan Repayment and Incentive Program to make health care employment more attractive to practitioners who both originate from Alaska, but who are also from the Outside. Particularly in hard-to-fill localities, people face obstacles such as limited financial resources, cultural barriers and geographical hindrances to health care access. This program would mirror similar loan repayment incentives in the Lower 48 that have been substantially successful as cost effective strategies in addressing workforce shortages both for health care and other professions. The program would be overseen by the Department of Health and Social Services (DHSS) and the commissioner would appoint an advisory council to communicate between program administrators and providers and would make recommendations back to the commissioner regarding program administration. The commissioner would use the data and input of the advisory council to annually prioritize 10 eligible practitioner-types according to relative need in Alaska. These 10 practitioner types would be further prioritized into two categories - Tier 1 and Tier 2. The Tier 1 category would include pharmacists, dentists and physicians with either an M.D. or a D.O., the types of practitioners that are in highest demand in Alaska. These types of practitioners often come out of medical school with the highest amount of loans. Tier 2 practitioners would initially include dental hygienists, nurse practitioners, registered nurses, physical therapists, physician assistants, clinical psychologists, and clinical social workers. These practitioners are also in high demand in Alaska, but to a lesser extent than the Tier 1 practitioners. MS. CESAR explained that each of the 10 practitioner types would be allocated 8-9 slots in the program, so the total number of program participants each year would be 90. She said 60 program slots would be allocated to regular site positions and the other 30 slots will go to the very hard-to-fill slots in areas that are labeled so by the commissioner. Current federally defined health care shortage areas are referred to as health profession shortage areas (HPSA) and these would help to guide the commissioner in defining very hard-to- fill slots, but he would not be confined to those and preference would be given to sites that serve individuals who have difficulty paying. She explained that eligible program participants must commit to three years, no more and no less, in exchange for either loan repayment support; or if they have no student loans owing, they could participate in the incentive payment component of the program. A Tier 1 practitioner serving in a regular site could receive up to $35,000/yr.; or if they choose to serve in a very hard-to- fill site, they could receive $47,000/yr. A Tier 2 practitioner serving in a regular site could receive up to $20,000/yr. or up to $27,000/yr. for a very hard-to-fill site. These figures are the same regardless of whether they are participating in the loan repayment component or the incentive payment. A participant in the loan repayment component who completes their three years of service can opt to work for up to a total of six years. Employers might be required to pay a matching amount at the commissioner's discretion, but that would be based on the employer's ability to pay. The Alaska Commission on Postsecondary Education would serve as payment agent for the loan payments. 1:41:01 PM She said that a $7.4 million price tag might seem high, but because 44 other states already offer such programs, Alaska is at a distinct disadvantage in hiring health care professionals. 1:42:03 PM SENATOR OLSON urged that if they are going to take advantage of existing residency programs, they end in July. Maybe those first graduates can come up here. 1:43:28 PM PAT CARR, Health Program Manager, Department of Health and Social Services (DHSS), said she was available to answer questions and that the administration does not support this bill due to the price tag. CHAIR DAVIS asked if she agreed that this program should be within the Department of Health and Social Services and if they have problems with anything other than the money. MS. CARR replied that they have been monitoring the healthcare work force for some time, and it is in the purview of responsibilities of the department. The concerns about the price tag and needing to add staff to manage the program are of concern. 1:44:33 PM CHAIR DAVIS said she didn't have a fiscal note from the department, and asked where it was. MS. CARR replied that the fiscal note went to the Governor's office. CHAIR DAVIS stated that they did not have it even though the administration knew this bill was up today. She asked if she had already told Senator Olson that the department didn't support this bill. MS. CARR replied that information should have reached him yesterday. 1:45:30 PM SENATOR DYSON pointed out a zero fiscal note from the Department of Education. 1:46:06 PM DIANE BERHENDS, Executive Director, Alaska Commission on Postsecondary Education, Department of Education, explained the reason they were asked to participate in the discussion around this program was their familiarity with education loans, and they agreed they were equipped to play the part of a disbursing agent on the loan repayment piece. 1:46:39 PM SENATOR DYSON said he was not aware of a shortage of physical therapists in this state, and asked where that information came from. MS. BEHRENDS said their packets contain the 2007 Alaska Health Workforce Vacancy Study, which gives that information. Physical therapists were chosen in consultation with the working group that helped to outline the proposed program. 1:48:18 PM SENATOR DYSON said he was particularly concerned that the state has had a long standing turf war between various levels of counselors and he sees that social workers are included here but other counselors are not, particularly counselors who deal with sexually abused children. He wanted to know why they are not listed and social workers are. He has heard it is because social workers have the best lobbyists. 1:49:50 PM CHAIR DAVIS recognized that Senator Ellis arrived at the meeting some time ago. 1:50:09 PM SUZANNA TRICK, WWAMI, said she was available to answer questions. 1:51:00 PM DELISSA CULPEPPER, CEO, Alaska Mental Health Trust Authority, said she has been working on health care workforce issues for some years and helped produce the Vacancy Study. All workforce areas that serve their beneficiaries have shortages across Alaska, both rural and urban. So three years ago, they began putting money into a larger workforce development issue. Loan repayment rose to the top as one strategy that could be used. So, for the last two years they have crafted a small demonstration project around master's level or higher behavioral health positions across the state to help with loan repayment and recruiting. Therefore, they have been involved as part of the coalition that crafted the details of this bill believing that incentives will help them compete with other states. She urged the committee to pass SB 139. 1:53:02 PM CHAIR DAVIS advised that they just received the fiscal note from the department. 1:53:51 PM SENATOR DYSON said he had the Health Workforce Vacancy Summary before him and on page 2, Table 1 showed a 17.7 percent vacancy rate of professions and therapists and a 13.9 percent vacancy rate for behavioral health professionals. Those are the highest rates of vacancy next to physician assistants. He said he thought they "missed it" by not including those mental health professionals and therapists and that someone "bluffed you" into putting the social workers in there instead. 1:56:14 PM MARIE DARLIN, Capital City Task Force, AARP, supported SB 139. She said that Alaska is going to have to do something like this if it is going to compete in recruitment and retention of providers. The cost of our inability to provide care to our people is greater than the cost of the program. 1:57:20 PM BETH SIRLES, Director, School of Social Work, University of Alaska Anchorage (UAA), said she is also co-chair of the Mental Health Trust Authority Workforce Development Focus Area Education and Training Committee, and supported SB 139. The Committee has been working for years to identify key workforce shortage areas in the state, and health care workers are at the top of the list. Their providers tell them regularly that their top priority is the recruitment and retention of health care providers. Several workforce studies show there is no question that Alaska has serious shortages of health providers, both Tier 1 and Tier 2. 1:59:03 PM TRACY TURLEY, full-time nurse practitioner student, said she when she gets out of school she will have over $95,000 in student loans, and that makes it very hard to pay for a mortgage at the same time. 1:59:51 PM MARY LOEB, Family Physician, Sunshine Community Health Center, said she has experienced the distress of unmet medical and dental needs in her community. One and a half years ago their community was down from five to two providers to staff two clinics. At that time she interviewed a lot of providers and administrators and she often heard that they would have to give up so much financially to work for the Center. 2:02:24 PM ROD BETIT, Alaska State Hospital and Nursing Home Association (ASHNHA), supported SB 139, because it addresses this critical hole in the health care workforce in Alaska. He hears stories first hand every day from Alaskans who can't obtain health care services. The investments made in the WWAMI program are great, but the fruits from that program won't be seen for many years; SB 139 will address the short term need. 2:04:45 PM MR. BETIT continued that he sees this as a rural bill primarily, but the problem exists in some urban areas, as well. "If we don't go after these work-ready health care professionals more aggressively, more competitively, with the limited number available, we're going to look worse rather than better five years from now." To do that they need funding and this bill wasn't premised on the notion that there would be any diminishment of funding by those who are going after health care professional. He said that urban hospitals and big clinics will continue to hire the available professionals, because they have the financial capacity to do so. This bill is aimed at the "safety net providers" who are willing to serve Medicaid/Medicare and uninsured patients, but don't have the discretionary income or the balance sheet to get professionals to their area. ASHNHA conducted a statewide survey in 2007 about health care attitudes. It clearly showed that the public feels that hospitals are in a position to make the workforce needs known and to champion some solutions to address those needs, even if the most pressing needs aren't hospital-based. This area has been selected by his board as a way to give back to the community in terms of trying to get that message out and develop some strategies for putting the solutions together. 2:07:34 PM He said that ASHNHA has been working with the Alaska Primary Care Association, the Alaska Native Health Board, the Alaska State Medical Association, the Alaska Dental Society, the Alaska Nurses Association, the Alaska Mental Health Trust Authority, the Alaska Commission on Postsecondary Education, the Alaska Pharmacists Association, and the Alaska Native Tribal Health Consortium. The Department of Health and Social Services (DHSS) has provided some staff support and he is sorry it can't support the bill due to its financial requirements. Even so, Mr. Betit said, he wants to put this before them as a good solution. The bill does not mandate a funding level each year. The fiscal note for $7 million provides a half million to the department to run the program annually, but the idea for the rest is to fund 90 health care professionals to come work in the state. If only half the money is available, then they could fund 45. It seems to be an excellent way to put something in place that can be used when funds are available. 2:09:15 PM MR. BETIT said he doesn't have all the details pinned down even though they've worked on this for 10 months. This legislation leaves a lot of discretion to the department, but the bill says that the Advisory Committee, once it makes a recommendation to the commissioner, wants it to be honored. Having been a state official, he has seen a lot of advisory committee's input not used. If the commissioner doesn't use the input, he needs to put in writing why not. He is very supportive of this legislation and he feels if this issue isn't dealt with now, it will be an even bigger problem in the future. 2:11:07 PM SENATOR DYSON asked if ASHNHA had input on which professionals would be included. MR. BETIT replied yes; they wrestled with this question at many meetings, and the reason they went with the master's level social worker is that those professionals could fill in other areas as well. However, they are open to discussion on this issue. SENATOR DYSON said the supporting documentation doesn't talk about a shortage of social workers, but does mention behavioral and mental health workers. MR. BETIT responded that it was felt that the social worker would be the stronger health profession to put in that package, but that was open to discussion. 2:13:44 PM CHAIR DAVIS said she supported this bill; it requires some money up front, but it would save in the long run, and it is not an unusual amount of money to put forward on something like this. 2:14:33 PM SENATOR PASKVAN asked if the department recognizes that it needs to attract health care workers or do they reject that need. Does the administration want to reject certain fields under the bill or limit the number, or is it a situation where, regardless of need they don't want to spend the money? MS. CARR replied that she would have to go back to the administration for answers. CHAIR DAVIS said she would appreciate that. MS. CARR said her department knows there are workforce shortages. On the other questions, she would get prepared responses for the committee. 2:18:13 PM SHELLEY HUGHES, Alaska Primary Care Association, said she worked with Mr. Betit and a number of others to craft this bill. They started by looking at what other states were doing and found that loan repayment and incentive programs were most effective. They found that only 2 percent of medical students are currently going into primary care. They hear from the 141 clinics in the state that are part of the Association, that they will have a candidate lined up and when they learn Alaska doesn't have an incentive program, and the candidate moves on. She clarified that the $7.5 million fiscal note is the encumbrance for 3 years and 90 participants. She also wanted to mention that, as they looked at the workforce study data, they found that recruiting physical therapists has been very hard. As for behavioral health, both psychologists and licensed clinical social workers are included. She explained that in order to keep a clinic's doors open you have to have providers who can bill to Medicaid and both psychologists and licensed clinical social workers are reimbursable through Medicaid. She didn't think that some of the other positions were billable like RNs. 2:22:12 PM CHAIR DAVIS closed public testimony and held SB 139 in committee.