Legislature(2009 - 2010)BUTROVICH 205

03/25/2009 01:30 PM Senate HEALTH & SOCIAL SERVICES

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
Heard & Held
Bills Previously Heard/Scheduled
Moved SB 12 Out of Committee
        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                                                               
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                                                               
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                                                               
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                                                               
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                                                               
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                                                               
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                                                               
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                                                               
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                                                               

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