Legislature(2007 - 2008)CAPITOL 106
01/30/2007 03:00 PM HEALTH, EDUCATION & SOCIAL SERVICES
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|Overview: Mentoring Project for Teachers and Principals - Department of Education and Early Development|
* first hearing in first committee of referral
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HB 18-POSTSECONDARY MEDICAL & OTHER EDUC. PROG. [Contains discussion of HB 55.] 3:09:38 PM CHAIR WILSON announced that the next order of business would be HOUSE BILL NO. 18 "An Act amending the functions and powers of the Alaska Commission on Postsecondary Education; and relating to the repayment provisions for medical education and postsecondary degree program participants." 3:09:41 PM REPRESENTATIVE SEATON moved to adopt CSHB 18, Version 25- LS0131\M, Mischel, 1/30/07. There being no objection, Version M was before the committee. 3:10:24 PM REPRESENTATIVE KEVIN MEYER, Alaska State Legislature, as sponsor of HB 18, explained that the number of students allowed to attend the WWAMI program hasn't been changed since 1971. However, the state's population and medical needs have increased significantly since that time. He explained that currently those attending the WWAMI program pay the in-state tuition at the University of [Washington] and the state pays for the out- of-state portion of the charges. This legislation, HB 18, proposes forgiving up to 20 percent each year the student [practices] in Alaska. In other words, if a student returns to Alaska for five years, the state will forgive the entire out-of- state portion. The thought is that [after five years], the physician would be established with a clientele that would keep that physician in Alaska. Representative Meyer opined that the WWAMI program has been very successful. In fact, one study shows that almost 80 percent of the students who utilize the WWAMI program return to Alaska as physicians. He then highlighted that the proposal in HB 18 will allow the residency program to occur outside of Alaska. This program is important and the cost incurred to utilize it is well worth it, he opined. 3:13:28 PM MIKE PAWLOWSKI, Staff to Representative Kevin Meyer, Alaska State Legislature, began by stating that the changes encompassed in Version M are meant to bring HB 18 and HB 55 together. He then paraphrased from a written statement, which read as follows [original punctuation provided]: Section 1: Replaced section one of HB 18 with section 1 of HB 55 and inserted clarifying language on line 9 that specifies the program should admit at least 20 participants each year. Section 2: Replaced one-third on page 2 line 7 with 50 percent (new page 2 line 6) to bring the base obligation a program participant accrues in line with existing statute. Replaced "student" with "program participant" throughout section 2 to better reflect the status of person under the WWAMI program since a person serving their residency is still under the program but not technically a student. 3:15:29 PM REPRESENTATIVE SEATON drew attention to Section 1 of Version M and asked if there are limitations on the WWAMI slots available. In other words, are there 20 slots in WWAMI per year for Alaskan students, he asked. MR. PAWLOWSKI deferred to upcoming witnesses who will testify as to the number of slots available and the overall implementation of the WWAMI program. 3:16:10 PM MR. PAWLOWSKI, in response to Representative Gardner, explained that under Version M, interest doesn't accrue during the residency program outside of the state. Version M, with the 50 percent, attempts to bring in line the state subsidy and the difference between resident and nonresident tuition. The state subsidy per WWAMI student is in and around $50,000 a year. The difference between resident and nonresident tuition is about $25,000 per year. "In the current program there was always an implicit subsidy in there and I think the rationale behind that is if you consider whether or not tuition ever covers the cost of educating a student, and it doesn't. There's a GF [general fund] in the University of Alaska system ... increment that will pay for the corresponding state responsibility for that student," he explained. Since WWAMI is Alaska's medical school, the remainder of the obligation is the state's part of paying for that student. Therefore, the difference is in terms of repayment. 3:18:02 PM REPRESENTATIVE GARDNER asked if those students who don't return to Alaska currently are responsible for the full $50,000 a year or only half of it. MR. PAWLOWSKI specified that it works out to about half under the current program and the proposed program. 3:18:39 PM REPRESENTATIVE FAIRCLOUGH highlighted that one of the goals is retention of physicians. She then inquired as to whether there is a chart illustrating the retention level of physicians who utilize WWAMI, stay in the Alaska, and practice in Alaska. MR. PAWLOWSKI related that the report should include such a chart. He offered to locate the chart for Representative Fairclough. 3:19:43 PM REPRESENTATIVE FAIRCLOUGH, referring to the report from the Alaska Physician Supply Task Force, echoed the earlier mentioned difference between the ratio of physicians to population in Alaska versus the national average. However, the report indicates that Alaska is above the national average in regard to the proportion of nurse practitioners and physician assistants per population. Therefore, she inquired as to the ratio of nurse practitioners and physician assistants per 1,000 in population in Alaska. MR. PAWLOWSKI said he wasn't sure, but suggested that others may be able to respond. 3:21:01 PM REPRESENTATIVE FAIRCLOUGH, referring to the issue of retention, asked if there has been consideration given to shortening the repayment fee by moving from a 20 percent over five years to 25 percent over four years. REPRESENTATIVE MEYER said that he hasn't had any such discussion. He reiterated his belief that the longer a physician is in the state and has his/her business established, the more likely that physician will remain in Alaska. Therefore, it probably doesn't matter much whether the repayment occurs over the course of four or five years. REPRESENTATIVE FAIRCLOUGH noted her appreciation to the sponsors for being proactive with regard to health care in Alaska, in which the fastest growing population is over age 65. The aforementioned is also impacting medical providers in the state. Representative Fairclough then stated her support of the concept of this legislation. 3:22:59 PM REPRESENTATIVE SEATON asked if the language referring to residing in Alaska means that the individual is eligible for a permanent fund dividend (PFD). He further asked if an individual attending school outside of Alaska who has an excused absence for four years would be eligible for this program. MR. PAWLOWSKI deferred to Ms. Barrans. 3:24:36 PM DENNIS VALENZENO, Ph.D., Director, Alaska WWAMI Biomedical Program, University of Alaska - Anchorage (UAA), informed the committee that he is responsible for the first year program that is given at the University of Alaska to the 10 Alaskans accepted into the WWAMI program, the pathway programs leading into medical education, as well as the collaboration of the education done in Alaska for the third and fourth year students. Dr. Valenzeno highlighted that the Alaska WWAMI program doesn't send students to the University of Washington to receive their medical education. At this time, students can complete three of the four years of medical school in state. Dr. Valenzeno said he highlighted the aforementioned because he didn't want to overlook the educators and physicians in Alaska who are providing an education. Furthermore, physicians do tend to stay where they are educated, and thus it's more likely that those physicians educated in Alaska will stay in Alaska. He attributed the aforementioned as one of the reasons Alaska experiences nearly 85 percent return on this investment in 10 slots as compared to the national average that's just under 40 percent. 3:26:47 PM DR. VALENZENO, in response to Representative Seaton, pointed out that with five states and six institutions, a significant amount of coordination must occur in order for class size to change. He related that the program can accommodate 20 students as early as this fall, but to go beyond 20 students would require some "ramp-up" time. He related his understanding that the University of Washington and the University of Alaska are available to accommodate [more than 20 students]. Of the 78 who applied for the WWAMI program this year, Dr. Valenzeno estimated that 30-35 are well-qualified for acceptance. 3:28:05 PM CHAIR WILSON asked if classrooms are being built to accommodate 20 students or will [the education] be done in shifts. DR. VALENZENO answered that current classrooms can be reconfigured to accommodate 20 students. However, additional study space would be needed for the program, which the university is addressing. Beyond 20 students, the physical size of the classroom and laboratory is limiting. 3:29:12 PM REPRESENTATIVE FAIRCLOUGH asked if the state has a contract with the WWAMI program. She then pointed out that the legislation before the committee utilizes "shall" language. She related her understanding that the contract with the University of Washington School of Medicine to qualify for 20 slots; the latitude is necessary because other states in the WWAMI program are competing for the vacant/new slots. She acknowledged that Alaska can't be guaranteed the additional 10 slots, but may obtain an additional 1-10 slots. DR. VALENZENO related his understanding that the current contract between Alaska and the University of Washington School of Medicine specifically states that Alaska has 10 slots. He relayed that representatives from the University of Washington School of Medicine have stated that the program can accept 20 students from Alaska. In further response to Representative Fairclough, he acknowledged that the contract would need to be amended, although he mentioned that he didn't have legal expertise on the matter. 3:31:18 PM ROD BETIT, President, Alaska State Hospital and Nursing Home Association (ASHNHA), noted that he is also testifying on behalf of a partnership that was formed from two different physician groups in Providence Hospital in order to highlight some of the access issues in the state. He reminded the committee that this [partnership] drew attention to the shortage of physicians in the state. He further reminded the committee that last year's capital budget appropriations provided funding to start the infrastructure improvements to increase the WWAMI program at the University of Alaska - Anchorage. Mr. Betit opined that the task force report is alarming in terms of the number of physicians that the state is short currently and the projected numbers over the next 10 years. The shortage is further compounded by the fact that current physicians desire more of a life than those at the end of their careers. Therefore, it isn't unrealistic to believe that 1.5 physicians will be required to replace a retiring physician. He noted that every state is facing this situation today. As the task force report points out, the state needs to be proactive and aggressive to attract the necessary number of physicians from medical schools, especially given the fact that the number of students graduating as physicians isn't keeping pace with the need. Mr. Betit opined that WWAMI is a great program with an excellent return to the state for its investment. The proposal today, he opined, is a critical step to begin to fill the gap and should move forward quickly in order to provide the University of Washington assurance as to Alaska's plans. He related that the State of Wyoming is also pursuing additional slots from the University of Washington. In conclusion, Mr. Betit urged the committee to pass HB 18 from committee. 3:35:24 PM REPRESENTATIVE GARDNER asked whether Mr. Betit is confident that the additional slots [at the University of Washington] will be available. MR. BETIT related that there has been considerable discussion on this matter over the last year and a half. Therefore, he said he was confident those slots would be available if the state provides the University of Washington assurance early on that such is the desire of the State of Alaska. 3:35:49 PM REPRESENTATIVE SEATON returned attention to Representative Fairclough's earlier comments regarding the task force report's assessment of need. He highlighted the finding that Alaska should maintain a higher ratio of mid-level providers, such as advanced nurse practitioners and physician assistants. He asked if the legislation addresses the aforementioned need. MR. BETIT said that to his knowledge nothing in the legislation addresses that. However, he noted that maintaining a higher ratio of mid-level providers was something that is necessary to address the shortage discussed by the task force. 3:37:25 PM MARIE DARLIN, Coordinator, AARP Capital City Task Force, directed attention to AARP's letter in support of HB 18, which should be in the committee packet. She opined that WWAMI is one way in which to address the shortage of physicians in Alaska. Furthermore, [increasing the number of slots in the] WWAMI program is one way to address the many AARP members who are unable to find physicians willing to accept patients with Medicare. She then highlighted that the Alaska Physician Supply Task Force suggested that there be as many as 30 slots per year in the WWAMI program. In conclusion, Ms. Darlin urged the committee members to vote in favor of HB 18. 3:40:04 PM SUZANNE TRYCK, Director, Regional Programs, University of Washington School of Medicine, urged the committee to pass HB 18 out of committee today. She explained that this legislation is timely because the University of Washington is currently going through its admissions process. Therefore, the sooner the legislation is passed, the sooner the University of Washington can invite more Alaskans to join classes. In response to Chair Wilson, Ms. Tryck confirmed that classes for 2007 begin in September and thus students are being admitted into the program now. 3:41:08 PM REPRESENTATIVE FAIRCLOUGH asked if Alaska has to amend the current contract with the State of Washington in order to add these proposed new slots. MS. TRYCK replied yes, adding that the contract is currently under review. The expectation, she said, is that the contract will be in place in time to offer the positions to the increased class size. In further response to Representative Fairclough, Ms. Tryck related the preference for the language of the legislation to provide latitude [with regard to the number of slots]. However, she informed the committee that the University of Washington has already committed to the extra 10 slots. 3:42:45 PM REPRESENTATIVE SEATON asked for clarity with regard to which commissioner the language in Section 1 of Version M refers. MS. TRYCK related her understanding that it refers to the commissioner of the Commission on Postsecondary Education. 3:43:32 PM JOEL GILBERTSON, Regional Director, Providence Health System Alaska, reiterated the importance of the passage of HB 18. Mr. Gilbertson then related his personal belief that the physician shortage in Alaska is one of the largest public health risks at this time. Across the state, including Anchorage, large portions of individuals aren't receiving timely access to care, continuity in care, and strong services to support chronic disease management. The aforementioned results in loss of care for individuals and creates an inefficient health care system. The WWAMI program provides additional man power to provide a myriad of health care services. As has been mentioned, almost 85 percent of the [Alaska] WWAMI participants practice in the state. He noted that elements of HB 18 ensure that such will continue in the future while opening the door to see more Medicare insured patients. In conclusion, Mr. Gilbertson urged passage of HB 18. 3:46:26 PM KAREN PERDUE, Associate Vice President, University of Alaska, remarked that being involved in the nursing expansion and the Physicians Supply Task Force has been a great experience. The University of Alaska supports the expansion embodied in HB 18. She confirmed that the University of Alaska has worked with the University of Washington to ensure that the additional 10 slots will be available. She mentioned that students wouldn't be admitted in the first year of the program if the university didn't believe the additional slots would be available later at the University of Washington. Ms. Perdue then highlighted that the fiscal note for the university's cost of the first year of the program isn't in the committee packet. The University of Alaska anticipates that its costs for the first year of 10 additional students would be $280,000. The aforementioned would be a one-time cost and doesn't accumulate as does the University of Washington costs do. The fiscal note also includes a request for additional capital money to complete and equip the classroom. Ms. Perdue related the university's strong support of HB 18. 3:48:40 PM CHAIR WILSON asked if the classroom will only be utilized by the medical students. MS. PERDUE said she doubted that the classroom would be available to others since the medical students really utilize the room throughout the day. 3:48:48 PM REPRESENTATIVE FAIRCLOUGH requested information regarding the administrative cost of the program. MS. PERDUE said she would provide such information. 3:49:26 PM REPRESENTATIVE SEATON noted that the committee was provided a summary of the projected costs in revenue in relation to doubling the size of the classroom. MS. PERDUE explained that the summary specifies the capital cost, of which $475,000 was appropriated last year. Therefore, the fiscal note will reflect that going forward. She further explained that the operating costs would be $280,000 as specified on the projected revenue side. 3:50:24 PM MIKE FORD, Alaska Native Health Board, noted his agreement with earlier testimony that Alaska has a very serious health problem. The Alaska Native Health Board, he related, views HB 18 as a step in the right direction. In fact, one of the priorities of the Alaska Native Health Board is to develop a sustainable workforce of health care professionals who will come to Alaska and stay in Alaska. He, too, urged the committee to pass HB 18. 3:51:44 PM CHAIR WILSON, upon determining no one else wished to testify, announced that public testimony was closed. 3:51:59 PM REPRESENTATIVE GARDNER related her understanding that HB 18 says that students repay the full amount that the state has paid. However, the sponsor statement for HB 18 says, "House Bill 18 removes the limit on the number of students currently set in statute, decreases the amount a person is required to pay back if they don't return to Alaska ...." Therefore, she asked if the legislation increases the amount a student has to pay if he/she doesn't return to Alaska. 3:53:24 PM DIANE BARRANS, Executive Director, Alaska Commission on Postsecondary Education (ACPE), Department of Education and Early Development, clarified that there is a change in terms of the principal of the loan, although the dollar amount hasn't changed. She related her understanding that the objective of the task force was to make it concrete with regard to how the principal obligation was determined. Therefore, rather than have the language of the differential between the resident and the nonresident tuition, a percentage approximating the same amount of money was utilized. Currently, an individual graduating from the WWAMI program this year will have a principal obligation of $76,000 on which interest would accrue. If that graduate failed to return to the state, the graduate would pay the principal plus the interest. However, Version M takes 50 percent of the state support fee and makes that the obligation, which amounts to about $75,000. With respect to the interest, there's a slight difference. She explained that currently interest accrues at the end of the graduate medical education program, but is deferred until repayment. Repayment is postponed until the completion of any residency program or period of service to public health, Indian health services, or the military. This legislation changes the aforementioned such that the interest doesn't begin to accrue until the [completion of any residency program or period of service to public health, Indian health services, or the military]. She opined that the reasoning behind the change in interest accrual is because there isn't an opportunity for all 20 students within Alaska's residency program. 3:56:04 PM REPRESENTATIVE SEATON referred to the change on page 1, line 6, from "may" to "shall" and posed a situation in which the ACPE doesn't receive enough funds from the legislature to cover 20 students. He asked if the ACPE is concerned with such a situation and whether it would place it in violation of the law. MS. BARRANS replied no because the current contract addresses the situation in which the legislature doesn't sufficiently fund the contract. In such a situation, the [number of students] would be relevant to the funding level. However, it does place the University of Washington School of Medicine in an awkward position because it will have a certain number of students and annual funding. 3:57:45 PM The committee took an at-ease from 3:57 p.m. to 4:00 p.m.. 4:00:30 PM MS. BARRANS said that as a fiscal agent for the state, she would ensure that there is a provision in the contract that contemplates a day in which the legislature wouldn't be able to fund the program. Therefore, everyone entering into the contract would understand what would occur in such a situation. Ms. Barrans clarified that this is an obligation of the State of Alaska not the Alaska Student Loan Corporation. 4:01:07 PM MS. BARRANS, in response to Representative Seaton, stated that the PFD residency requirements wouldn't suffice. The ACPE has specifically defined a resident for the purposes of eligibility for this program as someone who has physically resided in the state for two years prior to admittance into the program, or that the absence from the state be solely due to the full-time educational pursuit of the individual or his/her spouse and that the two years preceding the absence, the individual was physically present in the state. 4:02:21 PM REPRESENTATIVE GARDNER inquired as to the repayment requirements for a graduate who doesn't return to the state to practice. MS. BARRANS explained that the only change would be in a situation in which an individual who attended a residency program outside of Alaska and served some period of service obligation to another entity; that individual would potentially have a number of years of interest-free status on the principal of the loan. Ms. Barrans characterized whether the legislature would want to have the interest added to the debt of the individual in the aforementioned situation and require such an individual to repay the entire debt as a policy call. The current interest on such a loan amounts to 8.25 percent. Ms. Barrans noted that currently the debt is interest free during the four years of the program and the repayment is over the course of 15 years. 4:04:36 PM REPRESENTATIVE GARDNER referred to page 2, line 5, which relates that a student of the program who doesn't return to Alaska and isn't in any of the other exclusionary programs is required to repay 50 percent of what the state has paid. MS. BARRANS replied yes. 4:05:13 PM REPRESENTATIVE GARDNER inquired as to why the state wouldn't require a student in such a situation to repay the full amount. MS. BARRANS relayed that the discussion around the original legislation were that students wouldn't take advantage of a program with a punitive debt if an individual didn't return to Alaska. While someone entering the program may intend to return to Alaska, there may be another outcome due to various life changes, she noted. MS. TRYCK explained that because the money is located in ACPE, it's viewed as a subsidy of students of medical education. However, it's structurally the same as the public funds for the University of Alaska. One way to view whether the student should repay 100 percent is to question whether every student in the University of Alaska pays the full cost of education. Ms. Tryck pointed out that when students attend private medical schools, they do pay a high tuition rate. Still, students in private medical schools don't pay 100 percent of the actual cost. 4:07:51 PM MS. BARRANS referred to the language on page 2, lines 18-22, which she characterized as "a grey area" that is difficult to program into a system code. She related that deleting the language would be preferable. 4:09:58 PM REPRESENTATIVE SEATON asked if the [language on page 2, lines 18-22] addresses a situation in which an individual is a perpetual student and isn't making progress toward graduation. MS. BARRANS said that in the over 20 years she has been with the program, that hasn't happened. In situations in which a student has to sit out one year, the status of the account is suspended until a resolution occurs. MS. TRYCK noted that WWAMI does have a means for terminating students. However, there are Alaskans who go into a fifth year and the program provides allowances for that. In further response to Representative Seaton, Ms. Tryck said that elimination of the provision wouldn't encourage students to become derelict with their education. 4:12:16 PM TIM KELLY, Lobbyist for the Alaska State Medical Association (ASMA), relayed that HB 18 is important legislation, which he characterized as a top priority this legislative session. He further relayed that ASMA is supportive of Version M. 4:13:34 PM CHAIR WILSON, upon determining no one else wished to testify, closed public testimony. 4:13:58 PM REPRESENTATIVE GARDNER moved that the committee adopt Amendment 1, as follows: Page 2, lines 18-22; Delete "If the commission finds that the program participant has withdrawn from the medical education, residency, or fellowship program, or that the program participant is otherwise failing to make adequate progress toward completion of the program, the commission may start the accrual of interest after notifying the program participant." There being no objection, Amendment 1 was adopted. 4:14:47 PM REPRESENTATIVE SEATON moved to report CSHB 18, Version 25- LS0131\M, Mischel, 1/30/07, [as amended] out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSHB 18(HES) was reported from the House Health, Education and Social Services Standing Committee.