Legislature(2019 - 2020)BUTROVICH 205
03/25/2019 01:30 PM Senate HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| SB93 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | SB 93 | TELECONFERENCED | |
ALASKA STATE LEGISLATURE
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
March 25, 2019
1:33 p.m.
MEMBERS PRESENT
Senator David Wilson, Chair
Senator John Coghill, Vice Chair
Senator Cathy Giessel
Senator Tom Begich
MEMBERS ABSENT
Senator Gary Stevens
COMMITTEE CALENDAR
SENATE BILL NO. 93
"An Act relating to a workforce enhancement program for health
care professionals employed in the state; and providing for an
effective date."
- HEARD & HELD
PREVIOUS COMMITTEE ACTION
BILL: SB 93
SHORT TITLE: MEDICAL PROVIDER INCENTIVES/LOAN REPAYM'T
SPONSOR(s): SENATOR(s) WILSON
03/18/19 (S) READ THE FIRST TIME - REFERRALS
03/18/19 (S) HSS, FIN
03/25/19 (S) HSS AT 1:30 PM BUTROVICH 205
WITNESS REGISTER
JILL LEWIS, Deputy Director
Division of Public Health
Department of Health and Social Services (DHSS)
Juneau, Alaska
POSITION STATEMENT: Presented a PowerPoint on SB 93.
RACHEL GEARHART, Clinical Director
JAMHI Health and Wellness, Inc.
Juneau, Alaska
POSITION STATEMENT: Supported SB 93.
TOM CHARD, Chief Executive Officer
Alaska Behavioral Health Association
Juneau, Alaska
POSITION STATEMENT: Supported SB 93.
JEANNIE MONK, Senior Vice President
Alaska State Hospital and Nursing Home Association (ASHNHA)
Juneau, Alaska
POSITION STATEMENT: Supported SB 93.
MOLLY GRAY, Executive Director
Alaska Pharmacists Association
Anchorage, Alaska
POSITION STATEMENT: Supported SB 93.
NANCY MERRIMAN, Executive Director
Alaska Primary Care Association
Anchorage, Alaska
POSITION STATEMENT: Supported SB 93.
THOMAS HUNT, M.D., representing self
Anchorage, Alaska
POSITION STATEMENT: Supported SB 93.
MIKE COONS, representing self
Palmer, Alaska
POSITION STATEMENT: Asked if SB 93 would incentivize doctors to
take on Medicare patients.
JEREMY O'NEIL, Administrator
Providence Valdez
Health Advisory Council
Valdez, Alaska
POSITION STATEMENT: Supported SB 93.
ZAN WHITMAN, representing self
Palmer, Alaska
POSITION STATEMENT: Supported SB 93.
ACTION NARRATIVE
1:33:28 PM
CHAIR DAVID WILSON called the Senate Health and Social Services
Standing Committee meeting to order at 1:33 p.m. Present at the
call to order were Senators Begich, Coghill, Giessel, and Chair
Wilson.
SB 93-MEDICAL PROVIDER INCENTIVES/LOAN REPAYM'T
1:33:46 PM
CHAIR WILSON announced that the only order of business would be
SENATE BILL NO. 93, "An Act relating to a workforce enhancement
program for health care professionals employed in the state; and
providing for an effective date."
1:33:55 PM
CHAIR WILSON made opening remarks.
1:34:31 PM
CHAIR WILSON explained that SB 93 builds upon the success of the
Alaska Health Care Professions Loan Repayment and Incentive
Program, commonly referred to as SHARP [Supporting Health Access
(through loan) Repayment Program]. Urban and rural communities
face a serious shortage of health care providers that will
readily worsen if this issue not immediately addressed. He said
that SHARP is a loan repayment and direct monetary incentive
program that would help to reduce staff shortages by filling
vacant health care provider positions in some of the most
underserved areas across the state. He said that SHARP-1 and
SHARP-2 have leveraged federal, state, Alaska Mental Health
Trust Authority and employer funding, with a focus on rural,
remote, and safety net providers.
CHAIR WILSON said that the program is administered by Department
of Health and Social Services (DHSS). It has supported more than
250 practitioners in nearly 60 sites across the state. The new
program, SHARP-3 will fill the gap between the federally funded
SHARP-1 and the state-funded SHARP-2 by allowing private
sponsorship in the form of local government, philanthropic
foundation, or employer support. He said that SHARP-3 will focus
on private-public partnerships and recruitment and retention by
offering incentives to new and experienced professionals who may
have exhausted other loan repayment options or who no longer
carry educational loan debt. Under SHARP-3, these professionals
must meet eligibility criteria and be engaged in qualified
employment, he said.
CHAIR WILSON stated that the program does not require any state
general funds, that user fees would cover the cost of
administering the program. SHARP-3 is a budget-neutral
initiative that will help address service shortages in the
current health care landscape, leverages community-level
investment across the state, and improves health outcomes of
Alaskans.
1:37:00 PM
JILL LEWIS, Deputy Director, Division of Public Health,
Department of Health and Social Services (DHSS), Juneau,
presented a PowerPoint on SB 93 titled, "SB 93 Medical Provider
Incentives/Loan Repayment. She reviewed slide 2, "SB 93."
• Establishes a Health Care Professionals Workforce
Enhancement Program to address shortage of health care
workforce.
• Health care professionals agree to work for three
years in underserved areas in exchange for repayment
of student loans or direct incentives.
• Employers fully fund the program. No unrestricted
general funds are involved.
• Replaces the existing program in AS 18.29 scheduled
for sunset June 30, 2019.
1:38:06 PM
MS. LEWIS said that employers will fully fund the program by
taking advantage of a federal tax exemption available only to a
state-run program. This public-private partnership can increase
the number of providers while minimizing the use of state funds.
It will replace SHARP-2, which was funded with state UGF
(unrestricted general funds) and will sunset on June 30, 2019.
1:38:45 PM
MS. LEWIS reviewed slide 3, "Challenges in health care access."
• Alaska needs a more optimal distribution of health
care professionals, across regions, across disciplines
and across populations served.
• Many citizens, especially in rural and frontier areas,
continue to experience challenges with accessing
health care.
• One reason access to care is limited, particularly in
rural Alaska, is due to shortages of healthcare
professionals.
• Health care sites struggle with recruiting and
retaining health care professionals.
• Health care professionals have challenges with large
student loan debt, high cost of living in rural and
remote locations, and resulting financial pressures.
MS. LEWIS said that health care is one of the largest and most
dynamic industries in Alaska, yet many citizens, especially in
rural areas, experience challenges accessing health care. The
availability of health care services is important for
maintaining health, preventing and managing diseases, reducing
costs from unnecessary emergency room use, hospital
readmissions, and the use of temporary staff. Alaska must
address the shortage of health care professionals, she said.
1:39:55 PM
MS. LEWIS said that the department tried to address some
challenges with an ongoing health care loan repayment program.
The initial program was SHARP-1, which was funded by a federal
grant, with a 50 percent match. It is currently provided by
outside parties and does not use any unrestricted general fund
(UGF) dollars. The department receives funding for the program
from the Mental Health Trust Authority, another philanthropic
entity, such as the Mat-Su Health foundation, or employer
contributions for the contracts. She said that [SB 93] does not
affect SHARP-1 because the program will operate under a federal
grant. She added that the SHARP-2 sunset will not affect SHARP-
1.
1:40:56 PM
MS. LEWIS reviewed slide 4, "SHARP-2."
• Operated 2013 2018
• No new contracts after 2015 due to GF budget
reductions
• 83 contracts: 39 Tier 1 and 44 Tier 2
â?¢ 47-53% positions very hard-to-fill
• $25,560 average payment per contract per year
â?¢ 10-30% employer match
• 31 employers distributed across 25 communities
â?¢ Primarily non-profit and hospital associated
â?¢ Similar numbers of tribal and non-tribal affiliated
organizations
Anchorage/Mat-Su 18% Statewide 12% Southeast 28%
Interior/Northern 3% Gulf Coast 12% Southwest 27%
She offered to review SHARP-2, which she described as more of a
head-to-head comparison with SB 93. She said that SHARP-2
operated between 2013 and the last contracts were completed in
2018. No new contracts were issued after 2015 due to budget
constraints that prevented the department from additional UGF to
issue new contracts. However, the state was able to pay out all
of the existing contracts to meet its contractual obligations.
After ramping up in the first year, and going full bore in 2014-
2015, the program issued 83 contracts, of which 39 Tier 1 and 44
Tier 2 contracts.
1:42:22 PM
MS.LEWIS reviewed slide 5, "An innovative solution."
A public-private partnership that ensures access to
health care by expanding the distribution of health
care professionals all Alaskans at no cost to the
state.
â?¢ SHARP-3 builds on the success of SHARP-1 and SHARP-2
with new practice settings, new occupations, new
employers, new locations, and new roles.
• Benefit will not be limited to rural areas or primary
care; there is also room for specialists and urban
health care professionals.
• Takes advantage of a federal law that exempts loan
repayment from federal income tax if awarded through a
state-run program.
â?¢ Public-private partnerships increases the number of
providers while minimizing the use of state funds.
MS. LEWIS said that SB 93 is an innovative solution. She
explained that with the sunset of SHARP-2 on June 30, 2019,
other incentive programs were needed to reduce the health care
worker shortages.
1:43:29 PM
MS. LEWIS reviewed slide 6, "Benefits."
Benefits
• Health care sites can hire much needed staff
• Health care professionals get assistance with their
student loans
• Alaskans have improved access to health care
• Access to health care is important for maintain health
and reducing costs
• All without the use of undesignated general funds
1:43:55 PM
MS. LEWIS reviewed slide 7, titled "SHARP-3," to demonstrate
SHARP-3.
• Health care professionals receive student loan
repayment and/or direct incentives for working in
underserved areas.
• Employer sites provide health care services in
underserved or health care professional shortage
areas.
• 3-year contract with renewals; 12-year lifetime limit.
• Employer payments fully cover cost of the
professional's program payment and an administrative
fee.
• An advisory council recommends eligibility criteria,
prioritization of sites and professionals for
participation, and contract awards.
MS. LEWIS said that the underserved or health professional
shortage area does not need to meet the federal designation. It
is state defined and therefore more flexible. The employer
payments for the first time will include an administrative fee,
which will make it completely self-sufficient.
1:45:38 PM
MS. LEWIS reviewed slide 8, titled "SHARP-3."
SHARP-3 Tiers
• Tier 1: dentist, pharmacist, physician
o $35,000/year regular or $47,250 very hard-to-fill
• Tier 2: dental hygienist, registered nurse, advanced
practice registered nurse, physician assistant,
physical therapist, clinical psychologist, counseling
psychologist, professional counselor, board certified
behavior analyst, marital and family therapist, or
clinical social worker
o $20,000/year regular or $27,000 very hard-to-fill
• Tier 3: not otherwise eligible under Tier 1 or Tier 2
MS. LEWIS said SHARP-1 and SHARP-2 only had two tiers. This
limited the occupations that could participate and left
significant unmet demand in the health care professional
shortages. SHARP-3 added a third tier.
She explained that a few differences exist between the programs.
Tier 1 and 2 aligned with SHARP-1 and SHARP-2 with a few
changes. The occupations in Tier 2 require masters' degrees as a
minimum. The new tier, Tier 3 will address occupations that were
not eligible under Tier 1 or Tier 2. The bill does not specify
the actual amounts for loan repayments but makes suggested
amounts and allows the commissioner to make the final decision.
The amounts listed on slide 8 for Tier 1 and Tier 2 reflect the
amounts for SHARP-1 and SHARP-2 contracts.
1:48:04 PM
SENATOR BEGICH asked which professions fell into the not
otherwise eligible category.
MS. LEWIS replied that many health care professionals besides
the ones listed do not require a master's degree, including
behavioral health occupations. Some management occupations are
difficult to recruit but these positions are essential for
financial stability and survival. An incentive or loan repayment
can be used for a chief financial operator in an area, if
needed. However, the he program is not limited to clinical
providers.
1:48:56 PM
SENATOR BEGICH related his understanding that the amounts would
be discretionary, based on need.
MS. LEWIS answered that is correct. The SHARP Advisory Council
will make recommendations on priorities and will help to
determine whether the specific application will help reduce the
shortages.
CHAIR WILSON remarked that the SHARP Advisory Council is a
statutorily formed council and is part of the DHSS organization
chart that Commissioner Crum provided during his department
overview to the committee. He asked for a description of hard to
fill positions and how the determination would be made.
MS. LEWIS replied that employers must provide documentation of
unsuccessful recruitment for a period of time.
1:50:41 PM
MS. LEWIS reviewed slide 9, which consisted of a flowchart
diagram to show how the program works and the state's
involvement in the process:
• Health care professionals work at eligible site for a
calendar quarter
• Sites report quarterly to SHARP on professionals'
hours worked
• SHARP adjusts maximum payment amount for hours worked
• SHARP invoices sites for professional's program
payment and administrative fee
• Sites send SHARP their quarterly payment
• SHARP makes loan payments to lenders, and/or direct
incentives to professionals
MS. LEWIS said that the administrative fees will probably be
five percent of loan value. Since employers pay after the work
is completed, the funds are never at risk if someone quits or
does not complete a contract. Loan payments are made to the
lender rather than the professional, which is a key factor in
the IRS exemption. This is the reason the loan payments are not
considered income. However, direct incentives to professionals
are taxable income. The program provides data regularly to the
advisory council on the contracts paid and pending amounts.
1:53:34 PM
SENATOR COGHILL asked for clarification about on loan payment
process.
MS. LEWIS answered that the professional employee has incurred
student loan debt. The loan repayment would be made against that
debt. The checks would go directly to the lender, not to the
professional.
SENATOR COGHILL asked if the direct incentive is an actual cash
payment to the professional.
MS. LEWIS answered yes; direct incentive goes from the state to
the employee because the lender is not involved in that process.
1:55:01 PM
MS. LEWIS reviewed slide 10, "In closing."
[SB 93]
? Keeps health care professionals in rural communities
? Promotes health and economic community stability
? Ensuring a healthier future for all Alaskans
? At the lowest possible cost.
1:55:30 PM
SENATOR GIESSEL expressed significant concerns about the cost of
health care for Alaskans and on balance billing. She asked
whether these professionals receiving SHARP funding are required
to be in-network providers or if the professionals can be out-
of-network providers. In network means the providers have signed
contracts with an insurer and negotiated reimbursement rates.
Out of network providers means that the providers have not
negotiated those rates and as a consequence, the insurance will
pay what it thinks is reasonable and the patient gets a
"surprise bill". This amount is the gap between what the
physician charges and what the insurance pays. The gap can be
substantial and a budget breaking for families. She asked
whether these providers were required to be in-network
providers.
MS. LEWIS replied that there was no such requirement.
1:56:58 PM
SENATOR GIESSEL said that it is possible that the recipients
could be out-of-network providers who are providing specialized
services, high-cost services, and adding to the cost burden of
their patients.
MS. LEWIS responded that the majority of these professionals
predominantly serve Medicaid, Medicare, and Indian Health
Services patients and a very small percentage serve patients
with private-pay insurance. Part of the underserved definition
is that the provider would be serving uninsured or publicly
covered patients.
1:57:53 PM
SENATOR GIESSEL asked if the committee could request how many
providers serve insured patients and uninsured patients, and the
number of out-of-network providers, who may submit surprise
bills. As a nurse practitioner, she understands what the term
underserved means. She asked if the department considered if
underserved areas have sufficient infrastructure to allow these
health care professionals to practice. For example, a
radiologist must have a certain level of technology available.
MS. LEWIS replied that an interested professional must find a
position with an eligible employer who has already proven work
in a health shortage area providing services for the
underserved. An employer must already have the infrastructure in
order to hire the professional or have the intent to provide the
necessary infrastructure.
SENATOR GIESSEL clarified that it is not necessarily the lack of
interest in the health care professional in serving in an area.
It may be the lack of infrastructure such as specialized
equipment or an internet connection that might limit how diverse
the provider group could be in a certain area.
MS. LEWIS acknowledged that some natural limitations on the
array of services that are available in a certain area exist.
This program would help ensure that the employer can staff for
services the providers can offer. If employers want to offer new
services, this could help them find staff, but it would not
address other types of issues that limit access to care.
2:00:55 PM
SENATOR COGHILL said that it appeared that most of the employers
would be using public dollars.
MS. LEWIS answered that if he meant that these employers serve
Medicaid or Medicare patients and therefore those are public
dollars, she would agree. She explained that the intent is to
provide access to care, especially primary care, as close to
home as possible since that care is less expensive. It can help
avoid more expensive care later on, she said.
SENATOR COGHILL related his understanding that this bill would
incentivize people to serve in public health care facilities,
such as the Indian Health Service and hospitals that bill
Medicaid. The bill would use different forms of public money to
incentivize the care.
CHAIR WILSON clarified that the intent is not to use state funds
to incentivize providers to utilize the funding. The money will
come from health foundations, private employers, and health
facilities. These funds will help incentivize the loan repayment
program. Using the state allows the funding to be tax
deductible. He offered to review the fiscal note later but said
that it is cost neutral.
2:03:06 PM
SENATOR COGHILL suggested that working with nonprofits and
Indian Health Services would not have any deductions. He asked
for the scope of money would be coming from for the program. He
asked for help understanding this as the bill progresses.
CHAIR WILSON said dentist providers, advance nurse
practitioners, and private behavioral health that are for profit
could benefit from tax deductions if the practices were in one
of the underserved designated places.
2:04:44 PM
MS. LEWIS presented the sectional analysis for SB 93:
Sec. 1. Adds a new Article 2, Health Care
Professionals Workforce Enhancement Program, to AS
18.29, Health Care Professions Loan Repayment and
Incentive Program, in which health care professionals
agree to work for three years at underserved sites
with health professional shortages in exchange for
repayment of student loans or direct incentives.
Employers fully fund the program. An advisory council
provides oversight and evaluation of the program.
Sec. 18.29.100. The legislation's intent is to ensure
that communities and individuals have equal access to
health care by providing health care services in
underserved or health care professional shortage
areas.
Sec. 18.29.105(a). The program's purpose is to address
the increasing shortage of health care professionals
in the state by expanding the distribution of health
care professionals.
Sec. 18.29.105(b). The program must include (1)
employer payments, (2) direct incentives, (3) student
loan repayment, (4) procedures for designation and
prioritization of eligible sites, (5) an application
process for eligible sites and health care
professionals in Tier I, II, and III occupations, (6)
public information and notices relating to the
program, and (7) a 12-year lifetime maximum for
participation by a health care professional.
2:06:22 PM
Sec. 18.29.105(c). An advisory council appointed by
the commissioner will provide program oversight and
evaluation, and make recommendations to the department
on (1) identification and monitoring of underserved
and shortage areas, (2) eligible sites, (3) employer's
ability to pay, (4) prioritization of sites and
professionals for participation,(5) contract award
priorities, (6) program capacity, (7) strategic plans,
and (8) program data management. The council consists
of members with health care expertise, including
expertise in economic issues affecting the hiring and
retention of health care professionals, but may not
include an employee of the department. Members are
uncompensated but entitled to per diem and travel
allowances.
Sec. 18.29.105(d). The commissioner shall, in
consultation with the advisory council, (1) administer
and implement the program, (2) classify eligible sites
as regular or very-hard-to-fill, (3) set annual
maximum program payment amounts, (4) establish
procedures for allowable leaves of absence, civil
penalties, and priorities for participation.
2:07:57 PM
Sec. 18.29.105(d)(4)(B). Civil penalties are not to
exceed $1,000 per violation of this chapter,
regulations, or contracts.
Sec. 18.29.105(e). The department must submit an
annual report to the advisory council on or before
July 1, describing the participation rates, costs, and
effect on health care shortage areas for the prior
calendar year.
Sec. 18.29.105(f). The department may (1) contract for
services and (2) adopt regulations.
2:08:54 PM
SENATOR BEGICH asked how services is defined.
MS. LEWIS said that if the department has such a volume that it
could not handle the program with its existing staff the type of
services would be most likely be to enlist the services of a
financial manager to manage the contracts.
She continued:
Sec. 18.29.110. Employers will make nonrefundable
quarterly payments to the department which (1) fully
cover the cost of the professional's program payment,
(2) may be adjusted based on the employer's ability to
pay, and (3) must include an administrative fee.
Employers may use funding for their payments from any
available source, including philanthropy, government,
community organizations, or individuals.
AS 18.29.115. Payments are initially three years with
up to three renewal periods for a maximum of 12 years.
Health care professional applicants must (1) submit an
application, (2) be otherwise eligible, and (3) not
exceed the 12-year lifetime limit. The combined amount
of loan repayment and direct incentive per
professional may not exceed the annual maximum program
payment amount. Payments are made after the
professional completes a calendar quarter of qualified
employment. Payments are prorated based on number of
qualified employment hours the professional worked.
The total number of program participants is limited by
available funding appropriated by the legislature.
AS 18.29.120. Eligible professionals may receive
direct incentive quarterly cash payments. Employers
provide the payment amount.
AS 18.29.125. Eligible professionals may receive
student loan repayments. Employers provide the payment
amount. Student loans are eligible if the loan was
issued by a government or commercial entity for
qualified student loan debt and resulted in a
certificate, license or degree required for employment
as a Tier I, II, or III professional. No more than
33.3% of the loan balance at the beginning of the
professional's participation will be paid in any one
year. Student loans are not eligible if these loans
are to be repaid by another source, consolidated with
an ineligible loan, or refinanced as an ineligible
loan.
2:12:25 PM
She said that providers cannot have a concurrent
obligation. For example, if someone was in the
National Health Service Corporation, the person could
not also be eligible for SHARP-2 since these providers
would benefit from one program or the other during the
same timeframe.
AS 18.29.130. Health care professionals must (1)
submit an application, (2) be engaged in qualified
employment at a participating eligible site, (3) be
licensed or exempt from licensure, (4) meet program
participation priorities, and (5) satisfy other
criteria. In addition, professionals with student loan
repayment must also have an unpaid balance on one or
more eligible student loans verified by the Alaska
Commission on Postsecondary Education.
2:13:31 PM
MS. LEWIS referred to the definitions but did not review them:
AS 18.29.199. Definitions.
(1) and (2) "Commissioner" and "department" mean the
department of health and social services.
(3) "Eligible site" means a service area or health
care facility that provides health care services in
underserved or health care professional shortage
areas.
(4) "Employer payment" means the payment an employer
makes to the department for participation in the
program.
(5) "Program" means the health care professionals
workforce enhancement program.
(6) "Qualified employment" means employment of a
health care professional for a three-year term at an
eligible site at which the professional is hired or
contracted and paid to work in a full-time or not less
than half-time position.
(7) "Tier I health care professional" means a licensed
or exempt from licensure dentist, pharmacist,
physician who spends at least 50% of his or her time
on direct patient health care services.
(8) "Tier II health care professional" means a
licensed or exempt from licensure dental hygienist,
registered nurse, advanced practice registered nurse,
physician assistant, physical therapist, clinical
psychologist, counseling psychologist, professional
counselor, board certified behavior analyst, marital
and family therapist, or clinical social worker.
(9) "Tier III health care professional" means a person
who is employed at an eligible sited who is not
otherwise eligible under tier I or tier II.
2:13:36 PM
SENATOR BEGICH directed attention to AS 18.29.130, which states
that the loans have to be verified by the Alaska Commission on
Postsecondary Education (ACPE). He said the legislature has
proposals before it to eliminate the commission. He asked how
the loans would be verified if that were to occur.
MS. LEWIS replied that it has been brought to their attention,
but the department has not fully considered it.
2:14:15 PM
CHAIR WILSON said that the ACPE is currently standing and it
would be difficult to consider pending legislation that has not
passed the body yet.
SENATOR BEGICH said he was pointing it out, so the department
had an awareness and it could be addressed, if needed.
CHAIR WILSON said the committee was soliciting suggested
amendments. He suggested the Department of Education and Early
Development could look consider that aspect. For example, it
could be the responsibility of one of the commissioners.
2:14:53 PM
MS. LEWIS continued the sectional analysis:
Sec. 2, 3, 7, 9 and 10. Moves advanced practice
registered nurses from the list of eligible
occupations in Tier II to Tier I if the Board of
Nursing requires completion of a Doctor of Nursing
degree to practice on or before July 1, 2024. Moving
advanced practice registered nurses to Tier 1 takes
effect 30 days after the Board of Nursing notifies the
revisor of statues that the board adopted regulations
requiring a doctorate per Sections 2, 3, and 7, but
only if the board gives notification on or before July
1, 2024.
Sec. 4. Repeals the existing health care loan
repayment and incentive program in AS 18.29.010
18.29.099, which is scheduled to sunset July 1, 2019.
Sec. 5. This act is applicable to applications or
contracts on or after July 1, 2019.
Sec. 6. The existing advisory council will act as a
transition council until a new advisory council is
appointed by the commissioner.
Sec. 8 and 11. This act is effective retroactive to
July 1, 2019, if Section 1 takes effect after July 1,
2019.
Sec. 12. Except for Sections 10 and 11, the effective
date is July 1, 2019.
2:16:33 PM
CHAIR WILSON said DHSS would like to discuss some potential
situations prior to the amendment process.
SENATOR GIESSEL commented that the bill does not state that it
is at the request of the department, but it sounds like it is.
CHAIR WILSON explained that the City of Valdez approached his
office with an interest in implementing something very similar.
He suggested that this bill was the result of discussions
between a number of different provider groups, including the
SHARP Advisory Council and the department about how to address
underserved areas with the upcoming sunset of SHARP-2.
2:17:41 PM
SENATOR GIESSEL said that she understood the goal. She
acknowledged that the state has underserved areas. However,
Section 18.29.100 reads, "The legislation's intent is to ensure
that communities and individuals have equal access to health
care by providing health care services in underserved or health
care professional shortage areas." However, that is unattainable
and sounds like federal wording, she said. She expressed concern
that the legislative intent sets unrealistic expectations.
Communities like Point Lay with 350 people will not have equal
access to health care providers as in other parts of the state.
The same could be said for McGrath, which has a nurse
practitioner. She asked for the source of the intent language.
Although it is a great idea, the legislature needs to be
realistic, she said. Many self-insured groups are sending people
outside of the state for surgery because the health care costs
are so high in Alaska.
2:19:12 PM
MS. LEWIS replied that part of the language came from the IRS
code related to the income tax exemption. It indicates that the
program is intended to provide for increased availability of
health care services in underserved areas or health care
professional shortage areas as determined by such state. The
language that Senator Giessel referred to is current language
under AS 18.29.010, related to the SHARP-2, which is a program
that has been in place since 2012.
SENATOR GIESSEL said that she agrees with "increased access."
That is a goal the state should have and is measurable and
achievable. Even if that language was articulated previously
does not mean that the committee should not change it.
CHAIR WILSON said he understood her sentiment.
2:20:47 PM
SENATOR COGHILL asked if SHARP 2 provides a direct subsidy to
contractors.
CHAIR WILSON replied that the state made payments on behalf of
the students with loans to the loan guarantors.
2:21:17 PM
SENATOR COGHILL related his understanding that that an incentive
exists if the payment is greater than the loan payment.
CHAIR WILSON added that most hospitals have a hiring bonus or
cash incentive for certain providers. Hospitals commonly offer
bonuses of $2,000 to $5,000 to nurses. He was familiar with one
hospital offering a bonus of up to $10,000 to obtain a health
care professional because of the shortages in the state. This
bill would not only offer a loan repayment, but it could also
offer incentives for communities to be more competitive.
SENATOR COGHILL asked if that would be up to the hiring
authority to provide the offer. He explained that he is
interested because providers could be working for governmental
entities or for the private sector. He asked for further
clarification how it would work if a government worker wanted
someone more than the private sector does, the agency could
increase the bonus.
2:22:53 PM
CHAIR WILSON said for example, hospital B would pay the
additional money to the state to provide the money for the
incentive.
SENATOR COGHILL said that sounds good in theory, until the state
starts providing grants under this system. He asked if
nonprofits that need nursing care could compete with private
doctors.
2:24:02 PM
MS. LEWIS recapped that he was asking if all the eligible sites
have the same level of dollar participation to avoid pitting
entities against each other. She said the department tries to
avoid these situations by allowing employers to get money for
incentives from any source since small practices may not be able
to come up with as much money as larger ones. The funding does
not have to come from earnings, but can come from philanthropy,
a GoFundMe account, or someone who willed the person money.
SENATOR COGHILL referred to Section 18.29.120, which read,
"Eligible professionals may receive direct incentive quarterly
cash payments. Employers provide the payment amount." He said it
appeared that the commissioner would establish an amount the
professional is qualified to receive. He asked how that would
work.
MS. LEWIS replied that under SHARP-2, the amounts were set in
statute. One issue that came up in discussions was that the
department found SHARP-2 was too restrictive because it set both
a dollar amount and capped the number of participants. The
department prefers to set the amounts in statute rather than to
cap the number of participants or to allow the commissioner to
set them. She suggested that this would allow the department to
meet the demand as the program grew. SHARP-2 only operated in
full force for two years, but it had 83 of the 90 maximum
participants allowed.
2:26:58 PM
CHAIR WILSON said he would hold off reviewing the fiscal note in
order to have time for public testimony.
SENATOR BEGICH pointed out that fiscal note, from the Department
of Health and Social Services (DHSS), Public Health, Emergency
Programs, OMB Number 2877, references Senate Bill 89 in the
analysis instead of SB 93.
CHAIR WILSON described that as a typo.
SENATOR BEGICH said that he wanted to make sure the committee
passes the right fiscal note.
MS. LEWIS agreed that Senator Begich was correct.
2:28:05 PM
RACHEL GEARHART, Clinical Director, JAMHI Health and Wellness,
Inc., Juneau, spoke in support of SB 93. She said she has been a
licensed clinical social worker in Alaska since 2008. She
volunteers on the SHARP Advisory Council and serves as co-chair.
She lives in Alaska Senate District Q, which is not a federally
designated geographic Health Professional Shortage Area (HPSA).
Unless someone works for the tribal health organization in
Juneau, the health care professionals are not eligible for
student loan repayment through SHARP-1 or National Health
Service Corps. The areas represented by Senator Begich, Senator
Giessel, Senator Coghill, and Senator Stevens are not federally
HPSAs. One part of Senator Wilson's district in upper Mat-Su is
designated for dental services. These districts will all benefit
from SB 93.
She said that Chair Wilson, as the sponsor of the bill,
understands how valuable the designation is for recruiting and
retaining quality health care professionals. The program can
extend the same recruitment and retention opportunities to the
whole state at no additional expenditures to the state. She
hoped there would be no sunset date for SHARP-3.
MS. GEARHART said that was one of the 83 recipients of SHARP-2.
She paid her student loan for seven years, then had a three-year
term for support of service. After 10 years she was free of
student loan debt, paying the debt off 20 years early. She still
works for the same agency she did when she received her SHARP-2
loan repayment. She said she has worked in Alaska almost 13
years, which demonstrates that recruitment and retention works.
2:30:50 PM
MS. GEARHART said those in the room cannot designate Alaska as a
HPSA, but the state can use SHARP-3 to recruit and retain
quality staff to serve vulnerable and underserved Alaskans. The
committee may be interested to know that [the SHARP Advisory
Council] receives data from the quarterly SHARP data reports
that Ms. Lewis described. The [council] can track who works
primarily in substance use capacities, such as people providing
Medicaid-assisted treatments, and can track which positions are
full time, permanent positions that are replacing what was once
filled by a costly locum tenens position. The [council] learns
important demographics that can be used for further recruitment
and retention efforts for Alaska's health care professionals,
she said.
MS. GEARHART said that SB 93 would allow the state's biggest
community mental health centers in Anchorage, Fairbanks, Juneau,
and Ketchikan to be eligible sites without having to also be
federally qualified health centers. Often the clients served at
those agencies are also being served with sliding fee schedules,
still serving vulnerable and underserved Alaskans in urban
populations could be served. SHARP-3 will not only expand
eligible sites, but it will also expand eligible professions.
For example, licensed professional counselors were not included
in SHARP-1. Occupational therapists, art therapists, case
managers, certified nurse assistants, training coordinators,
chemical dependency counselors, health care faculty members,
phlebotomists, and peer recover coaches are just some examples
of professions that could could be included in SHARP-3 in the
Tier 3 setting.
2:32:40 PM
MS. GEARHART said that in her line of work, the therapeutic
alliance is considered the most important factor in how well
people will work together. Clients in primary, dental, or health
care with high ACEs [Adverse Childhood Experiences] scores, or
high trauma, often have comorbid conditions and coexisting
disorders. Once these patients start to connect with the
provider, these patients make progress and have improved health
outcomes. SHARP-3 support for service helps all Alaskans live
their own best lives, she said.
2:34:06 PM
TOM CHARD, Chief Executive Officer, Alaska Behavioral Health
Association, Juneau, spoke in support of SB 93. He said the
Alaska Behavioral Health Association is a private, nonprofit
group of over 60 mental health and substance abuse treatment
providers, secular and non-secular, tribal and non-tribal health
care providers who help people of all ages achieve and maintain
recovery from behavioral health disorders. These providers are
united in their vision of access to quality, cost effective
behavioral health care for Alaskans. To date, 328 SHARP
contracts have been signed. Of those, 94 practitioners have been
behavioral health providers, he said. Both SHARP-1 and SHARP-2
limit who can participate by practitioner type and location. He
listed the first half dozen provider organizations that have
health care practitioners who participated in order to give
members a sense of who is involved, including the Alaska Island
Community Services in Wrangell, Central Peninsula Hospital in
Soldotna, Bethel Family Clinic, Bristol Bay Area Health
Corporation in Dillingham, Compassionate Directions in Palmer,
and Cordova Community Medical Center.
2:35:39 PM
MR. CHARD said that SB 93 would allow for a greater variety of
health care providers. The association currently has 12
qualified behavioral health provider types. Many of these
practitioners are not eligible for SHARP-1 or SHARP-2, either
because of the provider type or their work location. The
provision that allows for an increased variety of health care
providers could also help support Alaskans who work in the
health care industry who are concurrently pursuing higher
education and credentialing. This bill would also allow health
care practitioners not located in the Health Professionals
Shortage Areas to participate. In part, this new provision will
recognize that a lot of health care services provided in urban
areas also benefit the balance of the state.
2:36:38 PM
He said that SB 93 would increase access to health care
services, improves the quality of health care, and reduces the
overall cost of health care. This is known as the triple aim and
usually achieving one aim is doing well. However, SB 93 achieves
all three without any state funding. The Alaska Behavioral
Health Association has worked diligently toward the solution
provided in SB 93. The ABHA is dedicated to seeing this through
for the benefit of Alaskans.
2:37:59 PM
JEANNIE MONK, Senior Vice President, Alaska State Hospital and
Nursing Home Association (ASHNHA), Juneau, spoke in support of
SB 93. She said that ASHNHA is a member of the SHARP Advisory
Council and has been involved with SHARP since its inception.
The proposed program provides one way to address the shortage of
health care professionals.
She said she echoes Ms. Gearhart's testimony. A number of small,
rural facilities in Alaska do not meet the requirements of
Health Professional Shortage Area and are not eligible for the
existing programs. SHARP-3 will support a variety of practice
settings, locations, and provider types. The council believes
that a broad set of eligible occupations is needed to address
changing workforce shortages. Currently, loan payment and
recruitment incentives are used throughout the Lower 48. In
order to attract health care professionals, Alaska needs to
offer the same type of assistance. This program would accomplish
this without using any general fund money. As part of this
program, it is important to give local control to allow
communities to solicit funds to support recruitment of providers
to meet their needs. The council supports the effort to build on
existing SHARP infrastructure while maximizing local
contributions. Funding can be contributed from different
sources, such as businesses, private foundations, and trade
associations, government entities such as cities, foundations,
or employers. Allowing additional types of funding will give one
more tool to address the challenge. ASHNHA is prepared to
support its members in efforts to utilize SHARP-3 as soon as it
is available.
MS. MONK said that while the council and ASHNHA support SHARP-3
and its emphasis on public-private partnerships, it is important
to remember that this program will provide only one piece of the
support needed to have a strong healthcare system in Alaska.
She recalled the committee members previously asked, "If we
build it, will they come. If we have this program, will private
funders and employers support it?" Her ASHNHA members believe
so. The ASHNHA members already make payments to recruit people
to staff their facilities. This program will allow employers a
structured way to provide loan repayments or incentives and the
associated tax benefits, which allows their dollars to go
further. One caveat is that in order for private industry and
communities to invest funds in this type of a program, the
industry needs a stable environment to conduct business. Health
care organizations need stability in the rates paid by Medicaid
and the future direction of the Medicaid program. These
organizations need a stable business environment to help face
the challenges of recruiting. Alaska hospitals and nursing homes
want to be part of the solution and are eager to continue SHARP
[3] and support workforce development in Alaska.
2:41:34 PM
MOLLY GRAY, Executive Director, Alaska Pharmacists Association
(APA), Anchorage, spoke in support of SB 93. She said the
program will benefit patients, practitioners, and the state.
This is a creative system of loan repayment for recruitment and
retention of health care workers. Over 30 pharmacists have
participated in this program to date, from Nome to Craig and
many places in between. These APA members join a whole multitude
of others in the health care industry who have benefitted from
this system. SHARP-3 is a winning proposition for all, she said.
2:42:53 PM
NANCY MERRIMAN, Executive Director, Alaska Primary Care
Association (APCA), Anchorage, spoke in support of SB 93. She
said she wanted to highlight three ways the legislation will
help health centers better serve Alaskans. First, Alaska has a
shortage of health professionals of all types. Health center
leaders constantly grapple with vacant health care clinician
positions. Although health care jobs remain the fastest growing
sector in the Alaska labor force, demand outpaces the
availability. Alaskans are growing older and need more health
care, especially with the increasing incidence of chronic
disease requiring additional constant care. Health care
professionals are not distributed evenly across the state.
Second, SHARP and other loan repayment programs have been
critical for community health care centers. Since its inception
in 2010, SHARP-1 issued 172 contracts to health centers and
SHARP-2 issued 47 to health care providers.
She said that when the Alaska Primary Care Association (APCA)
surveys health care centers about the most important workforce
issues, the response is overwhelmingly about recruitment and
retention and the centers appreciation of SHARP. In 2018, 80 out
of the 105 candidates accepted in the SHARP-1 program were
practicing in community health centers. Third, SHARP-3 is
innovative and does not require any state general fund dollars.
APCA appreciates the SHARP Advisory Council's innovative
thinking and contribution to the solution of the health care
workforce shortages in Alaska. SHARP-3 can be privately funded,
which means that loan repayment and longevity incentives can be
expanded to more practitioner types and clinical sites. This
will greatly increase the variety of health professionals and
sites who participate. She directed attention to APCA's letter
of support for more detail.
2:45:40 PM
THOMAS HUNT, M.D., representing self, Anchorage, spoke in
support of SB 93. He said he is has served in several roles as
the medical director of three urban and rural FQHCs [Federally
Qualified Health Centers] community health care centers, and
later chief executive of the Providence Medical Group. He has
recruited scores of providers to Anchorage and Alaska in
general. He said that SHARP helped quite a bit because many of
these services are urban and those providers would not qualify
for the National Health Service Corps reimbursement as Ms.
Gearhart pointed out.
He said regarding Senator Giessel's concern, that many of the
services that Alaskans want in Anchorage, these subspecialists
would not be attracted to the state because of a lack of
reimbursement or enough population to defend hiring a pediatric
endocrinologist. Everyone wants subspecialists and while doctors
can export that care to Seattle, pediatric endocrinology is not
a surgical specialty. It is the type of provider patients see
every month so it would become even more expensive in that
setting. SHARP-3 would allow loan repayment for subspecialists
working in cities is a huge improvement over SHARP-1 and SHARP-
2. For example, he recently spoke to an inpatient psychiatrist
who provides medical consultations to acute medical inpatients
in the hospitals in Anchorage. She would not be eligible for
reimbursement under SHARP-1 or SHARP-2 or the National Health
Corp because there are plenty of psychiatrists in Anchorage.
However, none are willing to do acute inpatient psychiatry. It
is hard to recruit psychiatrists, much less into that type of
difficult environment. SHARP-3 will offer providers the
potential to keep this inpatient psychiatrist in the community
via loan repayment.
2:48:14 PM
MIKE COONS, representing self, Palmer, asked if SB 93 would
incentivize doctors to take on Medicare patients. He said he had
numerous questions about health care professional shortage
areas. He serves on the Alaska Commission on Aging and as the
president of a senior advocacy organization. One of the biggest
problems seniors face with their health care is that many
doctors in Anchorage, the Mat-Su Valley, and throughout the
state who do not take Medicare patients, which creates a
critical shortage. He related his own experience, that he became
a patient with his provider before he turned 65. He later found
out that his doctor would not have accepted him as a patient if
he had applied after he turned 65. He asked if this bill will
provide any incentive for repayment for doctors to take on
Medicare patients.
CHAIR WILSON replied that due to time constraints, the committee
cannot answer questions. However, if Mr. Coons contacts his
office that he will try to answer his questions.
2:50:48 PM
JEREMY O'NEIL, Administrator, Providence Valdez, Health Advisory
Council, Valdez, spoke in support of SB 93. He said is also an
ex-officio member of the Providence Health Advisory Council. He
offered his belief that SHARP-2 was a good program, but it will
sunset and has not issued new contracts for a few years. Valdez
has benefitted from SHARP-1 and SHARP-2. The community has a
licensed clinical social worker, a registered nurse, and a
physical therapist who have been critical members of the Valdez
care team for a number of years. Valdez has an 11-bed critical
access hospital, 10-bed long-term care, 24/7 emergency room and
a primary care clinic. However, only a handful of doctors run
all those services for a population of 4,000 in the winter and
8,000 in the summer. Valdez faces extreme difficulty in
recruiting and retaining health care providers due to Valdez's
geographically isolation. The high cost of travel coupled with
the lack of community connections and longevity means that using
itinerant health care services results in less than ideal care.
The high cost of medical debt for education is a huge burden on
new providers. Being able to partner with private foundations,
local governments, and employers with SHARP-3 will remove the
state as the funding source. Making this available to those
community stakeholders who are willing to invest will further
the providers' ability to be competitive.
He said that in 2017, Valdez conducted a community health needs
assessment and identified four priorities. The first priority is
to support a local health care provider workforce. The
recruitment and retention of health care professionals is an
increasingly difficult prospect. SHARP-3 is a tool that
communities can use to address this issue. Health care graduates
specifically, like pharmacists, therapists, mental health
counselors, and physicians, require advanced degrees and come
out straddled with tremendous amounts of education debt. The
Providence Valdez Health Advisory Council passed a resolution
that the council will share with the committee.
2:54:23 PM
ZAN WHITMAN, representing self, Palmer, spoke in support of SB
93. He said he is a psychiatric nurse practitioner working with
Providence Health and Services. He said that being a recipient
of SHARP has made a large difference in his decision to practice
in Alaska and has given him the ability to continue to serve.
The program works well as a means to recruit and retain
qualified health providers. Expanding SHARP is beneficial since
including more health care services and providers in the SHARP
program can only benefit the state, he said.
2:55:39 PM
CHAIR WILSON closed public testimony on SB 93.
2:57:02 PM
SENATOR GIESSEL requested information pertaining to Sections 7,
9, and 10. She asked the Chair to provide the source that would
require an advanced practice registered nurse (APRN) to hold a
doctoral degree.
[CHAIR WILSON held SB 93 in committee.]
2:58:17 PM
There being no further business to come before the committee,
Chair Wilson adjourned the Senate Health and Social Services
Standing Committee at 2:58 p.
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB 93 v A.PDF |
SHSS 3/25/2019 1:30:00 PM |
SB 93 |
| Senate Bill 93 Sponsor Statement.pdf |
SHSS 3/25/2019 1:30:00 PM |
|
| SB 93 v A Sectional Analysis.pdf |
SHSS 3/25/2019 1:30:00 PM SHSS 4/1/2019 1:30:00 PM |
SB 93 |
| SB 93 Letters of Support 3.21.19.pdf |
SHSS 3/25/2019 1:30:00 PM SHSS 4/1/2019 1:30:00 PM |
SB 93 |
| SHARP-AKJournal-article.pdf |
SFIN 4/9/2019 9:00:00 AM SHSS 3/25/2019 1:30:00 PM SHSS 4/1/2019 1:30:00 PM |
SB 93 |
| AAC 7. 24 Health and Social Services HCPLRand IP.pdf |
SHSS 3/25/2019 1:30:00 PM SHSS 4/1/2019 1:30:00 PM |
SB 93 |
| SHARP-IRS TAX EXEMPTION.pdf |
SHSS 3/25/2019 1:30:00 PM SHSS 4/1/2019 1:30:00 PM |
SB 93 |
| Final Report to Leg 2018 SHARP III.pdf |
SFIN 4/9/2019 9:00:00 AM SHSS 3/25/2019 1:30:00 PM SHSS 4/1/2019 1:30:00 PM |
SB 93 |
| SB093 DHSS Slides.pdf |
SHSS 3/25/2019 1:30:00 PM SHSS 4/1/2019 1:30:00 PM |
SB 93 |
| SB 93 DCCED fiscal note.pdf |
SHSS 3/25/2019 1:30:00 PM SHSS 4/1/2019 1:30:00 PM |
SB 93 |
| SB 93 DHSS Fiscal Note.pdf |
SHSS 3/25/2019 1:30:00 PM SHSS 4/1/2019 1:30:00 PM |
SB 93 |
| SB 93 LoS T Hunt MD.pdf |
SHSS 3/25/2019 1:30:00 PM SHSS 4/1/2019 1:30:00 PM |
SB 93 |
| ANTHC SB93 LOS 3-21-19.pdf |
SHSS 3/25/2019 1:30:00 PM SHSS 4/1/2019 1:30:00 PM |
SB 93 |