Legislature(2019 - 2020)BUTROVICH 205

03/25/2019 01:30 PM HEALTH & SOCIAL SERVICES

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Audio Topic
01:33:28 PM Start
01:33:52 PM SB93
02:58:17 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
*+ SB 93 MEDICAL PROVIDER INCENTIVES/LOAN REPAYM'T TELECONFERENCED
Heard & Held
-Invited Testimony Followed by Public Testimony-
<Time Limit May Be Set>
                    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                                                                                                            
                                                                                                                                
OTHER LEGISLATORS PRESENT                                                                                                     
                                                                                                                                
                                                                                                                                
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: Introduced 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 (ASHNA)                                                                      
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                                                                    
                                                                                                                                
1:33:52 PM                                                                                                                    
CHAIR WILSON announced  the consideration of SB 93.  He noted his                                                               
intent to  introduce the  bill, take  public testimony,  and hold                                                               
the bill in committee.                                                                                                          
                                                                                                                                
CHAIR  WILSON said  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.  If  not                                                               
immediately addressed,  this shortage will rapidly  worsen. SHARP                                                               
is a  loan repayment and  direct monetary incentive  program that                                                               
helps  reduce  staff  shortages by  filling  vacant  health  care                                                               
provider positions in  some of the most  underserved areas across                                                               
the state. SHARP-1 and 2  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  to   date,  the  program,   which  is                                                               
administered by Department of Health  and Social Services (DHSS),                                                               
has  supported more  than 250  practitioners in  nearly 60  sites                                                               
across the  state. SHARP-3  fills 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.  SHARP-3  focuses 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. These  professionals must meet eligibility                                                               
criteria and be engaged in qualified employment.                                                                                
                                                                                                                                
CHAIR WILSON  said that  the program does  not require  any state                                                               
general   funds;   user   fees   cover  the   cost   of   program                                                               
administration.  SHARP-3  is  a  budget-neutral  initiative  that                                                               
addresses   service  shortages   in  the   current  health   care                                                               
landscape,  leverages   community-level  investment   across  the                                                               
state, and improves health outcomes of Alaskans.                                                                                
                                                                                                                                
1:36:48 PM                                                                                                                    
JILL  LEWIS,   Deputy  Director,   Division  of   Public  Health,                                                               
Department of Health and Social  Services (DHSS), Juneau, Alaska,                                                               
presented the following information on SB p3:                                                                                   
                                                                                                                                
        • 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.                                                                                             
                                                                                                                                
MS.  LEWIS  said  employers  fully fund  the  program  by  taking                                                               
advantage of a federal tax exemption  that is available only to a                                                               
state-run program.  The public-private partnership  increases 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 sunsets June 30, 2019.                                                                         
                                                                                                                                
MS. LEWIS  presented the following  information on  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  health  care  is one  of  the  largest and  most                                                               
dynamic  industries  in  Alaska,  but  many  citizens  experience                                                               
challenges  accessing health  care, especially  in rural  Alaska.                                                               
The  availability  of  health  care  services  is  important  for                                                               
maintaining   health,  for   preventing  and   managing  disease,                                                               
reducing  costs from  unnecessary  emergency  room use,  hospital                                                               
readmissions, and  use of  temporary staff.  The state  of Alaska                                                               
must address the shortage of health care professionals.                                                                         
                                                                                                                                
MS.  LEWIS  said  they  have  tried  to  address  some  of  those                                                               
challenges with  an ongoing health  care loan  repayment program.                                                               
The  first iteration  of that  was SHARP-1  with a  federal grant                                                               
source. It  does require  a 50 percent  match, which  is provided                                                               
solely by outside parties. There is  no UGF money. They get money                                                               
from the Mental Health Trust  or another philanthropic entity and                                                               
the  employers contributed.  This  bill does  not affect  SHARP-1                                                               
because it  is operated under  the federal grant.  The sunsetting                                                               
of  SHARP-2 also  does not  affect SHARP-1,  the federal  option.                                                               
SHARP-2 is more of a head-to-head comparison with SB 93.                                                                        
                                                                                                                                
MS. LEWIS presented the following information on 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%                                                                      
                                                                                                                                
MS. LEWIS said the state paid  out all existing contracts to meet                                                               
contractual obligations,  although no  new contracts  were issued                                                               
after 2015. Tier 1 gets paid more than Tier 2.                                                                                  
                                                                                                                                
MS.  LEWIS  presented  information  showing  that  SB  93  is  an                                                               
innovative solution:                                                                                                            
                                                                                                                                
        â?¢ 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 with the sunset of SHARP-2 on June 30, 2019,                                                                
other incentive programs are needed to reduce the health care                                                                   
worker shortages.                                                                                                               
                                                                                                                                
1:43:29 PM                                                                                                                    
MS. LEWIS showed reasons why SB 93 is a win-win opportunity:                                                                    
                                                                                                                                
     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                                                                     
                                                                                                                                
MS. LEWIS presented information on how SHARP-3 works:                                                                           
                                                                                                                                
        • 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 have  to the 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.                                                                                  
                                                                                                                                
MS. LEWIS reviewed the tiers in 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 can participate and has  left a lot                                                               
of  unmet  demand in  addressing  the  health care  professionals                                                               
shortage. SHARP-3 has a new, third  tier. Tier 1 and 2 align with                                                               
what  was  in  SHARP-1  and  SHARP-2  with  a  few  changes.  The                                                               
occupations  in  Tier 2  generally  have  master's degrees  as  a                                                               
minimum. Tier 3 are for  occupations otherwise not eligible under                                                               
Tier 1  or Tier 2.  The bill  doesn't specify the  actual amounts                                                               
for loan  repayments. These are  suggested amounts. It  leaves it                                                               
to the  commissioner. These are the  amounts used for Tier  1 and                                                               
Tier 2 with SHARP-1 and SHARP-2.                                                                                                
                                                                                                                                
1:48:04 PM                                                                                                                    
SENATOR BEGICH asked who would be in not otherwise eligible.                                                                    
                                                                                                                                
MS.  LEWIS replied  that there  are  a lot  of behavioral  health                                                               
occupations  besides  the  listed ones.  Many  behavioral  health                                                               
occupations  don't  require  a  master's  degree  and  management                                                               
occupations are difficult to recruit,  but essential to financial                                                               
stability and  survival. An  incentive or  loan repayment  can be                                                               
used to  get a chief financial  operator if that is  needed in an                                                               
area. It is not limited to clinical providers.                                                                                  
                                                                                                                                
SENATOR  BEGICH clarified  that it  would then  be discretionary,                                                               
based on need.                                                                                                                  
                                                                                                                                
MS. LEWIS  answered that  is correct.  The advisory  council will                                                               
provide  recommendations  on  prioritization  and  will  help  to                                                               
determine  whether it  will  help reduce  the  shortages when  an                                                               
employer submits an application.                                                                                                
                                                                                                                                
CHAIR WILSON  pointed out that  the SHARP advisory council  is in                                                               
the  DHSS  organization  chart that  Commissioner  Crum  provided                                                               
during  his  department  overview  to  the  committee.  It  is  a                                                               
statutory  council  that  is  already  formed.  He  asked  for  a                                                               
description of hard to fill and how the determination is made.                                                                  
                                                                                                                                
MS. LEWIS  replied that employers  must provide  documentation of                                                               
unsuccessful recruitment for a period of time.                                                                                  
                                                                                                                                
MS. LEWIS  presented a diagram of  how the how the  program works                                                               
and how the state is involved 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 fee will probably be five                                                               
percent  of loan  value. The  employers don't  pay up  front. The                                                               
work has  already been completed, so  funds are never at  risk if                                                               
someone quits or does not  complete a contract. Direct incentives                                                               
to professionals are taxable income.                                                                                            
                                                                                                                                
1:53:34 PM                                                                                                                    
SENATOR COGHILL  asked for clarification about  who loan payments                                                               
are made to.                                                                                                                    
                                                                                                                                
MS.  LEWIS  answered that  the  professional,  the employee,  has                                                               
incurred  student loan  debt.  The loan  repayment  goes to  that                                                               
debt.  The  checks  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,  that   because  there  is  no  lender                                                               
involved, the payment goes to the employee from the state.                                                                      
                                                                                                                                
MS. LEWIS  closed her  presentation by stating  that SB  93 keeps                                                               
health care  professionals in rural communities,  promotes health                                                               
and economic community stability,  and ensures a healthier future                                                               
for all Alaskans at the lowest possible cost.                                                                                   
                                                                                                                                
1:55:30 PM                                                                                                                    
SENATOR GIESSEL said  she has had significant  concerns about the                                                               
cost of health care for Alaskans.  She also has had concern about                                                               
balance  billing. She  asked whether  these  folks getting  SHARP                                                               
funding are  required to  be in  network or  can they  be out-of-                                                               
network providers.  In network means  they have  signed contracts                                                               
with  an  insurer  and negotiated  reimbursement  rates.  Out  of                                                               
network  means they  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. It is the gap between what                                                               
the physician  charges and what  the insurance pays. The  gap can                                                               
be substantial  and a  budget breaker for  a family.  These folks                                                               
are getting these benefits. She asked  if they are required to be                                                               
in-network providers.                                                                                                           
                                                                                                                                
MS. LEWIS replied that there is no such requirement.                                                                            
                                                                                                                                
SENATOR GIESSEL said  that it is possible, then,  that they 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  someone  is  serving   uninsured  or  publicly  covered                                                               
patients.                                                                                                                       
                                                                                                                                
SENATOR GIESSEL  asked for  information about  how many  of these                                                               
providers  do serve  insured patients  or uninsured  patients and                                                               
may  be submitting  surprise  bills  as out-of-network  providers                                                               
which  consequently  results  in   surprise  bills.  As  a  nurse                                                               
practitioner,  she knows  what the  term  underserved means.  She                                                               
asked  if the  infrastructure is  available in  these underserved                                                               
areas that  allows these health  care professionals  to practice.                                                               
For example, for a radiologist, there  must be a certain level of                                                               
technology available. She asked if that has been considered.                                                                    
                                                                                                                                
MS. LEWIS  replied that  an interested  professional must  find a                                                               
position with  an eligible employer  who has already  proven that                                                               
the  employer is  doing work  with  the underserved  in a  health                                                               
shortage  area.  An  employer  would have  to  already  have  the                                                               
infrastructure in  order to bring  a person  on or the  intent to                                                               
provide that 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 Internet  connection that  might limit  how diverse                                                               
the provider group could be in a certain area.                                                                                  
                                                                                                                                
MS. LEWIS  responded that there  are some natural  limitations on                                                               
the array of  services available in a certain  area. This program                                                               
helps to  ensure that  they can  staff for what  they can  do. If                                                               
employers want  to offer new  services this could help  them find                                                               
staff, but  it doesn't address  those other types of  issues that                                                               
limit access to care.                                                                                                           
                                                                                                                                
SENATOR COGHILL  asked if the  biggest portion of  employers will                                                               
be public dollars.                                                                                                              
                                                                                                                                
MS.  LEWIS answered  that if  he means  that the  employer serves                                                               
Medicaid  or Medicare  patients  and therefore  those are  public                                                               
dollars, she  would say  yes. Part  of the  intent is  to provide                                                               
access  to care,  especially primary  care, and  do it  closer to                                                               
home, which is  less expensive and helps to  avoid more expensive                                                               
care down the road.                                                                                                             
                                                                                                                                
SENATOR COGHILL said this  is a way to draw people  to an area of                                                               
need. At  first, he thought  this was about private  doctors, but                                                               
it is not.  It is mostly public service areas  like Indian Health                                                               
Service and hospitals  that are billing Medicaid. It  is really a                                                               
way to finance people into  that sector. They are using different                                                               
forms of public money to incentivize  it. That is how it looks to                                                               
him.                                                                                                                            
                                                                                                                                
CHAIR WILSON clarified that the intent  is there will be no state                                                               
dollars  to incentivize  providers  to utilize  the funding.  The                                                               
money will  come from health foundations,  private employers, and                                                               
the health  facilities themselves to  pay for this. It  will help                                                               
them to incentivize  the loan repayment program.  Using the state                                                               
allows it to  be tax deductible. It is cost  neutral. They can go                                                               
over the fiscal note after the sectional.                                                                                       
                                                                                                                                
SENATOR COGHILL asked where the scope of money would be coming                                                                  
from for the program. He asked for help filling that in as they                                                                 
moved along.                                                                                                                    
                                                                                                                                
CHAIR  WILSON  said  dentists  will  be  covered  under  SHARP-3.                                                               
Private clinics  for advanced  nurse practitioners  could benefit                                                               
from  this.  Private  behavioral  health entities  that  are  for                                                               
profit  could  benefit if  they  are  in  one of  the  designated                                                               
places.                                                                                                                         
                                                                                                                                
2:04:26 PM                                                                                                                    
MS. LEWIS presented the sectional analysis for SB 93 Version A:                                                                 
                                                                                                                                
     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.                                                                          
                                                                                                                                
          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.                                                                          
                                                                                                                                
          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 what is defined as services.                                                                               
                                                                                                                                
MS. LEWIS said  the type of services would be  most likely entail                                                               
someone  to assist  with  the financial  aspect  of managing  the                                                               
contracts if  they get to such  a volume that they  cannot handle                                                               
it with  the staffing they  have. They  might need to  enlist the                                                               
services  of  a  financial  agent  to  help.  She  continued  the                                                               
sectional:                                                                                                                      
                                                                                                                                
          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 they are to be                                                               
          repaid   by  another   source,  consolidated   with  an                                                               
          ineligible loan, or refinanced as an ineligible loan.                                                                 
                                                                                                                                
          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.                                                                                
                                                                                                                                
          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 said that AS  18.29.130 states that the loans have                                                               
to  be  verified  by  the   Alaska  Commission  on  Postsecondary                                                               
Education. There  are proposals  to eliminate the  commission. He                                                               
asked how they would verify that.                                                                                               
                                                                                                                                
MS. LEWIS  replied that it  has been brought to  their attention,                                                               
but they haven't thought it through all the way yet.                                                                            
                                                                                                                                
CHAIR WILSON  said it  is currently  standing and  it is  hard to                                                               
write on pending legislation that hasn't passed the body yet.                                                                   
                                                                                                                                
SENATOR BEGICH  said he was pointing  out that it should  be part                                                               
of  the thought  process and  he sees  that it  already is  under                                                               
consideration.                                                                                                                  
                                                                                                                                
CHAIR  WILSON said  they were  looking at  ideas for  amendments.                                                               
Perhaps the  Department of Education and  Early Development could                                                               
look  at that.  It  could be  the responsibility  of  one of  the                                                               
commissioners.                                                                                                                  
                                                                                                                                
MS. LEWIS continued the sectional:                                                                                              
                                                                                                                                
     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.                                                                                                           
                                                                                                                                
CHAIR WILSON said  there are some potential  situations that need                                                               
to be fixed. DHSS wants to run through some amendments.                                                                         
                                                                                                                                
SENATOR GIESSEL  said the bill doesn't  say it is at  the request                                                               
of the department, but it sounds like it is.                                                                                    
                                                                                                                                
CHAIR WILSON said  the bill was at the request  of the department                                                               
and many  folks at the  SHARP council.  Last session the  city of                                                               
Valdez approached his office wanting  to implement something very                                                               
similar. This  is an  iteration going  on between  many different                                                               
provider groups, the SHARP council,  and the department about how                                                               
to come up with a new iteration with the sunsetting SHARP-2.                                                                    
                                                                                                                                
SENATOR GIESSEL said that she  understands the goal. They do have                                                               
underserved  areas. Section  18.29.100, legislative  intent reads                                                               
"intended to  ensure that communities and  individuals have equal                                                               
access to  health care." That  is unattainable. This  sounds like                                                               
federal  wording.  She is  concerned  about  the wording  setting                                                               
unrealistic  expectations. Communities  like Point  Lay with  350                                                               
people  are  not  going  to  have equal  access  to  health  care                                                               
providers as  other parts of  the state.  The same could  be said                                                               
for  McGrath, which  has a  nurse practitioner.  That is  why she                                                               
asks where the  language came from. It is a  great idea, but they                                                               
should be  realistic. Not everyone  in the state will  have equal                                                               
access.  Many  of  the self-insured  groups  are  sending  people                                                               
outside of  the state because the  cost is so high  in Alaska. It                                                               
is a concern that they  are setting unrealistic expectations with                                                               
language like "equal access."                                                                                                   
                                                                                                                                
MS. LEWIS  replied that the IRS  code that relates to  the income                                                               
tax exemption  says 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. That  is where  part of  the language  came from.                                                               
That language that  Senator Giessel is referring to  exists in AS                                                               
18.29.010, which  is the SHARP-2  program that has been  in place                                                               
since 2012.                                                                                                                     
                                                                                                                                
SENATOR  GIESSEL said  that she  agrees with  "increased access."                                                               
That  is  a   goal  they  should  have  and   is  measurable  and                                                               
achievable. Whether  it was  articulated previously  doesn't mean                                                               
they should not change it.                                                                                                      
                                                                                                                                
CHAIR WILSON said she understood her sentiment.                                                                                 
                                                                                                                                
SENATOR  COGHILL  asked   if  there  was  a   direct  subsidy  to                                                               
contractors in the first iteration of  SHARP. He asked if that is                                                               
in this bill.                                                                                                                   
                                                                                                                                
CHAIR WILSON  replied that the  state made payments on  behalf of                                                               
the students with loans to the loan guarantors.                                                                                 
                                                                                                                                
SENATOR  COGHILL   said  regarding   the  direct   incentive,  he                                                               
understands that  there is still  an incentive if the  payment is                                                               
greater than the loan payment.                                                                                                  
                                                                                                                                
CHAIR  WILSON said  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 has seen  one offer a                                                               
bonus of up to $10,000 to  get a health care professional because                                                               
of the shortages  in the state. This says not  only can they give                                                               
someone loan repayment,  but they can also offer  an incentive to                                                               
be competitive.                                                                                                                 
                                                                                                                                
SENATOR  COGHILL  asked  if  that  would  be  up  to  the  hiring                                                               
authority  to offer  that.  He  is asking  because  there is  the                                                               
private part  and government part.  He asked  how it is  going to                                                               
work  out if  a government  worker  wants someone  more than  the                                                               
private sector and they can increase the bonus.                                                                                 
                                                                                                                                
2:22:53 PM                                                                                                                    
CHAIR WILSON  said that it  wouldn't necessarily be the  state of                                                               
Alaska paying state  of Alaska dollars. Hospital B  would pay the                                                               
additional money to  the state to give that person  the money for                                                               
the incentive.                                                                                                                  
                                                                                                                                
SENATOR  COGHILL said  that sounds  good until  the state  starts                                                               
giving grants  and they start  doing this under this  system. The                                                               
nonprofits that may need nursing  care could compete with private                                                               
doctors locally.                                                                                                                
                                                                                                                                
MS.  LEWIS said  that if  she  understood the  question, all  the                                                               
eligible   sites   have  the   same   level   of  dollar   amount                                                               
participation, so  they are  not pitted against  each other  in a                                                               
situation where one  can offer more money than  another. They try                                                               
to  avoid situations  where small  practices may  not be  able to                                                               
come up  with as much  money by allowing  them to get  money from                                                               
any source. It does not have  to come from their own earnings. It                                                               
can come from philanthropy or a  GoFundMe account. It can be from                                                               
someone who willed them money.  It doesn't matter where the money                                                               
came from.  They can find  other money  to support that.  In that                                                               
way they think they are not pitting people against each other.                                                                  
                                                                                                                                
SENATOR   COGHILL  said   that  in   Section  18.29.120,   direct                                                               
incentives,   the   commissioner   establishes  an   amount   the                                                               
professional is qualified to receive. He asked how that works.                                                                  
                                                                                                                                
MS.  LEWIS replied  that  in  SHARP-2, the  amounts  were set  in                                                               
statute. That is  one issue that came up  in discussions. SHARP-2                                                               
was  too restrictive  because it  set  both a  dollar amount  and                                                               
capped the  number of participants.  It has been brought  up that                                                               
they should do one or the other  in this bill and not leave it to                                                               
regulation. Setting the amount in  statute would be preferable to                                                               
capping the  number of participants  so that they could  meet the                                                               
demand as  the program  grew. Although  SHARP-2 only  operated in                                                               
full force  for two years, it  had 83 participants out  of the 90                                                               
max. The amounts could be in  statute instead of leaving it up to                                                               
the commissioner.                                                                                                               
                                                                                                                                
CHAIR WILSON  said he would hold  off going over the  fiscal note                                                               
in order to have time for public testimony.                                                                                     
                                                                                                                                
SENATOR BEGICH  pointed out  that SB089 is  referenced in  the in                                                               
first fiscal note, OMB Number 2877, instead of SB 93.                                                                           
                                                                                                                                
CHAIR WILSON replied that it is just a typo.                                                                                    
                                                                                                                                
SENATOR BEGICH  said that he just  wanted to make sure  they pass                                                               
the right fiscal note.                                                                                                          
                                                                                                                                
MS. LEWIS said it is right.                                                                                                     
                                                                                                                                
2:28:05 PM                                                                                                                    
RACHEL GEARHART,  Clinical Director,  JAMHI Health  and Wellness,                                                               
Inc., Juneau,  Alaska, supported SB 93.  She said she has  been a                                                               
licensed  clinical  social  worker  in  Alaska  since  2008.  She                                                               
volunteers to  sit on the  SHARP 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 town,                                                               
they 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  HPSAs. One part of Senator  Wilson's district in                                                               
upper Mat-Su is designated for dental,  so the bill is of benefit                                                               
to all  of them. She  knows that Chair  Wilson as the  sponsor of                                                               
the  bill  understands  how  valuable   the  designation  is  for                                                               
recruiting and retaining quality  health care professionals. They                                                               
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. They  have                                                               
dabbled  in this  arena  with  SHARP-2. She  was  one  of the  83                                                               
recipients of  SHARP-2. She had  paid her student loan  for seven                                                               
years and had a three-year term  for support of service. After 10                                                               
years she was free of student loan  debt and paid the debt off 20                                                               
years early. She still works at  the same agency she did when she                                                               
received  her SHARP.  She has  been working  in Alaska  almost 13                                                               
years. Recruitment and retention work.                                                                                          
                                                                                                                                
MS. GEARHART said those in the  room cannot designate Alaska as a                                                               
HPSA,  but they  can use  SHARP-3 to  recruit and  retain quality                                                               
staff to  serve vulnerable and  underserved Alaskans. They  get a                                                               
fair amount  of data from  the quarterly SHARP data  reports that                                                               
Ms.  Lewis  described. They  can  track  who works  primarily  in                                                               
substance  use capacities,  such  as  people providing  Medicaid-                                                               
assisted  treatments. They  can  track which  positions are  full                                                               
time,  permanent  positions  that  are replacing  what  was  once                                                               
filled by  a costly locum  tenens position. They  learn important                                                               
demographics  that  can  be  used  for  further  recruitment  and                                                               
retention efforts for Alaska's health care professionals.                                                                       
                                                                                                                                
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,                                                               
so  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.                                                                                                                 
                                                                                                                                
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.  Once  clients  in primary  care  or                                                               
dental care or health care,  those people with high ACEs [Adverse                                                               
Childhood Experiences]  scores, high trauma, often  with comorbid                                                               
conditions and  coexisting disorders, once they  start to connect                                                               
with  the  provider,  there  is   progress  and  improved  health                                                               
outcomes.  Disruptions  in  service  delivery  because  of  staff                                                               
turnover that may  be due to high cost of  living is unavoidable.                                                               
SHARP-3 support  for service  helps all  Alaskans live  their own                                                               
best lives.                                                                                                                     
                                                                                                                                
2:34:06 PM                                                                                                                    
TOM  CHARD, Chief  Executive  Officer,  Alaska Behavioral  Health                                                               
Association, Juneau, Alaska, supported SB  93. He said the Alaska                                                               
Behavioral Health  Association is  a private, nonprofit  group of                                                               
over  60 mental  health and  substance abuse  treatment providers                                                               
helping 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. Both SHARP-1 and SHARP-2  limit who can participate by                                                               
practitioner type and location.  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  are just  a  few of  the agencies  who                                                               
participated  in SHARP.  He stopped  reading once  he got  to the                                                               
c's.                                                                                                                            
                                                                                                                                
MR. CHARD said that SB 93  allows for a greater variety of health                                                               
care  providers. In  behavioral  health, they  currently have  12                                                               
qualified  behavioral  health  provider   types.  Many  of  these                                                               
practitioners  are not  eligible for  SHARP-1 or  SHARP-2, either                                                               
because of provider  type or where they work.  The provision that                                                               
allows for  an increased variety  of health care  providers could                                                               
also help  support Alaskans  who are working  in health  care and                                                               
concurrently  pursuing higher  education and  credentialing. This                                                               
bill would  also allow health  care practitioners not  located in                                                               
Health  Professionals  Shortage  Areas   to  participate.  SB  93                                                               
increases access  to health care  services, improves  the quality                                                               
of health care,  and reduces the overall cost of  health care. It                                                               
is  known as  the triple  aim and  usually achieving  one aim  is                                                               
doing well. Achieving all three  is practically unheard of. SB 93                                                               
achieves all three  with no state funding.  The Alaska Behavioral                                                               
Health  Association has  worked  diligently  toward the  solution                                                               
provided in SB 93. They are  dedicated to seeing this through for                                                               
the benefit of Alaskans.                                                                                                        
                                                                                                                                
2:37:36 PM                                                                                                                    
CHAIR WILSON opened public testimony and set a two-minute limit.                                                                
                                                                                                                                
2:37:59 PM                                                                                                                    
JEANNIE MONK,  Senior Vice President,  Alaska State  Hospital and                                                               
Nursing Home  Association (ASHNA),  Juneau, Alaska,  supported SB                                                               
93. She  said that  ASHNA is  a member of  the SHARP  council and                                                               
have been involved  with SHARP since its  inception. The proposed                                                               
program  is  one way  to  address  the  shortage of  health  care                                                               
professionals. She  echoes what  Ms. Gearhart  said. 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.  They believe                                                               
that a  broad set  of eligible occupations  is needed  to address                                                               
changing  workforce   shortages.  Currently,  loan   payment  and                                                               
recruitment incentives are  used across the country.  In order to                                                               
attract  health care  professionals,  Alaska needs  to offer  the                                                               
same  type of  assistance.  This program  does  this without  any                                                               
general funds. As  part of this program, it is  important to give                                                               
local control,  so that  local communities  can solicit  funds to                                                               
support recruitment of providers to  meet their local needs. They                                                               
support  the effort  to build  on  existing SHARP  infrastructure                                                               
while maximizing  local contribution. Money could  be contributed                                                               
from different  sources, such as a  business, private foundation,                                                               
trade   association,  government   entities  such   as  a   city,                                                               
foundations,  or  employers.  Bringing  in  additional  types  of                                                               
funding will give  one more tool to address  the challenge. ASHNA                                                               
is prepared to support its  members in efforts to utilize SHARP-3                                                               
as soon as its available.                                                                                                       
                                                                                                                                
MS. MONK  said that while  they support SHARP-3 and  the emphasis                                                               
on public-private partnerships, it  is important to remember that                                                               
this program  is only one piece  of the support needed  to have a                                                               
strong  health care  system in  Alaska. She  heard the  committee                                                               
members ask the question, "If we  build it, will they come. If we                                                               
have  this program,  will private  funders and  employers support                                                               
it." Her  members say  yes. They already  make these  payments to                                                               
recruit people to  staff their facilities and  this program gives                                                               
employers  a   structured  way  to  provide   loan  repayment  or                                                               
incentives  and the  associated tax  benefit, which  allows their                                                               
dollars to go  further. However, one caveat is that  in order for                                                               
private industry and communities to  invest funds in this type of                                                               
a program,  they need a  stable environment to  conduct business.                                                               
Health care  organizations need  stability in  the rates  paid by                                                               
Medicaid;  they to  know  the future  direction  of the  Medicaid                                                               
program. They  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                                                               
and support workforce development in Alaska.                                                                                    
                                                                                                                                
2:41:34 PM                                                                                                                    
MOLLY GRAY,  Executive Director, Alaska  Pharmacists Association,                                                               
Anchorage,  Alaska,  supported  SB   93.  She  said  the  program                                                               
benefits  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.  They join  a whole  multitude of  others in  the health                                                               
care industry  who have benefitted  from this system. SHARP  is a                                                               
winning proposition for all.                                                                                                    
                                                                                                                                
2:42:53 PM                                                                                                                    
NANCY   MERRIMAN,  Executive   Director,   Alaska  Primary   Care                                                               
Association,  Anchorage, Alaska,  supported SB  93. She  said she                                                               
wanted to highlight  three ways the legislation  will help health                                                               
center better serve Alaskans. One,  there is a shortage of health                                                               
professionals  of  all types  in  Alaska.  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  needing more health  care. There                                                               
is  an increasing  incidence of  chronic  disease requiring  more                                                               
constant  care. Health  care  professionals  are not  distributed                                                               
evenly  across the  state. Two,  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 with health care providers.                                                               
When the  Alaska Primary Care  Association (APCA)  surveys health                                                               
care  centers  about the  most  important  workforce issues,  the                                                               
response  is all  about recruitment  and retention  and how  much                                                               
they  appreciated  SHARP.  In  2018  alone, 80  out  of  the  105                                                               
candidates  who  were  awarded  into  the  SHARP-1  program  were                                                               
practicing  in   community  health  center.  Three,   SHARP-3  is                                                               
innovative  and  requires no  state  general  fund dollars.  APCA                                                               
appreciates   the   SHARP   council   innovative   thinking   and                                                               
contribution  to  the  solution  of  the  health  care  workforce                                                               
shortages in  Alaska. SHARP-3 being  privately funded  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 asked the committee  to refer to their letter of                                                               
support for more detail.                                                                                                        
                                                                                                                                
2:45:36 PM                                                                                                                    
THOMAS   HUNT,  M.D.,   representing  self,   Anchorage,  Alaska,                                                               
supported  SB  93. He  said  he  was  medical director  of  three                                                               
community health care centers,  FQHCs [Federally Qualified Health                                                               
Centers],  urban and  rural,  and later  chief  executive of  the                                                               
Providence Medical  Group in Anchorage.  He has  recruited scores                                                               
of providers of  all stripes to Anchorage and  Alaska in general.                                                               
SHARP helped a  lot because many of these services  are urban and                                                               
would  not   qualify  for  the  National   Health  Service  Corps                                                               
reimbursement.  Regarding Senator  Giessel's  concern, they  want                                                               
these services  in Anchorage; these are  subspecialists who would                                                               
not  be  attracted to  the  state  because  there is  not  enough                                                               
reimbursement because  there is  not enough population  to defend                                                               
getting,  for example,  a  pediatric  endocrinologist. They  want                                                               
them.  They could  export  that care  to  Seattle, but  pediatric                                                               
endocrinology  is not  a surgical  specialty. It  is the  type of                                                               
provider seen  every month. SHARP-3  allowing loan  repayment for                                                               
subspecialists in cities  is a huge improvement  over SHARP-1 and                                                               
SHARP-2. He recently spoke to  an inpatient psychiatrist who does                                                               
consultation   work  with   acute  medical   inpatients  in   the                                                               
hospitals.  She would  not be  eligible  for reimbursement  under                                                               
SHARP-1 or  SHARP-2 and  the National  Health Corp  because there                                                               
are plenty  of psychiatrists in  Anchorage, but none  are willing                                                               
to  do  acute  inpatient  psychiatry.   It  is  hard  to  recruit                                                               
psychiatrists  anyway,  much  less  to  that  kind  of  difficult                                                               
environment.  SHARP-3 offers  the potential  to keep  her in  the                                                               
community with loan repayment.                                                                                                  
                                                                                                                                
2:48:14 PM                                                                                                                    
MIKE COONS,  representing self,  Palmer, Alaska,  asked if  SB 93                                                               
would incentivize doctors  to take on Medicare  patients. He said                                                               
he   had   many   questions,   especially   about   health   care                                                               
professionals shortage  areas. He  wears two hats.  He is  on the                                                               
Commission  on   Aging  and  president   of  a   senior  advocacy                                                               
organization. One of the biggest  problems is that there are many                                                               
doctors in Anchorage  and the Valley and across the  state who do                                                               
not do  Medicare. That  is becoming a  critical shortage.  He saw                                                               
his doctor  in Palmer before he  turned 65. He found  out that if                                                               
he  hadn't been  seen before  by his  doctor he  would have  been                                                               
turned  down.  He  asked  if  this  provides  any  incentive  for                                                               
repayment for doctors to take on Medicare patients.                                                                             
                                                                                                                                
CHAIR WILSON replied  that if Mr. Coons would  contact his office                                                               
later,  they would  try to  answer his  questions, but  he cannot                                                               
answer questions during public testimony.                                                                                       
                                                                                                                                
MR. COONS  said his biggest  concern is  that there should  be an                                                               
incentive to help more seniors be seen under Medicare.                                                                          
                                                                                                                                
2:50:48 PM                                                                                                                    
JEREMY O'NEIL, Administrator,  Providence Valdez, Health Advisory                                                               
Council, Valdez, Alaska, supported SB 93.  He said is also an ex-                                                               
officio member of the Providence Health Advisory Council. SHARP-                                                                
2 was  a good program,  but it is  sunsetting and has  not issued                                                               
new contracts for a few  years. Valdez has benefitted from SHARP-                                                               
1 and SHARP-2.  They have had 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.  There is a                                                               
handful of  doctors who 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.  It  is  geographically  isolated. The  high  cost  of                                                               
traveling staff,  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 recruits. Being  able to                                                               
partner   with  private   foundations,  local   governments,  and                                                               
employers  with SHARP-3  will  remove the  state  as the  funding                                                               
source. Making  it available to those  community stakeholders who                                                               
are  willing  to   invest  will  further  their   ability  to  be                                                               
competitive. In  2017, Valdez conducted a  community health needs                                                               
assessment  and  identified four  priorities.  Number  one 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. College  graduates are leaving school with                                                               
significant  debt.  Health   care  graduates  specifically,  like                                                               
pharmacists,   therapists,   mental    health   counselors,   and                                                               
physicians, require advanced degrees  and they come out straddled                                                               
with tremendous amounts of education  debt. The Providence Valdez                                                               
Health Advisory Council passed a  resolution that they will share                                                               
with the committee.                                                                                                             
                                                                                                                                
2:54:23 PM                                                                                                                    
ZAN WHITMAN, representing self,  Palmer, Alaska, supported SB 93.                                                               
He  said he  is  a psychiatric  nurse  practitioner working  with                                                               
Providence  Health  and   Services.  He  is  calling   in  as  an                                                               
individual.  Being  a  recipient  of   SHARP  has  made  a  large                                                               
difference in  his decision to  practice in Alaska. It  has given                                                               
him the ability to continue to  serve. He can verify that it does                                                               
work well as a method  for recruitment and retention of qualified                                                               
health  providers. Expanding  SHARP is  beneficial and  including                                                               
more health care services and  providers in the SHARP program can                                                               
only benefit the state.                                                                                                         
                                                                                                                                
2:55:39 PM                                                                                                                    
CHAIR WILSON closed public testimony.                                                                                           
                                                                                                                                
CHAIR WILSON said  his office would pass  out the recommendations                                                               
and amendments suggested  by DHSS to committee  members. He noted                                                               
that he  had not wanted  to introduce a  bill, "if you  build it,                                                               
they will come."  The committee has letters in  their packet from                                                               
hospitals and  other entities  stating that  they would  fund the                                                               
program. He did  not want to build a structure  that would not be                                                               
utilized. That  was one of  the requirements to carry  this piece                                                               
of legislation.                                                                                                                 
                                                                                                                                
SENATOR  GIESSEL   said  that   she  would   request  information                                                               
pertaining to  Sections 7, 9,  and 10.  She asked where  did this                                                               
requirement  that an  advanced practice  registered nurse  have a                                                               
doctoral  degree come  from. She  would  appreciate Chair  Wilson                                                               
providing that to the committee.                                                                                                
                                                                                                                                
[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.m.                                                                                                 

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