HOUSE BILL NO. 18 An Act amending the functions and powers of the Alaska Commission on Postsecondary Education; and relating to the repayment provisions for medical education and postsecondary degree program participants. MICHAEL PAWLOWSKI, STAFF, CO-CHAIR MEYER, explained that HB 18 is intended to increase the number of students in the WWAMI program. The WWAMI program is Alaska's medical school program and is a partnership between Washington, Wyoming, Alaska, Montana and Idaho (WWAMI), in which each of those states contributes to the Medical School at the University of Washington (UW) based on the amount of students they have entering the program. For Alaska, that number has traditionally been 10. The WWAMI student pays in-state tuition at the University of Washington and agrees to return to Alaska to practice medicine. Mr. Pawlowski continued, a student must repay a portion of the State's subsidy if they do not return to Alaska to practice medicine. The State forgives 20% of the obligation for each year they practice in Alaska. The WWAMI program has been immensely successful and has received national recognition for several years. It has been ranked the #1 Family Medical Education program in America for 15 consecutive years. Mr. Pawlowski noted that Alaska needs to expand WWAMI because the State is facing a significant physician shortage; a shortage which leads to more expensive and less available medical care throughout Alaska. HB 18 accomplishes the following: · Expanding the WWAMI program in section 1 · Allowing students to serve their residency outside Alaska without accumulating interest in Section 2 - (There are limited opportunities to pursue residency in Alaska now with only 12 slots at Providence); · Envisioning 20 students entering WWAMI a year, which means that eight of those would have no opportunity to pursue their residency in Alaska Expanding the WWAMI program was one of the key recommendations in the recently released report, "Alaska Physician Supply Task Force" included in the packets. Alaska already has fewer physicians per capita than the rest of the U.S. And as our physicians are approaching retirement age, the State needs to do everything possible to recruit more and HB 18 is a first step toward bridging that gap. 1:46:36 PM Representative Thomas referenced language "sufficient to accommodate 20 new people each year" & wondered if that amount would be compounded each year. He wanted to be on record, clarifying that would only be 20 students a year. Mr. Pawlowski acknowledged it was not a compounding equation and would only be 20 new freshmen each year. Representative Gara hoped to finely tune the legislation. He pointed out the shortage in the State of certain types of doctors. He noted that many doctors come to Alaska because they make a lot more money. He proposed tying eligibility for participants that are willing to go into the fields the State has serious shortages. Mr. Pawlowski thought it would be difficult to adjust for a career path, not understanding specifics when entering into the medical path. Representative Gara recommended adding incentives for specific areas & if those were not met, the student would not be given the subsidies and the annual loan payments would not be forgiven. 1:50:41 PM Representative Nelson inquired why the proposed legislation stopped at the number 10, given the serious need throughout the State. Mr. Pawlowski explained that the bill intends to "establish the floor", understanding capacity issues in both the University of Alaska and the University of Washington. Increasing the number could be worked out over time. 1:52:08 PM JOEL GILBERTSON, (TESTIFIED VIA TELECONFERENCE), REGIONAL DIRECTOR, STRATEGIC DEVLEOPMENT & ADMINISTRATION, PROVIDENCE HOSPITAL, ANCHORAGE, discussed that the physician shortage in the State of Alaska at this time is a serious public health threat. There is a physician shortage in all specialty types making for fragmented and reduced access to care. In the Anchorage market place, there are a number of seniors unable to receive basic primary care services. Mr. Gilbertson recommended increasing the WWAMI class size, a move that Providence Hospital strongly supports. The WWAMI program has been a key element for retention. Approximately 85% of the students graduating through the program have remained in Alaska. Those individuals are involved in core services of the State. It has been a great investment. He acknowledged that the problem is still acute statewide. Representative Crawford commented on concerns voiced by constituents in Anchorage that medical access is at a crisis point. He thought that the bill would provide a beginning step, however, worried about how to address the short-term fix. Mr. Gilbertson agreed that there is a need for both short and long term fixes. The bill would not be the sole solution; core problems need to be addressed. The U.S. Congressional delegation has taken an interest in access to care. There are a number of efforts in the Anchorage area that are happening right now. One is the Anchorage Neighborhood Health Center, which handles many Natives coming from rural communities. The program has inadequate facilities and can not meet the volume demand. The clinic is undergoing an assessment through the Denali Commission to look at ways to grow the center. The other large primary care facility practicing in Anchorage is the Family Medicine Residency Program. That clinic trains residents, receiving some federal support, however, has been loosing money on an annual basis. Most states support their programs through direct funding and reimbursements. Alaska's reimbursement thus far, has barely kept up with what is happening in other states. There is interest in strengthening the residency program. Representative Crawford questioned what was needed to enhance the program. Mr. Gilbertson explained that there is no one solution to solving the crisis. The Neighborhood Health Center is largely a capital project. That revenue structure is stronger as they have access to cost base reimbursement; their issue is physical space and capacity. It is a capital project. He urged that both clinics be strengthened & expanded and requested further funding. 2:01:15 PM Representative Gara understood that where a person goes to medical school has a relationship on where they end up practicing, and where the residency program is done has an even stronger affect on where they end up practicing. Mr. Gilbertson agreed that was true. Representative Gara noted that the residency programs offered in Alaska are not as substantial as they could be. Mr. Gilbertson advised that the residency program would like to expand the number of slots available in Alaska. Given a more predictable revenue stream, they would be able to expand their actual office hours. A secondary benefit of more residents coming out of the program, would be more doctors feeding out into rural areas. Representative Gara questioned if the residency program provided practitioners for both the rural and urban areas. Mr. Gilbertson explained that a good percentage have gone on to work in rural areas through the Native Health Corporations. It helps with the long-term training, being around primary care and internal medicine. Representative Gara recommended that a quicker solution for those closer to practicing, would be consideration of expanding State support of the residency program, especially in family care. 2:05:04 PM DR. PETER MARSHALL, (TESTIFIED VIA TELECONFERENCE), FAMILY AND GENERAL PRACTICE, CHAIR OF WWAMI ADMISSIONS, NORTH POLE, referenced the letter he submitted to the member's packets. (Copy on File). Dr. Marshall discussed the dire need for medical doctors in the bush areas and in Fairbanks & Anchorage. He addressed the barriers that Alaska students encounter when applying to other schools. Alaska, currently, only has 10 spots and last year, there were 78 applicants. The students attempting to get into the program apply against other states; states tend to be "stringy" with the spots, reserving them for their own residents. Well qualified students are at a disadvantage in trying to apply to other medical schools. Doubling the class size to 20, would increase the ration and would help the situation. 2:08:46 PM Representative Crawford commented that Amendment 1, 25- LS0131\K.1, Mischel, 2/06/07, could have increased the program number from 20 to 30. He was informed there was not enough physical space to accommodate that many. He agreed to not offer the amendment at this time. He asked when the program could be expanded. Dr. Marshall responded that he was not equipped to answer that. The University of Washington (UW) has made a decision to increase their class size over the next few years. He believed eventually, Alaska could have 30 students in the program and supported such a plan. 2:11:10 PM ROD BEATTIE, PRESIDENT, ALASKA STATE HOSPITAL & NURSING HOME ASSOCIATION (ASHNHA), JUNEAU, noted that the membership of his agency has identified the proposed issue as their most critical concern this legislative session. He referenced the agency handout. (Copy on File). ASHNHA strongly supports passage of HB 18. There are approximately seven ways to get additional physicians into Alaska: · Medical schools · Residency programs statewide · Federal assignments · Self selection · Loan repayment programs · Recruitment bonuses · Travelers Mr. Beattie reiterated that HB 18 is critical legislation. He pointed out that Alaska currently suffers from a shortage of over 300 physicians. The public is not receiving the care needed. He urged that the bill move swiftly out of Committee and that the University of Washington is looking for a quick response; timing is critical. 2:16:14 PM Co-Chair Meyer questioned how soon ASHNHA needs to know if passage of the bill could happen. Mr. Beattie replied that the deadline to complete the contract negotiations is the beginning of March 2007. Representative Gara asked the areas of the most acute shortages. Mr. Beattie responded a lot of the newer specialty areas and elder care, OB's, surgeries, cardiology, and internal medicine. He added that targeting students into specific areas would be problematic. Co-Chair Meyer asked if the State's residency program could accommodate all 20 students; he understood that only Providence Hospital offered a residency program. Mr. Beattie replied that was correct and that it currently offers a 12-position residency program. 2:18:07 PM DR. ROLAND GOWER, (TESTIFIED VIA TELECONFERENCE), PRESIDENT, ALASKA STATE MEDICAL ASSOCIATION (ASMA), GENERAL SURGEON, ANCHORAGE, provided a copy of his testimony. (Copy on File). Dr. Gower pointed out that ASMA strongly supports HB 18. He echoed the crisis given the doctor shortage throughout Alaska. There is a nationwide shortage and recruitment will not get any easier in the future for Alaska. He thought that it made sense for Alaska to "grow our own students" into the field. There are Alaska students that want the training but do not have a school to go to. The State providing a reasonable payback acts as an incentive. It is important to nurture this resource. He offered to answer questions of the Committee. Representative Gara inquired how the legislation would increase the family residency program throughout the State. Dr. Gower explained he was not an expert on that program. There is a critical mass consideration of the number of physicians that can be trained in that area. He commented on specialty training and thought it would be possible to provide some training to specialists in Alaska but many of that type training can not happen in the State. He recommended perhaps creating rotations in the Alaska hospitals with residents from other states. 2:24:21 PM PAT LUBY, (TESTIFIED VIA TELECONFERENCE), ADVOCACY DIRECTOR, ALASKA ASSOCIATION OF RETIRED PERSONS (AARP), ANCHORAGE, stated that AARP supports HB 18. He claimed that AARP members tend to see physicians more often than the younger set. Now seniors are staying in the State after retirement since the health services are improving. HB 18 is an excellent first step in addressing the statewide physician shortage. He urged support. 2:26:12 PM Co-Chair Meyer noted that Representative Crawford had WITHDRAWN his amendment. Co-Chair Meyer pointed out the fiscal notes, highlighting the new note by the University of Alaska. Representative Hawker noted the number of new positions being added into the system and the note associated. He worried that the student-faculty ratio was excessive. He pointed out the capital expenditure request included. Representative Hawker requested a better evaluation. Co-Chair Meyer agreed that the capital request should be addressed in the Capital Budget. Mr. Pawlowski clarified that under the program, until the actual slots are added, the incoming class at UAA would not be above 20 people. 2:29:43 PM PAT PITNEY, VICE PRESIDENT OF PLANNING & BUDGET, UNIVERSITY OF ALASKA, advised that the fiscal note before the committee was precise. There would not be two part-time positions; of the $344 thousand, approximately $44 thousand dollars would be used for staffing assistance. It would add to staffing support for the WWAMI program. The two faculty would add to the existing faculty in the current program. There are seven faculty in the program and approximately ½ of those are dedicated for WWAMI teaching. They are also dedicated to some biological and chemistry teaching positions in the other departments and research and service. The course curriculum in the first year is very intensive. There is course work with lab and teaching requirements; it is more one-on-one. It would be a significantly larger load. She stressed that the request to move to 20 students will happen at the beginning of next school year. Representative Hawker did not understand the merits or demerits of the ratio argument. He was concerned with the travel component, the contractual & supplies. Ms. Pitney explained that those numbers were a rough estimate and they assume a modest salary. The travel allocation would be used for the entire department. Co-Chair Meyer thought the fiscal request should be analyzed during a subcommittee process. Co Chair Chenault agreed it should be examined during subcommittee before moving forward; he recommended that the capital expenditure be included in the Capital Budget Request (CBR). He asked that the fiscal note be removed and provided to the subcommittee for consideration. 2:34:11 PM Co-Chair Meyer reminded members that the University received $475 thousand dollars last year with the understanding that the remainder would be allocated FY08. Representative Gara inquired if the bill should pass how that would be affecting the capital request process. He asked if construction would be completed by then. Ms. Pitney responded that the $475 thousand appropriated last year was being used as the planning part of the construction process. In the event that the bill passes, the original $475 thousand dollars allows the planning and the second allocation in the amount of $475 thousand dollars will cover the overall construction. Construction completion is planned for during the summer and will be ready for incoming students. Representative Gara asked if the capital upgrade was really needed. Ms. Pitney emphasized it was. 2:36:57 PM Co Chair Chenault referenced comments that the allocation from last year budget was being used for planning of the renovation. Ms. Pitney responded that the University is preparing for success of the program as the need is high; the planning portion was less than $475 thousand dollars. Co Chair Chenault understood the concern to get the funding. He worried about the funding from last year being used. Ms. Pitney replied only a small piece of that amount was used. 2:38:50 PM SUSANNE TRYCK, (TESTIFIED VIA TELECONFERENCE), DIRECTOR, ALASKA REGIONAL AFFAIRS, UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE, explained that the issue of the number of faculty in the program is a bit difficult to grasp. At the University of Alaska - Anchorage (UAA), the numbers for faculty is lower than in some of other states. It is not uncommon for a faculty in the second year at the UW, to teach three or four lectures in a semester. There is a lot of time involved in research, which makes the teaching time less. The proposed numbers are in line with the other WWAMI states. Ms. Tryck clarified that they can not accommodate all 20 WWAMI students in the family medicine residency program unless they only intend to practice family medicine. There is no direct link in terms of the numbers. It would be cumbersome to attempt to tie the shortage of statewide doctors with those students selected for the WWAMI program. The amount of time it takes to complete the program is usually seven years. Ms. Tryck urged that the bill pass from committee at this time given the deadline. 2:42:00 PM Co-Chair Meyer recommended that the University of Alaska fiscal note be reduced to zero. Vice Chair Stoltze MOVED to REPORT CS HB 18 (HES) out of Committee with individual recommendations and with the accompanying fiscal notes including the new zero note by the House Finance Committee. Vice Chair Stoltze briefly OBJECTED. Vice Chair Stoltze noted that he supports the initiative to bring more doctors into Alaska. He worried if it had not been mandated, it would not have come through the University. He complimented the statewide professionals for making the legislation happen and wanted to make sure the leadership on the issue continues to be the medical community. Vice Chair Stoltze WITHDREW his OBJECTION. There being NO further OBJECTIONS, it was so ordered. CS HB 18 (HES) was reported out of Committee with a "do pass" recommendation and with a new zero note by the House Finance Committee and fiscal note #1 by the Alaska Commission on Postsecondary Education dated 1/31/07. AT EASE: 2:44:39 PM RECONVENED: 2:50:46 PM