Legislature(2019 - 2020)BUTROVICH 205

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

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

Document Name Date/Time Subjects
SB 93 v A.PDF SHSS 3/25/2019 1:30:00 PM
SB 93
Senate Bill 93 Sponsor Statement.pdf SHSS 3/25/2019 1:30:00 PM
SB 93 v A Sectional Analysis.pdf SHSS 3/25/2019 1:30:00 PM
SHSS 4/1/2019 1:30:00 PM
SB 93
SB 93 Letters of Support 3.21.19.pdf SHSS 3/25/2019 1:30:00 PM
SHSS 4/1/2019 1:30:00 PM
SB 93
SHARP-AKJournal-article.pdf SFIN 4/9/2019 9:00:00 AM
SHSS 3/25/2019 1:30:00 PM
SHSS 4/1/2019 1:30:00 PM
SB 93
AAC 7. 24 Health and Social Services HCPLRand IP.pdf SHSS 3/25/2019 1:30:00 PM
SHSS 4/1/2019 1:30:00 PM
SB 93
SHARP-IRS TAX EXEMPTION.pdf SHSS 3/25/2019 1:30:00 PM
SHSS 4/1/2019 1:30:00 PM
SB 93
Final Report to Leg 2018 SHARP III.pdf SFIN 4/9/2019 9:00:00 AM
SHSS 3/25/2019 1:30:00 PM
SHSS 4/1/2019 1:30:00 PM
SB 93
SB093 DHSS Slides.pdf SHSS 3/25/2019 1:30:00 PM
SHSS 4/1/2019 1:30:00 PM
SB 93
SB 93 DCCED fiscal note.pdf SHSS 3/25/2019 1:30:00 PM
SHSS 4/1/2019 1:30:00 PM
SB 93
SB 93 DHSS Fiscal Note.pdf SHSS 3/25/2019 1:30:00 PM
SHSS 4/1/2019 1:30:00 PM
SB 93
SB 93 LoS T Hunt MD.pdf SHSS 3/25/2019 1:30:00 PM
SHSS 4/1/2019 1:30:00 PM
SB 93
ANTHC SB93 LOS 3-21-19.pdf SHSS 3/25/2019 1:30:00 PM
SHSS 4/1/2019 1:30:00 PM
SB 93