HOUSE BILL NO. 78 "An Act establishing a loan repayment program and employment incentive program for certain health care professionals employed in the state; and providing for an effective date." 3:03:49 PM Co-Chair Thomas MOVED to ADOPT proposed committee substitute for HB 78, Work Draft 27-LS0147\O (Mischel, 3/1/12). Co-Chair Stoltze OBJECTED for discussion. JOE MICHEL, STAFF, REPRESENTATIVE BILL STOLTZE, discussed the changes in the CS. He stated that each of the three changes involved the addition of the term "advanced nurse practitioner" to the legislation. He explained that the insertion of the term was made on page 7, Section 2, page 7, Section 3 and finally page 8, Section 5. Co-Chair Stoltze explained that the legislation did not increase the pool of money, but instead increased the pool of eligible people. 3:07:08 PM Mr. Michel stated that the fiscal note had not changed along with the CS. Co-Chair Stoltze WITHDREW his objection. There being NO further OBJECTION, Work Draft 27-LS0147\O was ADOPTED. 3:07:29 PM REPRESENTATIVE BOB HERRON, SPONSOR, thanked the committee for hearing the bill. He spoke about the limited access to healthcare providers in rural Alaska. He explained that both rural and urban Alaskans suffered as a result of the shortage of health care providers. The legislation created a loan repayment and direct cash incentive program to attract and retain providers in ten different direct care professions. He explained that the intent of the legislation was to capture new graduates as well as established professionals. He acknowledged the federally funded programs, but noted their inadequacy. He proposed HB 78, which was designed by Alaskans, for Alaskans. He pointed out that 47 other states had similar incentive programs. The legislation allowed for competition with those other states. He mentioned the abundance of support received in the form of letters from his constituents and others around the state. 3:10:23 PM Representative Neuman talked about creating competitive opportunities to incentivize an increase in health care professionals in Alaska. He wondered if the incentive might lower medical costs paid by Alaskans. Representative Herron appreciated the question. He admitted that he did not have the answer to that very large question. Representative Neuman expressed his goal of understanding the investment for Alaska. He pointed out page 2, line 17, which stated a lifetime maximum period of 12 years for participation in the program. He asked how the 12-year time period was selected. LIZ CLEMENT, STAFF, REPRESENTATIVE BOB HERRON, pointed out page 3, line 13 stating "the department may approve loaner payment and direct incentive programs for an initial period of 3 years," which would allow an applicant to participate in the program for six years. The number was derived following conversations with health care providers faced with recruiting professionals as well as professionals faced with the repayment of loans. The maximum was six years, except for very few select individuals who may return to school for further certification may be eligible for an additional six years. She provided an example of a nurse who was eligible for the six-year limit, and then chose to attend medical school, would be then eligible for an additional six years. Representative Neuman asked about page 4, lines 17 through 23, which discussed the amounts of annual payments for professionals. He assumed that the amount provided recordable income for the professionals. Representative Herron replied in the affirmative. Representative Neuman asked about an opportunity for one health professional to qualify for more than one section since some were specialized. Ms. Clement responded that a professional may chose only one section at a time. She noted that the bill allowed the Department of Health and Social Services (DHSS) the latitude to develop regulations that specified procedures and eligibility details for the program. 3:16:49 PM Vice-chair Fairclough asked about the dollar amounts for loan repayments and how they were constructed. She wondered how the plan compared to other states offering similar incentive programs. Ms. Clement replied that the workgroup responsible for providing the concept proposal for the legislation considered factors such as educational cost standards and pay scale ranges across the nation. She provided examples of lengthy and expensive educational routes for physicians, dentists, and pharmacists. She stated that each state's program was different and tailored to its own needs. The dollar amounts listed in HB 78 tended to land in the middle upon comparison to the other states with similar incentive programs. Co-Chair Stoltze recalled that the bill nearly passed in 2010, but questions regarding cost retained it in the finance committee. Representative Wilson asked about cost of living adjustments to the amounts listed in the bill. Represented Herron replied that the amounts were set and not available for adjustment. Representative Wilson queried the difference between an advanced nurse practitioner and a nurse practitioner. Co-Chair Stoltze asked to defer the question to the nursing representative scheduled to testify later in the meeting. Representative Neuman understood the issue regarding difficulty recruiting medical professionals in Alaska. He wondered about other state programs addressing the recruitment of medical professionals. He wondered about total state spending for the medical field in Alaska. Ms. Clement responded that the Washington, Alaska, Montana, and Idaho Medical Education Program (WAMI) and Western Interstate Commission for Higher Education (WICHE) were two additional state programs. She noted that a couple of federally funded programs like the National Health Service Corps (NHSC) and Indian Health Service (IHS) also existed. She offered to provide additional information upon further research. She noted that federal funding included federal requirements regarding the use of the money. 3:22:04 PM Representative Gara understood that Alaska required additional family practice physicians and internists. He wondered if any aspect of the legislation granted a priority to those high need professions. Representative Herron replied that the board would address the greatest needs. Representative Gara opined that WAMI was a great program, although it did not differentiate between high-need professionals compared to lower-need medical professionals. He appreciated HB 78 and its focus on the needs of the state. Co-Chair Stoltze remarked that the program proposed in HB 78 addressed criteria pertaining to the greatest needs for service in Alaska. Representative Herron agreed with Co-Chair Stoltze. Representative Guttenberg appreciated that WAMI helped attain tuition for medical school, while HB 78 would recruit those professionals to Alaska. 3:25:46 PM Representative Doogan pointed to language on page 5, line 27 "may not exceed 90 participants annually." He requested further information about the limit. Representative Herron replied that the limit related to cost control. The program would face review in 2019. Co-Chair Stoltze opined that the money proposed in the fiscal note would not stretch far enough. 3:27:40 PM CHRISTINE POTTER, PRESIDENT, ALASKA NURSE PRACTITIONER ASSOCIATION (via teleconference), spoke in support of the legislation. She explained that there were over 500 licensed nurse practitioners in the state. She pointed out that 40 percent of Alaskan nurse practitioners work in medically underserved communities. She added that 70 percent of nurse practitioners accept Medicare for reimbursement and 88 percent accept Medicaid. She added that 39 percent of nurse practitioners practice in rural areas with 8 percent practicing as the sole licensed providers in their communities. She spoke to the question regarding differentiation between advanced nurse practitioners and nurse practitioners. She remarked that there was very little difference between the two in Alaska. The two terms tend to be used interchangeably. Co-Chair Stoltze remarked that ANP sounded better than NP. Ms. Potter agreed. DEBBIE THOMPSON, EXECUTIVE DIRECTOR, ALASKA NURSES ASSOCIATION (via teleconference), spoke in favor of the legislation. She thanked the committee members for their time. MARY SULLIVAN, ALASKA PRIMARY CARE ASSOCIATION (via teleconference), vocalized support for the legislation. Co-Chair Stoltze appreciated his meeting with the Alaska Primary Care Association. Ms. Sullivan thanked Co-Chair Stoltze. 3:31:11 PM MARIE DARLIN, AMERICAN ASSOCIATION OF RETIRED PERSONS- ALASKA, supported the legislation. She reminded the committee that the estimated economic value of the seniors was $1.7 billion. She believed that retention of retired citizens in Alaska would benefit the state. Co-Chair Stoltze welcomed staff from the Soldotna hospital. Co-Chair Stoltze CLOSED public testimony. Vice-chair Fairclough asked whether the bill required a participant to be an Alaskan resident. Representative Herron replied no. Vice-chair Fairclough wondered whether the bill required a participant to become an Alaskan resident. Representative Herron did not know. Vice-chair Fairclough believed that the people benefiting from the program should be Alaskan residents as opposed to commuters. Co-Chair Stoltze wondered if DHSS might have included a vetting requirement in its proposition. Representative Guttenberg pointed to page 4, line 2(g) related to loan repayments, "the department shall prorate loan repayments and direct incentives under the program based upon a number of hours of a qualified employment worked in a quarter." He understood the statement to read that if a person commuted, their payments might be reduced. Vice-chair Fairclough remarked that the state was working to attract qualified health care providers. It was important that the individuals were residents if the bill paid $35,000 per year to retire student loans. She queried the intent of the legislation. Co-Chair Stoltze requested testimony from the department. PATRICIA CARR, DIRECTOR, HEALTH PLANNING AND SYSTEMS DEVELOPMENT, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, replied that the bill stipulated that the applicant must be licensed or exempt from state licensing, which might relate to residency requirements as they relate to licensing. Vice-chair Fairclough countered that practitioners could be licensed in multiple states. 3:38:24 PM Ms. Carr replied in the affirmative. She thought that the issue could be addressed under the program guidelines. Co-Chair Stoltze sensed Vice-chair Fairclough's hesitation and asked if she had further questions. Vice-chair Fairclough replied that she did not wish to hold the bill in the finance committee. She referred to concern by current employers to have medical professionals remain in a community. She understood that the cash incentives provided that opportunity for medical professionals as stated in HB 78. She hoped that the professionals interested in the program would remain in Alaska. She spoke in favor of an eligibility requirement within the program ensuring Alaskan citizenship. Representative Edgmon wondered about the practical implications of a physician residing in more than one state. Ms. Carr replied that the issue would be considered in terms of the application process. She imagined that the issue would be vetted in the program guidelines. 3:42:29 PM Vice-chair Fairclough knew about dentists that commuted back and forth to rural Alaska. She did not know how prevalent the occurrence was. She wondered whether the criteria existed in other states. Representative Doogan clarified that a considerable amount of his medical treatment was performed by medical professionals called "travelers." He thought that the state may not be in a position to impose a residency requirement and to attract as many physicians as desired. Representative Herron elaborated that a technical amendment could be crafted to represent the effort to have physicians become residents but not to require it. He agreed that the intent of the legislation was to incentivize a long-term commitment from medical professionals. He believed that continuity of care was an important contribution in medical care. 3:46:50 PM Vice-chair Fairclough expressed her interest in working with Representative Herron on the issue. She respected the need for additional medical personnel in rural Alaska. Co-Chair Thomas had grown up in rural Alaska and had seen IHS doctors that traveled and worked to have their loans paid off. He expressed concern about the potential for a provider to receive dual payments from federal and state sources. He added that newcomers either appreciate the state and its lifestyle or they choose to leave. Representative Herron responded that a provider could not receive dual payments; the practice was prohibited. 3:50:12 PM Representative Neuman discussed the competitive nature of the legislation that was limited to 90 people. He opined that the program intention was sound. He hoped to see the benefit to the state regarding the potential savings resulting from the ability for patients to receive medical care in-state. Representative Herron replied that a time period of two years should determine the interest in, and success of the program. The fiscal note was nearly $2.9 million, with $2.1 million from the general fund. The remainder of the money would be contributed by providers. The participants seek out certain candidates and they also contribute funds, making the bill an unusual vehicle intended to stabilize the work force in Alaska. Co-Chair Stoltze preferred to work further on the bill in committee. He proposed additional efforts to refine the bill while in house finance, including a well-constructed amendment. 3:54:30 PM Representative Edgmon responded to a question by Representative Neuman related to missions and measures. He reminded the committee that seniors were the fastest growing segment of the population. He stressed that caring for the needs of the seniors was in the state's best interest. Representative Doogan recommended that the highest value be placed on attracting qualified doctors and nurses. He opined that the value of retaining the qualified practitioners was secondary. Co-Chair Stoltze intended to schedule the bill at the earliest possible time. 3:56:57 PM Representative Gara had one concern related to the bill. He discussed a shortage of knee and heart doctors. He suggested language stating that a rarity of physicians or nurses with a certain specialty be considered a priority. Representative Herron looked forward to working with members on amendments. HB 78 was HEARD and HELD in Committee for further consideration.