SENATE FINANCE COMMITTEE March 25, 2019 9:01 a.m. 9:01:54 AM CALL TO ORDER Co-Chair Stedman called the Senate Finance Committee meeting to order at 9:01 a.m. MEMBERS PRESENT Senator Natasha von Imhof, Co-Chair Senator Bert Stedman, Co-Chair Senator Lyman Hoffman Senator Peter Micciche Senator Donny Olson Senator Mike Shower Senator David Wilson MEMBERS ABSENT Senator Bill Wielechowski Senator Click Bishop ALSO PRESENT Suzanne Allen MD MPH, Vice Dean for Academic, Rural and Regional Affairs, University of Washington School of Medicine; Senator Cathy Giessel; Senator Gary Stevens. SUMMARY ^OVERVIEW OF ALASKA'S WWAMI PROGRAM 9:03:47 AM SUZANNE ALLEN MD MPH, VICE DEAN FOR ACADEMIC, RURAL AND REGIONAL AFFAIRS, UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE, discussed the presentation, "WWAMI School of Medical Education, Senate Finance Committee, March 25, 2019" (copy on file). She offered a brief personal background. 9:04:29 AM Ms. Allen highlighted Slide 2. The slide showed photographs of the students currently enrolled in the program. She relayed that Alaska had been Washingtons first partner in the program, back in 1971. The program allowed students from each partner state to participate in medical school and complete most of their medical training within their home state. 9:04:54 AM Ms. Allen looked at Slide 3, "Alaska WWAMI Students are from Diverse Backgrounds." The slide showed the communities from which the current WWAMI student hailed. She stressed that the goal of the program was to improve community health by providing a physician workforce that met the needs of the communities within each partner state. 9:05:16 AM Ms. Allen highlighted Slide 4, "Physician Workforce Needs in Alaska": Chronic shortages  ? Primary Care, Psychiatry, Emergency Medicine ? Rural areas Annual Need  ? Approximately 60 new physicians/year ? Population growing older- greater need for care ? Alaska Physicians (40 percent over age 55) Recruitment, retention  ? Expensive ($100K-$1M), difficult to retain ? Compete with entire nation which has a shortage of primary care physicians Need for public medical education in Alaska  ? Alaska residents more likely to return to Alaska to practice 9:07:19 AM Ms. Allen looked at Slide 5, "Medical Education": Every State in our country funds medical education  ? Publicly funded medical schools through their respective University systems ? Through cooperative compacts such as WWAMI WWAMI uniquely suited to Alaska  ? Opportunity for 20 Alaska students each year to attend one of the top 10 medical schools in the country ? Alaska students may complete entire medical education in Alaska with exception of two clinical rotations at University of Washington in Seattle 9:08:16 AM Ms. Allen discussed Slide 6, "Medical Education": ? Cost to Alaska  ? $750,000 per year from UA (.0023 percent of UA's FY19 UGF spend; .00084 percent of UA's total budget) for classroom teaching in the first year ? $3.1 million per year from State of Alaska funding for years 2 4 including second year classroom teaching ? This is $5.50/Alaskan compared to >$20.00/North Dakotan, a state with a similar population 9:09:38 AM Senator Wilson queried the cost for a student to complete the program. 9:09:42 AM Ms. Allen replied that tuition for the program was $35,000, per year. The total number of credit hours needed to graduate is 140, she did not know the cost per credit hour. 9:10:11 AM Co-Chair von Imhof wondered about the return on investment for the program. 9:10:22 AM Ms. Allen replied that return on investment would be discussed in future slides. 9:10:40 AM Senator Shower understood that there were 80 total students currently benefitting from the program. 9:10:52 AM Ms. Allen replied in the affirmative. 9:10:59 AM Co-Chair Stedman understood that the program was at capacity. 9:11:02 AM Ms. Allen replied in the affirmative. 9:11:09 AM Co-Chair von Imhof asked about trends in program interest. 9:11:14 AM Ms. Allen said that there was slight variation from year to year, generally between 80 and 90 students applied per year, 20 were selected. 9:11:37 AM Ms. Allen addressed Slide 7, "Strong Return on Investment": Financial plus for Alaska  ? >70 percent of funds invested by the state are spent in Alaska ? Classroom instruction Management of 59 clerkships and 20 volunteer preceptorships Creates jobs  ? Faculty and staff who educate 80 medical students per year ? New physicians contribute to the growth of Alaska's healthcare industry ? Economic impact of one primary care physician estimated at over $1 million per year WWAMI graduates return to Alaska  ? Return on investment of 71 percent, 61 percent returning Alaskans ? 11 percent of licensed Alaska physicians are WWAMI graduates ? Largest contributing medical school to Alaska physician workforce 9:13:30 AM Senator Hoffman aske what percentage of students from the program, that returned to the state, were practicing in rural Alaska. 9:13:49 AM Ms. Allen agreed to provide the information to the committee. 9:14:10 AM Senator Hoffman also requested information about how many people from rural Alaska were applying for, and being accepted to, the program. 9:14:32 AM Senator Shower requested additional information about clerkships and volunteer preceptorships. 9:14:45 AM Ms. Allen related that student spent 3 semesters in the classroom; 4 days a week in the classroom and 1 day per week doing clinical work. The volunteer preceptors were people who mentored the students during their clinical work in the first 3 semesters. After the classroom work, students began rotations in various required fields of medicine, including clinical rotations. The rotations were 4 to 6 weeks in length. 9:16:35 AM Senator Shower asked about the 59 clerkships. 9:16:37 AM Ms. Allen replied that the clerkships were rotations students performed in a myriad of medical fields. She shared that a future slide contained a map of the state that showed where the clinical clerkships occurred. 9:17:11 AM Co-Chair Stedman asked whether the program had a drop out factor. 9:17:38 AM Ms. Allen shared that the program had a low rate of non- completion. She said that there had been a handful of students over the years that had not completed medical school for various reasons, but that it was less than 1 percent of students who were not successful for academic reasons. 9:18:11 AM Senator Olson asked whether vacancies could be filled if a student failed to finish the program. 9:18:26 AM Ms. Allen responded that once the student left the program, the University of Washington no longer billed the state for that students education. 9:18:58 AM Senator Micciche asked whether there had ever been a number requirement for years of service to the state, post completion of the program. 9:19:22 AM Ms. Allen replied that students were required to work in the state once they were fully licensed, 3 years for rural area work and 5 years for urban area practice. She said that if students did not return to the state, they are required to pay back 50 percent of what the state paid for their education. 9:19:52 AM Ms. Allen addressed Slide 8, "WWAMI Program Founding Goals": Access to Publicly Supported Medical Education  ? WWAMI is Alaska's medical school ? UWSOM receives >6000 out of state applications/yr and admits 0.3 percent of those applicants ? 1 in 300 chance of Alaska student acceptance to UW School of Medicine ? Publicly funded schools give significant preference to their own state residents ? WWAMI guarantees 20 Alaska students admission with in-state tuition ? 1 in 4 chance of acceptance to UW School of Medicine Avoid excessive capital costs by using existing  educational infrastructure  ? Recent new medical schools >$100M Create Community-Based Medical Education  Clinical training in Alaska has grown to 59 clerkship sites 9:21:32 AM Ms. Allen looked at Slide 9, "Alaska WWAMI Program Site Map, 2018-2019."The map showed where the program offered clinical training opportunities in the state. 9:21:49 AM Senator Wilson understood that not all sites on the map were continually utilized. 9:21:52 AM Ms. Allen agreed. She explained that the intent was to place students all around the state, but occasionally clinical sites were implementing new systems and were not prepared to take on a training student. 9:22:28 AM Ms. Allen addressed Slide 10, "WWAMI Program Founding Goals": Expand GME (residency programs) across WWAMI  ? Alaska Family Medicine Residency Program ? UW Pediatric Residency Track ? Need for Internal Medicine & Psychiatric Residency Programs Increase the number of primary care physicians  /address maldistribution of physicians  ? AK WWAMI graduate return rate is 61 percent, and grows to 71 percent as WWAMI grads from other sites come to practice in Alaska ? AK WWAMI grads must payback ? of state investment if they do not return (3 years rural, 5 years urban) ? >50 percent of AK WWAMI graduates choose primary care 9:23:48 AM Senator Micciche wondered about the money paid back by student who did not finish the program. He surmised that if 39 percent did not finish the program, the payback figure would be $604,000, per year. He queried where the paid back money was used. 9:24:06 AM Ms. Allen responded that the funds were deposited back into the states general fund. 9:24:20 AM Ms. Allen highlighted Slide 11, "Alaska WWAMI Graduates Practice Throughout Alaska." She discussed slide 12, "Alaska WWAMI": 1971: University of Alaska Fairbanks 5-10 students/year 1989: University of Alaska Anchorage 10 students/year 2007: Increased from 10 to 20 students/year   Ms. Allen reiterated that Alaska was the first state to become program partners with Washington State in 1971. At that time the program, located in Fairbanks, had 5 students. The program moved to Anchorage in 1989, and in 2007 the program increased from 10 to 20 students per year. The first 20 student class graduated in 2007. 9:25:05 AM Ms. Allen addressed slide 13, "Alaska WWAMI Admissions": Alaska WWAMI Admissions Committee: Katie Sheridan MD, Chair: WWAMI alumna Family Medicine Soldotna Nora Nagaruk MD: WWAMI alumna Internal Medicine Nome Donna Galbreath MD WWAMI alumna Family Medicine ANMC Bob Urata MD WWAMI alumnus Family Medicine Juneau Pete Schaab MD Orthopedic surgeon (retired) Anchorage Interviews at UAA decisions made jointly with UWSOM Admissions Executive Committee 80-95 applicants/year for 20 students (also select 10 alternates) Have the pipeline applicants to grow to 30 excellent students/year 9:26:01 AM Senator Olson asked whether there were any non-physicians on the Admissions Committee. 9:26:10 AM Ms. Allen said that there had previously a public member, who was no longer on the committee, and who had not been replaced. 9:26:39 AM Senator Hoffman asked how long members served on the Admissions Committee. 9:26:47 AM Ms. Allen replied 6 years; 3-year terms, renewable one- time. 9:27:21 AM Senator Hoffman asked whether the committee was voluntary. 9:27:24 AM Ms. Allen replied in the affirmative. 9:27:56 AM Ms. Allen looked at Slide 14, "WWAMI Curriculum 2018-2019": Enhanced integration, active learning, patient care  focus  Three Phases    ?Foundations Phase at UAA ? 18 months (3 semesters, equivalent of years 1 and 2) clinically focused curriculum ? UAA Alaska model chosen as new curriculum template ?Patient Care Phase (clinical training required clerkships) ?Exploration and Focus Phase (advanced clinical training, research, residency prep) 9:28:27 AM Ms. Allen highlighted Slide 15, "WWAMI Curriculum 2018- 2019": Alaska WWAMI Clinical Training Communities: ? Anchorage ? Eagle River ? Palmer / Wasilla ? Talkeetna ? Fairbanks ? Delta Junction ? Galena ? Homer ? Seward ? Soldotna ? Juneau ? Sitka ? Haines ? Petersburg ? Ketchikan ? Craig ? Metlakatla ? Kodiak ? Unalaska ? Bethel ? Nome ? Naknek ? Dillingham ? Valdez ? Utqiagvik ? Kotzebue ? Unalakleet 9:28:40 AM Ms. Allen highlighted Slide 16, "WWAMI Rural Programs": RUOP (Rural Underserved Opportunities Program)  ? Began 1989 One-month clinical experience between 1st 2nd year ? 53 percent of students who participated in RUOP go into primary care WRITE (WWAMI Rural Integrated Training Experience)  ? Began 1996 ? Longitudinal integrated clerkship family medicine, internal medicine, pediatrics, and psychiatry clinical rotations in Patient Care Phase ? 67 percent in primary care 42 percent family medicine, 16 percent internal medicine, 9 percent pediatrics ? 35 percent in rural TRUST (Targeted Rural Under Served Track)  ? Began 2016 ? Longitudinal integrated curriculum across 4 years in continuity community 9:30:21 AM Co-Chair von Imhof asked whether the other states involved in the program had rural areas served by WWAMI students. 9:30:53 AM Ms. Allen relayed that the rural programs were within all the states involved in the program. She said that students could go between states; students were placed in rural areas where opportunity existed and in their home states when possible. 9:32:01 AM Co-Chair von Imhof understood that there could be more interest in areas than clinical sites to accommodate them. She wondered whether housing was an issue in placement. 9:32:31 AM Ms. Allen replied that the RUOP program sometimes experience a housing bottleneck in the summer months when the number of people visiting Alaska increased. 9:32:52 AM Senator Wilson asked whether students from other states involved in the program were recruited to practice in Alaska. 9:33:16 AM Ms. Allen responded that students could request areas to perform their training. She said that some students prioritized training in their own states, but others wanted to do training in areas outside their home state. 9:34:37 AM Senator Wilson asked whether there was as aggressive movement to recruit students from other states involved in the program. 9:34:51 AM Ms. Allen stated that the different practice locations where students went to perform their medical training would be the strongest advocates for encouraging students to come back and practice in that location when they graduate. Overall, the program did not recruit people to come back to practice in Alaska but did highlight the benefits of returning to work in their home communities. 9:35:28 AM Senator Hoffman asked how many WWAMI graduates were serving in Alaska. He requested a list by community. 9:35:42 AM Ms. Allen replied that there were currently 212 WWAMI graduates practicing in the state. She noted that the list of communities where those students were practicing was on Slide 11. 9:35:55 AM Senator Hoffman asked that the list be broken down by number. 9:35:58 AM Ms. Allen agreed to provide that information. 9:36:07 AM Ms. Allen discussed Slide 17, "Trust Continuum." She relayed that the program was recruiting from rural and underserved communities. 9:37:06 AM Ms. Allen addressed Slide 18, "WWAMI": Alaska's Medical School It takes a village??. UAA WWAMI Foundations Faculty:  1 PhD (8 FT) ?29 MD (4 FT; 3 0.5 FTE; several 0.2 FTE), many volunteer ?20 MD clinical preceptors (volunteer) ?12 summer RUOP preceptors (volunteer) ?8 PhD/MD summer research mentors Faculty have UAA and UWSOM faculty appointments 9:37:37 AM Ms. Allen looked at Slide 19, "Alaska WWAMI Clinical Faculty": Alaska has >200 WWAMI clinical faculty* teaching medical students and residents in 26 communities. ? They teach first, second, third and fourth year WWAMI medical students, and family medicine and pediatric residents. ? 377 clinical experience opportunities across the state for medical students and residents. ? 234 third and fourth year required and elective clinical rotations, including four longitudinal continuity rotations ? (6 months-Kodiak, Soldotna, Juneau, Ketchikan) * UW School of Medicine faculty appointments 9:38:27 AM Senator Shower asked how the performance of the clinical faculty was measured and tracked. 9:38:59 AM Ms. Allen stated that each person training a medical student was required to have a license to practice and be board certified. She said that the teachers were required to teach 50 hours per year to keep their faculty appointment. She shared that student evaluations were strongly considered. 9:40:20 AM Senator Micciche asked whether there were differences in practice requirements, or materials covered, between a WWAMI graduate at a participating university and a graduate of the same medical school who had not been in the program. Ms. Allen replied that there was no difference in training for a student receiving medical training under WWAMI and a student, not participating in WWAMI, enrolled in a medical program at a participating university. All the medical schools in the program provided the same training to students. 9:41:42 AM Senator Micciche asked whether the state had a foundation that supported the cost of the program. 9:41:55 AM Ms. Allen replied that the program was publicly funded and did not receive funds from any foundations. 9:42:06 AM Co-Chair Stedman surmised that the cost of the program was $39,000, per student, per year. He noted that the state was currently facing budgetary constraints and wondered whether the program had explored other funding options. 9:42:48 AM Ms. Allen replied that there had not been conversations with other groups about alternative funding opportunities. 9:43:00 AM Senator Micciche wondered why only 5 states participated in the program. 9:43:07 AM Ms. Allen replied that the program had been created during the last expansion of medical education in the country. She shared that the signing of Medicare into law in the 1960s had increased the need for increased physicians to accommodate the number of people that were not insured for healthcare. At that time, the states surrounding participating WWAMI states already had medical schools, the consortium was built to provide publicly supported medical education to increase the physician workforce. She noted that Wyoming had not been part of the original consortium and had joined in 1996. 9:44:25 AM Senator Wilson queried the actual cost of running the program. He thought that the cost to the state was approximately $1.2 million. 9:44:52 AM Ms. Allen said that the cost was approximately $7 million for the 20 students in the program each year. She cited Slide 6. She said that the students paid their own tuition, the state paid for what it cost for each student to participate in the program. 9:46:10 AM Senator Wilson asked for a cost breakdown for the program. 9:46:16 AM Co-Chair Stedman interjected that the breakdown should go back several years to provide a historical cost reference. 9:46:25 AM Co-Chair von Imhof wanted to see a line item list, over 4- years, of funding sources and the percentage return on investment to the state. She wondered about the last bullet point on Slide 6 and asked about the costs to other states. She asked whether there had been any discussion of starting an endowment to fund the program. 9:48:09 AM Ms. Allen replied that she would provide the information. She said that there were 160 students enrolled in the program in Washington State; 40 in Idaho, 30 in Montana, and 20 in Wyoming. She said that the other states funded the program similarly to Alaska through state funding and student tuition. She was unaware of any conversations about creating an endowment. 9:49:01 AM Co-Chair Stedman thought that there would be endowment discussion in the future. 9:49:13 AM Ms. Allen addressed slide 20, "WWAMI School of Medical Education." 9:49:38 AM Ms. Allen looked at slide 21, "WWAMI School of Medical Education." 9:50:00 AM Co-Chair Stedman asked whether Senator Olson had participated in the program for his medical training. 9:50:04 AM Senator Olson replied that he had not been accepted into the program. He pointed to Slide 4, he wondered how many physicians left the state each year to practice elsewhere. 9:50:27 AM Ms. Allen responded that she could not provide specifics on the reason for the annual number of physicians needed each year in the state. 9:50:56 AM Senator Olson asked whether other states had a payback program for their students that chose to practice in states other than their home state. 9:51:12 AM Ms. Allen replied that Wyoming was the only other state that had a payback requirement. 9:51:50 AM Senator Olson asked about licensing requirements that might differ from state to state. 9:52:05 AM Ms. Allen responded that each state had a State Board of Medicine that controlled licensing, she did not believe that there was a difference, whether the student was from the state or not, in the ability to receive a state license to practice. 9:53:20 AM Senator Shower wondered what would happen to students currently enrolled in the program if the funding were pulled due to the governors budget cuts. 9:53:39 AM Ms. Allen said that current students would be allowed to complete their education, they would be charged out-of- state, and not in-state tuition. She said that additional classes would not be recruited. 9:54:38 AM Senator Micciche asked whether the potential obligation to pay back 50 percent made a difference on the student return rate. He wondered whether more WWAMI than non-WWAMI graduates returned to the state. 9:55:17 AM Ms. Allen believed that the return rate of WWAMI graduates was higher than the national average. 9:55:47 AM Senator Olson thought that North Dakota required their graduates to complete their medical training at the Mayo Clinic. 9:55:56 AM Ms. Allen said that currently all four years were completed within North Dakota. She said that in the 1970s the first two years would be completed in North Dakota, after which students were distributed between the Mayo Clinic and the University of Minnesota to complete medical training. 9:56:18 AM Senator Olson asked whether Alaska had considered a similar program of covering basic science years at a lower cost than the clinical years. 9:56:32 AM Ms. Allen shared that the accrediting body no longer allowed for a separately accredited first and last two years of schooling. The closest to the previous model was the WWAMI program, which allowed the first three years to be performed on regional campuses, with clinical training completion available across the five participating states. 9:57:05 AM Senator Olson asked about programs that granted allopathic (MD) versus osteopathic (DO) degrees and wondered whether changes in that process had occurred. 9:57:16 AM Ms. Allen replied that the medical school training had similarities, DO physicians learned more about Manipulations than MDs. 9:57:57 AM Senator Olson queried the chairman of the Admissions Committee. 9:58:04 AM Ms. Allen replied the chairman was Dr. Kate Sheridan. 9:58:33 AM Co-Chair Stedman discussed housekeeping. ADJOURNMENT 9:59:20 AM The meeting was adjourned at 9:59 a.m.