Alaska Health Policy Review

On January 29, 2009, leading representatives from six Alaska organizations convened to present their knowledge, concerns, and recommendations to the House Health and Social Services Standing Committee. On the agenda: Alaska's health care professional workforce. The overall theme: Alaska is in great need of health care reform efforts to recruit, train, and retain health care professionals.

The panel issued a preliminary statement on the current situation of workforce shortages in Alaska, including brief solutions to this dilemma:

The Problem

In Alaska, healthcare is delivered to our citizens by providers, public and private, tribal and non-tribal, situated across our great land in very diverse settings. Healthcare is a very large industry in Alaska, and has grown substantially during the last decade. However, as in much of the nation, our providers are experiencing large and growing practitioner vacancies. The healthcare workforce vacancy rate is now over 10 percent and growing, with particularly hard-to-fill positions being found in much of rural Alaska, and amongst "safety net providers" who deliver substantial care to patients covered by Medicaid, Medicare or who are simply uninsured. This workforce shortage is wide-spread (e.g. all 119 healthcare occupations), and is increasingly problematic, disruptive and expensive. The situation is now often characterized as an emerging public health crisis. The problem is one of both shortage and mal-distribution, is interagency in scope, and the common view is that it will not relent to anything other than a multi-pronged and coordinated approach.

Possible Solutions

The panel presents the healthcare workforce shortage and mal-distribution problem, each presenter from his or her organizational and professional vantage. Three main strategies for solution are discussed: (a.) Increasing training of more workers, particularly through the University of Alaska's statewide Health Program; (b.) Beginning a robust "support-for-service" program, which includes a loan repayment and incentive program to enhance recruitment and retention; and (c.) Augmenting interagency planning and collaboration via the forthcoming Alaska Health Care Commission.

Dr. Jay Butler, chief medical officer for the Department of Health and Social Services and facilitator, opened the hearing by discussing the Four Pillars of Health Care Reform: Access, Cost, Quality, and Prevention. He noted that, "Access influences cost, quality, and whether or not we can deliver prevention services."

Karen Perdue, associate vice president for Health Programs, UAA (former commissioner for DHSS)

Perdue discussed the role of the university in recruiting and training health care professionals, and the current struggles with meeting those goals.

Health care is one of the largest employers in Alaska, providing 8 to 9 percent of total state jobs. These positions are not concentrated in one community or only in urban communities. Health care is a very diverse industry, with 119 occupations in Alaska. In Alaska, shortages are everywhere, which leads to the hiring of temporary positions and a great cost during recruitment and retention efforts.

"Labor is a big cost of healthcare ... we are paying a high cost for healthcare; we're hiring a lot of temporary people."

Perdue pointed out that there was a 62 percent job growth in Alaska health care jobs from 1992 to 2002. She mentioned that the Department of Labor & Workforce Development (DLWD) reported that nine of the ten fastest growing Alaska jobs were in health care. Additionally, half of the health care jobs are at the associate or the direct service workers levels.

Pharmacists, dentists, and therapists have the highest rates of vacancies in the state. Many have given up recruiting for these positions, especially in rural areas. A large percentage of the health care workforce is over the age of 50, and retiring positions are causing a greater need for recruitment. Close to 43 percent of future vacancies in health care positions will be due to retirement.

Perdue commented on the staggering costs associated with recruitment and vacancies. On average, Alaska spends $11 million in recruitment and $13 million in hiring itinerant (traveling) health care workers.

Rep. Seaton asked, "On the shortages and use of itinerants, how much of this is related to hospitals not wanting to use new nurses ... training, follow-up. Are there young nurses out there that can't find jobs?"

Perdue responded, "All of our [nursing] graduates get jobs ... we're educating generalist nurses ... there is a struggle that we're not able to meet all of the specialty nursing needs of the state."

Rep. Seaton asked the reasons for the nursing shortage, to which Perdue replied, "We have 700 students that want to be nurses. We do not have a shortage of students who want to be nurses." She mentioned that despite the high interest in the nursing program, "We continue to have a faculty shortage ... we have a problem with students being able to complete the clinical in hospitals." Thus, the faculty shortage is directly related to the nursing shortage.

Perdue continued with a discussion on the major improvements in health professional programs at UAA since 2002. The university has achieved several goals in expanding health and allied science programs including:

doubling the graduates in the nursing program;
doubling enrollment in WWAMI (medical school option through the University of Washington);
creating a Master in Public Health program and doubling the enrollment;
expanding enrollment and capacity of the Bachelor's and Master's in Social Work;
partnering with Creighton University to offer a Doctorate in Occupational Therapy online.

Future goals include using the governor's money from the budget to create a UAA physician's assistant program (which is offered currently through a partnership with the University of Washington).

Perdue noted that mid-level health care providers, like those who obtain an associate degree in Allied Health and Nursing, are of high value in rural areas and efforts are needed to enhance these programs for retention in remote areas. Studies have shown that the majority of health profession students stay within 50 miles of where they finish their training. She discussed, in response to a question from Senator Davis, what UAA has done with previous state funding to expand the Allied Health programs,

"In 2001, we had 96 admissions ... in the nursing program, we had no students outside of Anchorage in the A.A.S. [Associate in Applied Science] degree, and now we have more students in the A.A.S. degree outside of Anchorage than we do in Anchorage, but we have grown the Anchorage program as well. The B.S. program [Bachelor in Nursing] continues to be in Anchorage, and we have grown our B.S. program as well."

She continued with, "This underscores the ... dynamic changes in the A.A.S. program ... 51 percent of our graduates are now coming outside of Anchorage for nursing."

Perdue discussed future goals of the university, indicating that with the Governor's recent allocation of $1.8 million in the FY 2010 budget, there is potential for a physical therapy program and a bachelor of science in Nutrition and Dietetics program.

"We talk a lot about obesity ... we are the only state in the union that does not have a 4-year degree in nutrition. We need to fix that. We think the time has come for that."

In response to a brief discussion on the physician assistant program (called MEDEX) offered through the University of Washington, Rep. Herron asked, "If we were going to compare ourselves to another state, which are sending people to UW types of facilities, is that 20 per year based upon the need in our state?"

Perdue responded, "Right now we send about 10 students per year to the MEDEX program, and we hope to get 20 into the program who can do all of their stuff here." She followed that the number is more related to the capacity of the state to train those admitted rather than overall need.

Rep. Keller asked, "Related to the health care commission that is coming forth, based upon your presentation, what kind of surgical effort are you going to make related to the commission?"

Perdue responded, "Workforce is a part of health care reform. It just is, because it's such a driver of cost and quality ... Cost and quality can be better managed by continuity of care. We really hope that we can get a strong effort of bringing in all these groups that we've been working with and feeding that information to the committee."

Marilyn Kasmar, executive director, Alaska Primary Care Association (APCA), Inc.

In response to an initial question about the number of physician's assistants in Alaska, she replied, "I understand that Alaska uses mid-levels, including nurse practitioners and physician's assistants about four times the national average."

Kasmar continued with her presentation, which focused on the workforce shortage from the perspective of the safety net, or the community health center. She described the APCA, a membership organization of Alaska community health centers (CHCs) and other safety net providers. CHCs have been an effective presence in Alaska since 2001, and there are now 141 sites in the state. She noted that CHCs are non-profit, serve the entire community, and do not turn anyone away, regardless of the inability to pay.

Community health centers are federally funded and can only be opened in underserved communities. CHCs provide comprehensive, primary, and preventive care, which includes medical, dental, and behavioral health care. Among the many benefits of CHCs, " ... they help keep patients out of emergency rooms, which are often used for primary care, which is a very expensive way to deliver primary care."

Rep. Coghill asked if a CHC could lose its funding if there were vacant physician jobs in the facility, to which Kasmar indicated that other providers step in during the interim and funding is not lost.

Co-chair Herron asked if it was necessary to have a minimal payment from clients for services through a sliding-fee scale.

Kasmar responded, "It does make a difference. Patients like to feel that they are contributing to the cost of care that's provided. They find pride in that. Typically, it is not supposed to be high enough to be a barrier. It is not intended to keep patients away, but it is intended to provide accountability for services. Also, to prevent people from popping in for a minor sniffle ... or when it's not really necessary."

Kasmar discussed the type of person who uses community health centers: typically the poor and uninsured. "Forty-eight percent are under 200 percent of the federal poverty level, so these are people who really are poor ... CHCs are there to serve the underserved."

Regarding who is paying for patients' care, "There is a large number of [uninsured] people out there, and it is growing as well." Additionally, "The further you get away from urban areas, the more uninsured you are seeing."

Similar to Karen Perdue's presentation, Kasmar indicated that the retirement of providers was leading to the further shortage of health care workers. There was growth in dental and mental health services between 2000 and 2005, but there is still a shortage of personnel. The expense and difficulty to recruit and retain providers is significant,

"This is a huge problem. If you talk to any of our executive directors, they'll tell you this is their number one issue: recruitment and retention. We don't expect it to get better; we do expect it to get worse. It's very disruptive to what we do in terms of being able to provide services, but also in the time and energy it takes to recruit providers. That time and energy that's being spent trying to get people to come work could be bettered directed toward other areas ... the more rural and remote you get the harder it seems to be to recruit qualified providers to your sites."

Rep. Seaton asked what solutions were being used to mitigate the shortage of health care providers in rural settings, to which Kasmar replied, "The administrators of these clinics will use any tool available to them to recruit. Some of the tools that are available are national programs that provide loan repayment, for example the National Health Service Corporation of the Indian Health Services provides loan repayment to providers as an incentive to get them to work in rural and remote areas."

Additionally, Kasmar noted "When a medical student comes out of medical school, it is not uncommon for them to have somewhere between 100 and 200 thousand dollars in debt. So, when they come out of school they are looking at this huge debt load and one of the primary concerns is to get that paid off. Alaska is one of only six states that do not offer, as a state, any kind of an incentive program, or a loan repayment or support-for-services to help with that issue ... some states have 2 [or] 3 programs ... other states can offer much better options that way and we are losing candidates because of that."

Kasmar discussed the factors driving the shortage, indicating that 75 percent of the practitioners do their work within 50 miles of their residency. She added that although the current leadership was preparing to retire, the next group of practitioners is not yet ready to take over.

Kasmar reminded the committee that the shortage is expected to get worse. She presented data from a national provider survey revealing that among providers on the job market, the loan repayment option was one of the most important things they consider. "Often the very first question asked by a provider is about the state loan repayment option."

Rod Betit, CEO, Alaska State Hospital & Nursing Home Association (ASHNHA)

Betit presented an overview of ASHNHA, and gave a perspective from the health care market. Betit mentioned that 24 of the top 110 biggest employers in Alaska were in health care services.

Discussing the industry perspective on health care costs, he mentioned the issues involved in vacancies. These include recruitment costs and costs for hiring itinerant nurses. He added, "There was $1.5 million saved by just one facility in nurse recruiting since local training has been made available by the university in concert with Fairbanks Memorial. This expanded nursing program has gone a long way to closing the gap, at least in the nursing profession. We still have problems, but it's been a huge improvement in doubling the number of nurses that are coming out of that program. And then to add the distance learning component to it so that it reaches out into the smaller communities has been another big asset."

Betit said that despite the progress in increasing the number of graduating nurses, there are still problems keeping enough patient care staff. He mentioned that when a temporary or itinerant nurse has to be hired, there is a 50 to 75 percent increase in cost for that care. Additionally, doing that causes breaks in continuity of care. This problem is bigger in rural and remote communities.

Betit said that the topic of trained professionals needs further discussion. "That's the piece that we really need to talk about because there's big competition for that throughout the country. There aren't enough doctors, dentists, nurses being graduated throughout the system even with the growth that's occurred to meet the coming need. We're in a fairly decent position, because we've done some things here to help close that gap, but my biggest concern, and the association's concern, is what happens in the small communities and with the safety net providers. Our big providers can hold their own in that competition, and go out and get those physician or those nurses. But when you get into the smaller communities and the really remote rural areas, that's not the case."

Betit moved forward to discuss the development of a loan repayment program. He offered many different kinds of options for loan repayment, direct incentives, and other types of tools used to recruit and retain workers. "We're not seeing much of a likelihood to close the gap without some help from the legislature." He reiterated that without the support from the state to initiate loan repayment or other incentive programs, we would not be able to fill any of the health care professional vacancies.

Delisa Culpepper, chief operating officer, Alaska Mental Health Trust Authority (AMHTA)

Culpepper began her presentation of the "Trust Workforce Development Focus Area," indicating her talk would involve the mental/behavioral health perspective of the workforce shortage. Listing five program areas that AMHTA hopes to change the system of services to its beneficiaries, she noted that four of the programs had begun five years earlier. However, the fifth program, "Workforce Development," only became a focus during the past year. "We have been working on workforce for many, many years, but not as a focus area. So we started a couple, three years ago saying we had to look at this in a more concerted effort."

Culpepper, like the other presenters, shared that the problems of workforce development include recruitment, training, and retention. Additionally, training is necessary not only in the formal educational sense, but also occupational training within communities.

Culpepper referred to the programs where training is especially needed:

Trust Training Cooperative
Geriatric Training - Alzheimer's
Credentialing and Quality Standards
Children's Mental Health Certification
Autism Workforce Development Capacity Building
Brain Injury training for professionals
Peer Support Workers
Disability Justice training for professionals

With regard to recruitment and retention, the Alaska Mental Health Trust Authority recommends many groups, programs, strategies, and studies to support workforce development. Additionally, Culpepper noted that the Alaska Mental Health Trust Authority needed to continue its vacancy studies and support for workforce development. "There are reasons people cycle in and out of jobs, it isn't always pay and benefits, it often is not knowing what their job is, not having good supervision and follow up, and other things."

She also noted, "We have major vacancies in psychiatrists in Anchorage, Fairbanks and Juneau, our three main areas where things funnel in for psychiatric care. And this has become a real problem in the last year. So we're looking at residency programs, which are often the only way to get the advanced degree people to come into a community."

"If we can't make a difference in whether or not there are major vacancies in the professions serving our beneficiaries across the state, we are not really doing our job in this area. So we will continue to help the university fund the vacancy study every other year to look at the needs across the state."

Culpepper ended her presentation by responding to a question by Rep. Seaton, who asked, "Are there any available opportunities for returning veterans?" Culpepper replied, "That is an area when we're looking at marketing jobs to new groups we're beginning to look into this ... you can have a second career, and because these are available in rural and urban areas, they are an area that we're beginning to work on for our vets."

Dr. Jay Butler, chief medical officer, Alaska Department of Health & Social Services

Butler concluded the meeting by giving a brief perspective from the physician side of the problem. He observed that the shortage of both primary care physicians and mid-level providers in Alaska and the nation. He noted that there have been dramatic declines in the number of medical students pursuing primary care position. Many are now choosing specialties over primary and pediatric care. He summarized the many reasons for the shortage including life style, lower pay than other specialties, debt from public medical school, length of training, and competition. He emphasized the value in "growing our own," with postgraduate training and a loan repayment program. He stated that he was aware that this topic would be first on the agenda for the new Alaska Health Care Commission.

No specific bills were on the agenda or discussed during this committee hearing. However, two bills in the current legislature address this issue. SB 18 Postsecondary Medical and Other Educ Prog and HB 58 Educ Loan Repayment Program both address ways to retain health care workers in Alaska following the completion of their education. HB 58 has not yet been heard in committee, and SB 18 was heard in (S) Education on February 27.

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