Dr. Rhyneer is a retired Alaska cardiologist, but "retired" may be misleading. He is a leading force in the effort to create a "Medicare-only clinic" in Anchorage, and convince the state to contribute perhaps $1 million to it. In this presentation Dr. Rhyneer discusses some of the rather unusual, even controversial aspects of his unique clinic such as the "one medical condition per visit" stipulation, and the anticipated roles of the physician and the mid-level providers. During the Q&A period, Dr. Rhyneer fields both hard-hitting and poignant questions from the audience. This presentation was given on March 24, 2010, at the Anchorage Senior Activity Center. The meeting was jointly sponsored by the the Senior Citizen Advisory Commission in partnership with the Seniors Behavioral Health Coalition. This transcript of the meeting has been lightly edited for clarity and length.

Links to selected topics

Who is Dr. Rhyneer?
Technology: The Reason Medical Costs are so High
Why are Specialists so Special?
Thinking: The Only Thing a Doctor Can Do
A Medical Home Only for Medicare Patients
What will This Clinic Need to Deliver Care?
Quality of Care: Why Only One Diagnosis Per Visit?
Price Controls on Physicians
Clinic Open and Running by Fall 2010
Will a Medicare Clinic Cause More Doctors to Reject New Patients?

[Dawnia Clements, chair of the commission] Let me just give you a brief overview of why we are here, and why we exist as a commission. Our main responsibility is to report to the mayor and to the assembly about the status of seniors in Anchorage. We recently met with the mayor and gave him many demographics about the coming "silver tsunami," which means we're going to have a lot more seniors in Anchorage, and we wanted him to be aware of what we are doing in that regard. We were instrumental in getting a municipal senior centers coordinator, Linda Meyer. The commission worked very hard to get that position. We support the efforts to implement an Aging and Disability Resource Center, the ADRC, here. We've been involved with transportation issues, which affect a lot of seniors.

We meet with service providers once a year to find out how they are doing with their service to seniors and that's where the rubber meets the road, so we feel it's very important keep in touch with them. We are working on a senior-friendly effort to get businesses to treat elders with a little more respect and a little more foresight because we are definitely consumers. You'll hear more about that as it develops. And of course, one of the things we've been doing is to keep abreast of what's been happening with Medicare. Many, many seniors in our town, including myself, cannot find a doctor and have gone from one doctor to another, calling to see if they will take Medicare patients after being kicked out of their doctor's office. In that regard, we have sponsored several get-togethers to discuss this and try to bring it to the attention of the Legislature, and to the municipal officials.

And that brings us here today. We've been very fortunate to have Dr. Rhyneer consent to come and give us an overview. He's a longtime physician in Anchorage, and I'm going to let him tell you a little bit more about his background and why he's so qualified to do this. Many of you know, he is responsible for the Heart Institute at Providence Hospital. I've known him and his wife, Marilyn, for many years, and I think he will be very open and honest in answering your questions. George, I'd like to just turn it over to you now, and you can tell them about yourself.

Who is Dr. Rhyneer?

Rhyneer: Well, thank you very much, Dawnia. Well, commissioners and familiar friends and faces in the audience, I thank you for allowing me to be here today to talk about what right now is my favorite subject. But before I get on with that, let me just tell you a little bit about myself. I grew up in Washington state, and I was always interested in coming to Alaska. It sounded like an exotic place.

When I was a kid in boy scouts, a fellow came through town who had been making movies of wildlife in Alaska. Our scout troop took him under our wing and agreed to sell tickets to his movie that he wanted to show in town. So I, being the dutiful boy scout, I got a pack of tickets that I started in my neighborhood, and I went down the street and the first person, the first door that seemed to be friendly-looking, it was a closed or a screen door, and I walked up and I knocked on the door thinking that I would try to sell these tickets to this movie.

I was very nervous. I was not used to giving this kind of presentation. I knocked on the door and this fellow got up from the dining room table, where he was having some guests for dinner, and walked to the door. "What do you want, kid?" I said, "Uh, uh, uh, sir, would you like to buy a ticket to Alaska?" And of course he guffawed, and I could hear all of the people in the background guffawing, and I don't think I sold a ticket, but I certainly slinked home.

I did my medical training [at] the University of Chicago. And from Chicago, the United States Public Health Service bought my ticket to Alaska. So I actually got a ticket, finally. I came up here in the late '60s and became the director of the tuberculosis control program for the state. I was with Public Health Service for a couple years, then went back to Oregon to finish up my cardiology training because that was the place in the country which had the most experience with open heart surgery. From there I came back up here and started practice in 1971.

Since that time, I've been involved with clinical medicine, in cardiology, practicing out of both hospitals and also doing clinics around the state. I helped get the cardiology program started at Providence Hospital. We did the first open heart surgery there on one of my patients. As time went on, I became involved with hospital politics, being chief of staff for couple of years. On several occasions, directing the cath [catheterization] lab, the cardiac coronary care unit, being on the Providence board, being on the Alaska licensing board, and generally have been rather involved with everything as things have gone along. Last May, I quit seeing patients in the office, and since that time I've been doing other things.


Actually, before I quit seeing patients it became  apparent to me that the community was suffering from the lack of primary care physicians to see people who had Medicare. The primary reason for that was how Medicare had developed over the years. Actually, I've been in practice longer than Medicare has been available. Lyndon Johnson, President Johnson, signed a law that created Medicare in 1965. I was an intern, a resident at that time. That made a huge difference in the way people over the age of 65 could be treated in this country for serious medical problems requiring hospitalization.

Before that time, many cities and many counties had city or county hospitals, and those are the places you went, by and large, if you are over the age of 65 and got sick. County hospitals were county hospitals, and when Medicare came into effect and [you] finally had the opportunity to go to your community hospital, go to your favorite physician, go to a university hospital -- Medicare would take care of that. It was a wonderful boon to this country and to the people who needed it. Back to selected topics list

Technology: The Reason Medical Costs are so High

The country still needs it, and the people still need it, but over the years, things have happened that were unpredictable at that time. First of all, technology has taken over. There are basically three reasons now, why we are here now today, and that has to do with the cost of medicine. The three biggest contributors to the cost of medicine are technology, technology, and technology. Everything else pales by comparison.

The amount of treatment that I could give a person who had a heart attack in 1971, when I came here, was minuscule compared to what happens today. Now, when I'm practicing, if I saw a person who had a heart attack, immediately dozens of great, well-trained, expensive people were called in to play, million dollar pieces of equipment were used. A person came into the hospital, had wonderful treatment, had their heart attack actually aborted -- stopped in midstream, so to speak. And instead of staying in the hospital for two or three weeks, suffering a major blow to your heart, you left the hospital the next day having had your heart attack taken care of and virtually no damage done.

For all that, it cost tens to hundreds of thousands of dollars, and it all revolves around technology. Who would want to go back to the time before we had CAT scans, before we had MRI, before we had heart surgery, before we had  angioplastic heart attacks, before we had medications which costs $50,000 a year when you have cancer but keep you alive for years and years on end? It's a price I think we should be willing to pay, but with this increase in costs, increase in imaging, increase in technology, Medicare does not set up or envision to be able to take care of this kind of problem, so we have developed a serious financial crunch.

As years go by, the cost of providing medical care for us has continued to skyrocket because of technology, but the ability and willingness of our fellow citizens and congressmen to pay for that has not kept up with that demand. Consequently, we have come to a position where the physician payments have turned out to be the lowest rung on the ladder of things that the government would like to pay for. They pay for imaging, they'll pay for surgery, but when you actually go to see a physician, it will not pay the physician for thinking.

That brings us to where we are today, a situation where, in this community, with the way that patients are [likely] to be seen, and the way physicians like to practice, there's not enough money in the Medicare payment system to take care of that problem. Consequently, that's why we're seeing that many of us cannot get by in primary care positions. Back to selected topics list

Why are Specialists so Special?

Specialists have somewhat of an advantage mostly because specialists' treatments are paid for at a higher relative rate. The value of your hourly pay as a surgeon is much higher than your hourly pay as an internist or family doc. Your hourly pay as a radiologist, or as an orthopedic surgeon, or as many other specialists, is much higher. It just turns out to be a historical fact based upon a series of events that I'd be glad to explain to you later, but take it from me, that is the case. We are stuck now with a situation where our primary care physicians and internists here in town cannot really continue seeing you in their practice, certainly not if all of the practice turned out to be Medicare.


So that made the case. About a year and a half ago, as I begin to think about this problem, I've tried to figure out ways to solve it. I thought, really, the way to solve this is to try to develop a very high efficiency way of delivering medical care. Right now, the physician treats the patient like he was trained to do, or she was trained to. That is, they do basically all the work. They do all the history taking, they do all the data gathering, they do all the telephone calling, prescription writing, make the record-keeping, all of that they do. As it turns out, doctors actually don't have to do all of that. Most people can be trained to do that with much less training than it requires to get an M.D. degree or go through residency. Back to selected topics list

Thinking: The Only Thing a Doctor Can Do

So if we take that into account, we could have a lot of the work by a doctor -- ordinarily things she or he has to do -- be done by somebody else, freeing the doctor up for what the doctor only can do, and that is: think. That can be done if you develop a process of the way patients are introduced, dealt with in the clinic, and seen from time to time. And with that, I've developed this model that I'll explain to you in a few moments.

After developing this model of procedure of doing the treatment, a group of organizations under the umbrella of an out-clinic called "Access" -- that includes Providence Hospital, the hospital association, the medical society and Alaska physicians and surgeons -- put some money in a pot. After we developed this clinic plan, we sent out an RFP [Request for Proposals] around the country to medical office business planners to see if they could take this business idea for working in the clinic, to see if the numbers then would justify actually running a clinic like this in the state, to see if it would be economically successful.

After about six months they gave us a report and a business plan. The business plan demonstrated that offering the clinic as we suggested would allow the clinic to see Medicare patients and break even in the third year. So with this plan in hand, we have now gone to the state legislature. I talked to the people in Finance -- Mike Hawker and Representative Stoltz, Senator Meyer -- are hearing this all. They pretty much think that they will be able to get this clinic a millions dollars startup costs, to get the clinic off and running, and to sustain it through the first three years of operation after which time it should be self-sustaining. Back to selected topics list

A Medical Home Only for Medicare Patients

This clinic would see Medicare patients only, or Medicare people who also have Medicaid. It would not see any other kind of a patient. That would allow a considerable amount of streamlining in the way the clinic does its operation. When you come in, you'd have expectations about what the clinic would provide you. Basically, it would provide you a medical home. You would see the same physician each time. You would largely see the same clinical staff each time. You would be evaluated by a nurse or a medical assistant or a nurse practitioner.

Your history, some of your physical examination, all the records would be obtained. Just like in a medical school setting then, your situation and you would be presented to the physician as Mrs. so-and-so, or Mr. so-and-so is coming in today. She's had diabetes for four years, blood sugars are not really well controlled. Last blood sugar was such and such. The physician would get all of the clinical data, and in a few moments, would be able to make an assessment of what the condition is, what the problem is, which next step to take, what to prescribe, and what next evaluations to make, and when next to see the person coming back at the clinic.

All this would take some time. You'd be spending most the time with the people who are getting your history and doing most of the preliminary data gathering. But you would see the physician, and the physician would apply all of his or her talents to your problem. And you would see the same physician again the next time you came back with us. You would get a longitudinal and ongoing relationship with your doctor and the people who are taking care of you. Using this kind of scheme, freeing up the doctor to just think and talk, would allow the physician actually to use his time most efficiently and allow the clinic then to operate in the black eventually, after the third year.


We expect that people will not be used to generally this way of being handled in a clinic. I think most people are going to be quite satisfied with the fact that they will have quite a bit of contact with medical personnel. They will have an ability to be seen as frequently as necessary and taking care of all of their medical problems, rather than just being triaged to a specialist. If specialists are needed, fortunately in this town specialists have no problem taking patients who are referred from family physicians or other physicians. If you need a cardiologist, the clinic would have no problem having you see a cardiologist. If you need an orthopedic surgeon, the orthopedic surgeon would be happy to see you. If you needed hospitalization, the hospitalist would be happy to take over your care in a hospital -- especially knowing that when you left the hospital, you'd have someplace to return to for your ongoing medical care. Back to selected topics list

What will This Clinic Need to Deliver Care?

Overall, you would get a marked upgrade for the kinds of things that are available right now. It is dependent upon several very important features of the clinic operation. First of all, it will have to have a medical record system, very likely electronic, which is robust and capable of taking care of a practice like this, allowing us to communicate with hospitals, [and] other referring physicians. Other referring physicians do the medical recording itself, send out prescription reminders, things of that sort.

It will also need, of course, a physician who has been around the block. This is not going to be the kind of clinic that can be run by someone who is just newly minted and is still learning. This will have to have a physician who has 10 or 20 years of experience, knows immediately whether a person is sick or healthy, and knows immediately the kinds of steps that need to be taken to come to the next point in treatment or diagnosis.


And lastly, it will have to have a manager, especially initially, that can keep their eye on the prize and will know how to deal with people, how to get the most out of people, how to get the best training between the physicians and the nurses and nurse practitioners, because everyone will be on a team in this clinic. Everyone would be part of taking care of the person, and everybody will be very important. Everybody will be working at their highest level of competence, and everybody will be actually challenged to improve their competence and to improve their skills.

We think that with the tentative salaries for this clinic, it's not going to be a place where you have to give your services. With participation of the patients in this way of taking care of yourself, we think it's highly likely that this clinic [will be] successful. But if we don't have those three components, it will be very difficult to make it go that way. We would be starting out with just one physician, a small array of nurses and nurse practitioners, a small office. As the need shows us, it can be expanded as fast as we can find new space if necessary, and [find] the talent to run the clinic. So that's the plan.

I know you have lots and lots of questions. There are lots of things happening, nationally and locally, and I have all the answers for them. [audience laughter]

Audience Member: Dr. Rhyneer, we have many younger people with disabilities who are also on Medicare. Will the clinic be seeing younger people also?

Rhyneer: Yes, anyone who has Medicare. That would include younger people with disabilities and people with chronic illnesses, renal insufficiencies, things like that -- anybody with Medicare. It's not going to be a cutoff because of age, it's going to be the kind of insurance you have which will allow whether you are seen in this clinic or not, and that's Medicare. Back to selected topics list

Quality of Care: Why Only One Diagnosis Per Visit?

Audience Member: It's very interesting to hear the details of your presentation. I have a copy of a document called "Alaska Medicare Clinic," which apparently is something like a concept paper, I guess, that you produced. In here it says, "Each clinic appointment will focus on one particular diagnosis. Other issues can be discussed at different appointments." I am really concerned about what this implies for quality of care. In other words, a lot of older people have multiple problems, and here it sounds like they have to keep coming back to the clinic to discuss these, and that patients will not be looked at as a whole, they'll be looked at as diagnosis by diagnosis. I have just one other question. I wonder if you've considered other models. For example, with that same million dollars, it seems to me you could use that to become a community health center that focuses on older people. That way, you'd get a higher reimbursement rate, you'd get some regular federal funding, and you also would not have to restrict each patient to one diagnosis per visit.

Rhyneer: Yes, those are questions that plagued us right from the beginning as well. Of course, all those were considered when we conceived this plan. As for the latter question about the federally qualified health clinic, we had our business planners that we hired in the Lower 48 looking at all the possible and conceivable ways of funding this clinic. Effectively, a qualified health clinic like the Neighborhood Health [Center] does indeed get, on the average, a higher reimbursement from Medicare, but they also have a number of other hoops they have to jump through that are required by law that we didn't think would get to where we wanted to go -- and that was seeing the most Medicare patients as possible -- so, we didn't go with the idea of a federally qualified health plan. We already have one in town, actually.

We didn't go with a Medicare Part C plan, which are the Medicare Advantage plans. These often do quite well in the Lower 48. This company that we hired looked at a number of those plans and actually suggested that we consider that up here as well. But unfortunately, or fortunately, we don't have that many Medicare patients right at this locale, and it takes, you know, many, many thousands to make it go with this kind of managed care Medicare plan, so we felt that that was not a viable feature as well.

It turns out that hospitals, if they develop an outpatient clinic associated with the hospital, also get higher reimbursement for their Medicare patients. Both hospitals actually have looked into this possibility. Both hospitals have held back on doing anything about this for several reasons. One is hospitalists generally lose money in outpatient clinics. Hospitals don't really have the expertise and don't really understand how an outpatient clinic is run. The hospitals in this town have traditionally lost money on their outpatient clinics, and there are several around the countryside. It also would exaggerate competition of an unkind sort, we thought, between the hospitals, so we did not go in that direction as well.


We felt that a simple plan that just took Medicare payment, period, would be the cleanest, easiest way to go, and might allow us not even to have to mail out bills, which is a very expensive proposition. That's how we sort of stuck with the Medicare only clinic plan that we've got here. There may be other ways of doing it; this is just the one we picked up. It just seemed to have the best advantage.

Now, as far as one visit, one problem; we are stuck with dealing with how Medicare pays for clinic visits. That's not how we would like to do it. We would like to get more money from Medicare, period. We would like to have Medicare pay for things in a rational fashion, but it doesn't. We are stuck with conditions as they present themselves. Unfortunately, we in Alaska have never been able to have an effect on the national scene when it comes to the Medicare problem. I personally have spent lots of time talking with Senator Stevens, and now Senator Begich about this problem, and we have little effect. We see we are ahead of the rest of the country in this problem, but the rest of the country, near as I can tell, is rapidly approaching a critical problem as well. So [we] are ahead of the game.

We do have to deal with how Medicare pays for clinic visits. Medicare payments are what we call "front-end loaded." You get more for seeing a person, relatively speaking, for the amount of time involved when you have primarily one problem with a visit. Other problems can be added on, but it's difficult to do that. It's a problem to do it that way in as much as you do require the person to come back for multiple visits if there are multiple problems. That is an aggravation. That's an expense for the person. It's an inconvenience and may not even be plausible for some people to do that, but it looks like that's the way we're going to have to go, for this clinic to be viable and to pay for itself, which we want as the ultimate goal.

Secondly, that's the disadvantage, but there is an advantage actually to being seen multiple times. When you are seen initially for heart failure -- although you have diabetes, hypertension and chronic obstructive lung disease -- those do not go unnoticed or undocumented by the patient and the people who are working in the clinic.  Although your heart failure may be the predominant and priority problem, get the treatment for that initiated. The next time you see the doctor, he will see how the heart failure has progressed or receded, and also see how that's affected your other problems that you have. With multiple visits, you get multiple chances to tell your problem to the doctor. How many of you, including me, have been to the doctor, go through the whole visit and you leave, walk out the door, you say, "Oh, I forgot to tell him about my chest pain." You know? That happens over and over again. This clinic, with a longitudinal view that you get by seeing a person on more than one occasion, will allow those oversights to be taken care of, and also allow the doctor to do much better than on a single visit. We think it's a downside, no doubt about it. It looks like it's going to be necessary for us to make the clinic financially viable. The other side is that actually over the long haul, it enhances your medical care.

Audience Member: Dr. Rhyneer, I have two questions. Number one is: this clinic will be a primary care clinic as I understand it. So; therefore, if there are multiple problems that require specialization, the doctor can certainly refer, isn't that correct?

Rhyneer: Yes.

Audience Member: And the second question is: will some of the retired physicians be volunteering there at the clinic?

Rhyneer: We are going to invite them to do so, yes. And we are going to invite physicians who are not retired, actually, to work in the clinic as well -- to fill in, to work a day or two from time to time, whatever they'd like to do. And if they find people that like them, or they like the individuals in the clinic, and they want to go to their other physician, they want to take the patient back to their own office, that's fine. It's not a problem.

Audience Member: My name is Nancy Harris, and I am a retired Navy nurse with a masters degree in human resource management. And I want to say today that I am extremely discouraged with our health care system as it looks and as it's developing. Medicare right now is a band-aid on a hemorrhaging artery. I had to move to Anchorage to get medical care because my doctor in Homer retired and the other doctors would not accept Medicare. I don't know how many people in here have been confronted with that. But just recently, I have an excellent internal medicine doctor at Elmendorf, but he does not cover every specialty. And when I was referred out for medical care, no one would accept it.

I also want to say that members of my family [have] lived in Canada for maybe 30 or 40 years now, and we have had some severe and critical medical problems in that country. My sister-in-law's neck was broken in a car wreck when she was going to see her doctor after six weeks from having a baby. She was in the hospital [for] quite a few months, and that hospital bill was 69 cents. About three weeks ago, my nephew in Prince Edward, who is 36 years old, had a cardiac embolus aneurysm to rupture. He was put on life support, and is still on life support, and he is a candidate for transplant. If that happened to a family here in the US, all of my relatives would be broke. So unless we get together, quit fighting like children, and decide on what we're going to do, then America is going to be a third world country. Back to selected topics list

Price Controls on Physicians

Audience Member: I was reading the article in the morning paper about the health care reform bill, and how it will hopefully impact Alaska with additional money. Will that affect the money that you need to get from the Legislature, and what could we do to help? Can we write our guys down there?

Rhyneer: I saw that. Actually, I heard that first on the Gavel to Gavel yesterday, and I saw it in the paper this morning. As I understand it, Senator Begich was able to get a provision in the new bill, that was signed into law yesterday, that would allow states to up its payments to physicians who see Medicare patients. I don't know what the restrictions or details of that are, so I don't know how it will turn out. It seems like it's an aggregation of the federal responsibility and dropping it on the state. The federal government actually restricts and has price controls. You may not be aware of that, but there are only a few price controls in the state and in this country. There are price controls on natural gas, price controls on electricity, and price controls on payments to physicians.


Now, the natural gas people can complain about a price that they can charge, go to the state and get that changed. Same with the people who make your electricity. They can go to the state and get the charge changed so that they can make a living. We can't. The physicians can't go to the government and say, "You're not paying enough for us to see a patient and make a living." We have a price control that has totally modified, and deformed, and disfigured how medicine is practiced in this country for Medicare patients.

So we have the federal government getting involved in that kind of a way, after denying a proper payment for patients. Now they are saying, "Listen, you and the state can now do it." I think that the state legislators are going be pretty upset about the idea [and they will not be] inclined to get involved with another obligation or payments of this sort. They are trying to reduce payments for Denali KidCare. They're going be stuck with increased payments for Medicaid. It seems to me that it's going to be a long haul, and extremely complicated for the state to settle some kind of a payment scheme to help us out in this situation. Now with that being said, if it does, it will make this clinic even more likely to be successful. That's how I see it.

Audience Member: I have a question. Since the major focus will be on older people, there are very few geriatric physicians in our city. Would you make that a primary pre-requisite for a physician?

Rhyneer: Well, actually, most of the people who are Medicare-aged, I wouldn't considered geriatrics. [Audience laughter]

Audience Member: I've had a gerontologist and there's a world of difference. It's like pediatrics. We have pediatric doctors, and they know the dosage and the developmental stages, and gerontologists know dementia and Alzheimer's and all of this. We need gerontologists, we need geriatric training in our nursing and in our volunteers. Alaska is really behind the times. We can't find anybody in geriatrics here, and the population and the demographics that are right in front of us? I live in the Pioneer home, and all of those people that live there have to go here and there and everywhere to see a doctor. [They] make numerous trips, most of them can't drive, they must have a family member or pay transportation, they're worn out by the time they get back and life becomes a drudgery. We need a central place for people to go have their problems taken care of, and have somebody on-site that's watching them. There are 180 residents in the Pioneer home, and every one of them has a separate doctor. There is no nurse practitioner, there's no doctor, there is no medical oversight over this residence. Back to selected topics list

Clinic Open and Running by Fall 2010

Audience Member: Dr. Rhyneer, under your medical plan, if you're getting funding this year, assuming that you'd be able to start July 1, when then would the clinic be open, and how many people can the clinic serve when it's opened?

Rhyneer: Well, assuming that the money gets in the state capital budget, the money, I guess, will be available July 1. If we get it into the budget, we'll start working on recruiting a clinic administrator, and physician right off the bat. And we can do that with some money that we are already have from donations around the state, around the country. If everything works out very well and we are able to find those two key individuals and a coterie of nurses and nursing assistants, nurse practitioners, we would hope to get going and open a clinic by fall. That would be the earliest I could see. Some of those things take a long time to get. I can imagine it's going to take a while to get a physician, especially if that person comes from out of state. It takes three or four months to get a state license, that sort of thing. So there a lot of things that can take time, that you just can't seem to rush, but we're optimistically looking for the end of summer, first part of fall.


It depends upon how many people we have working in the clinic as to how many people can be seen. We're thinking that each nurse, nurse practitioner, or medical assistant would probably see a patient every 15 or 20 minutes. If we had three of those individuals, then the doctor would be seeing nine to twelve patients an hour. If you multiple that times eight, we're looking at up to 50 patients a day, and that's 300 a week. How many of those over time will be returns? Since there's no clinic that's exactly like this around the country, we don't actually have any way of knowing, ultimately, how many patients we could take care of on a full-time basis with this clinic, but we'll be finding out.

Audience Member: This is actually two questions that the Commission on Aging called in with. The first one, I think you spoke a little of this earlier, but they want to know, is this set up to be like a nonprofit, like a 501 c 3? If it's not, how would you get money from the state or the government? The second question is, if someone does have multiple problems, how long can you anticipate the wait being in between visits?

Rhyneer: First of all, the clinic is a 501 c 3 nonprofit charitable organization under the state of Alaska. We do have the 501 c 3 designation from the IRS. That allows us to get grant money from the state, and also get donations from around the community which we virtually have been able to do. Those then are, of course, tax-exempt. The question was how long between visits. Well it would depend upon the nature of the problem. Sometimes it's best to wait two or three weeks to develop some data before you see a person again for some problem. Other times, you'd like to see them the next day. That will depend upon the clinical circumstances. If a person comes in and [says], "I can't breathe, I've got this horrible obstructive lung disease," and at the last minute they say, "Also, I've been having chest pain," you're not going to have them come back in two weeks to go over the chest pain. That kind of a situation would be dealt with immediately. The idea being that visits would be timed for clinical efficacy, rather than anything else.

Audience Member: Well I have a question about our [Medicare] Part D, prescription drug thing. Have you gotten any indication as to how that will affect your program, or be affected by your program, anything along those lines that you've been able to think about so far?

Rhyneer: Well, we have not rolled that into the thinking about this clinic. How the patient gets their medications, and how they pay for them is [outside of] the purview of the clinic and its operation. We are going to try to start simple, small, and try to build efficiency and efficacy into doing it that way. As time goes on, I'm sure we'll find situations where we should become involved and can become involved with things like the Part D payment for our medications, for developing social workers on-site, or a host of other things which would be very desirable in this clinic, but which at the beginning would not make it possible to survive if we started it up, all at the outset.

Audience Member: Thank you for that comment. It is a great lead-in. I run the Medicare information office, and I can't wait to have another phone number besides the appointment desk at the Anchorage Neighborhood Health Clinic. I look forward to the coordination that I suspect will happen between the two organizations as to which one is available to take new patients so that I'm not overloading my referrals to one place or the other. I would like to offer, as I work with Joan on this, maybe having a Medicare counselor at the clinic to do Part D counseling, so that when people are given prescriptions and they're overwhelmed with the choice of what Part D plan to get into, or they might need extra help paying, that we would be glad to have, if there's space, somebody from our office at no cost to do that counseling. If you are open to that kind of partnership, we would be, definitely.

Rhyneer: Well, thank you very much, I will answer to that promise.

Audience Member: I would like to respond to this lady. My name is Maryanne Porter, I'm the endowment trustee for the Senior Center, and have been for 12 years. I've been on the board, I would like to point out that the Senior Center has a Medicare counselor, here.

Audience member: I have a quick question. Dr. Rhyneer, are you taking volunteers?

Rhyneer: Of course. You bet. Back to selected topics list

Will a Medicare Clinic Cause More Doctors to Reject New Patients?

Audience Member: Dr. Rhyneer, I have a physician who fortunately covers Medicare patients but not new ones. I wonder, will this affect doctors who take Medicare patients and say, "Okay, you've got a clinic now you can go to." Do you think they might stop taking Medicare patients?

Rhyneer: I would hope not, but I have no way of knowing that. Physicians in this town are embarrassed by the circumstances that we find ourselves. We aren't happy about it. Those who can feel like they could take Medicare patients, do. Those that feel like they can't, don't. But the fact that some of them don't is an embarrassment to us as a physician community, and we're doing best to try and solve that problem.

Audience Member: You mentioned that you would try to hopefully eliminate the invoicing. Does that mean you're not going to pursue secondary insurance?

Dr. Rhyneer: No, we would try to pursue secondary insurance but I think when at all possible, we would try to have the patient themselves do most of that effort. But there again, billing is very expensive. Medicare doesn't pay for that. Telephone calling, answering telephone calls, nurse calls and whatnot, is very expensive and time-consuming, and Medicare doesn't pay for that. We are trying to do a clinic which we hope gets the job done, but also demonstrates really what Medicare pays for. We, physicians, are used to a lot of things being done in the office that Medicare doesn't pay for. Those things are to be done gratis at this time, but we will not be able to do too many things that Medicare doesn't pay for. Back to selected topics list

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Early warning! AHPR Editor Lawrence Weiss will be teaching HS 690 Alaska Health Policy in Fall 2010, a class offered by the Master of Public Health Program at UAA. This course is also open to persons who are not in the MPH program with permission of the department. It will be entirely online so you can do most of it at 2 a.m. in your jammies if you like.

The focus will be on health-related public policy in Alaska. The educational style will be fast-moving, highly interactive, and intellectually challenging. The curriculum will explore what health policy is, what impact it has on day-to-day practical operation of health care, how it is created, who influences it, and how national policies may affect health policy in Alaska.

Teleconferenced guest speakers will include some or all of the following: state legislators, lobbyists, program administrators, and advocates. Main source materials will include selections from approximately 1,800 pages of back issues of Alaska Health Policy Review, and a variety of relevant websites and other online resources. Students will conduct a high priority health policy analysis with practical application in Alaska, and will have the opportunity to have it reviewed for possible publication in Alaska Health Policy Review.

Sound interesting? Contact Katie Frost, ankrf@uaa.alaska.edu, administrative assistant in the UAA Department of Health Sciences. Ask her to put you on the "interested" list for HS 690 Alaska Health Policy so you can learn more about it and have the opportunity to sign up later this year. This class will be interesting, fun, and a great opportunity to network with like-minded health policy wonks!

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Health policy bills continue to move along as the Legislature wraps ups the session. Several bills were heard and moved out of committees, and many were passed in one chamber and read for the first time in the opposing chamber. One new bill was introduced on March 31, HB 423 Policy for Securing Health Care Services, which proposes a new policy stating that residents of Alaska have the right to purchase or decline health care or health insurance without any penalty, and that the Attorney General enforces this policy.

SB 215 Pioneer Home Rx Drug Benefit is scheduled to be heard in (H) STA on April 1.
HB 50 Limit Overtime for Registered Nurses passed unanimously in the House and was transmitted to the Senate for a first reading on March 25, then read for the first time on the Senate floor and referred to (S) FIN on March 26.

HB 110 Psychologists' Licensing & Practice was heard in and moved out of (S) EDC on March 26. HB 235 Prof Student Exchange Loan Forgiveness was heard and held in (H) FIN on March 26. HB 392 Incentives for Certain Medical Providers was scheduled but not heard in (H) HSS on March 30. SB 139 Incentives for Certain Medical Providers was heard and held in (S)FIN on March 31.

HB 292 Grants to Disaster Victims passed unanimously in the House and was transmitted to the Senate on March 30; read for the first time in the Senate, and referred to (S) FIN on March 31. HB 309 Dental Care Insurance was heard in, amended, and CSHB 309 moved out of (H) HSS on March 25, and was referred to (H) FIN on March 29. SB 38 Pharmacy Benefits Managers; Managed Care is scheduled to be heard in (S) L&C on April 1. SB 238 Medicaid for Medical and Intermediate Care was scheduled to be heard in (H) HSS on April 1. SB 258 Dental Care Insurance (CSSB 258) passed unanimously in the Senate and was transmitted to the House on March 30, and was read for the first time in the House and referred to (H) FIN on March 31.

HB 52 Post-Trial Juror Counseling was heard in and moved out of (H) FIN on March 26, referred to (H)RLS on March 29, and moved from (H) RLS to Calendar on March 31. HB 302 Mental Health Budget passed unanimously in the Senate on March 30.

SB 263 Extend Board of Professional Counselors was read for the first time on the House floor, and was referred to (H) L&C on March 26. HB 25 Health Reform Policy Commission was heard in (H) HSS on March 30. HB 376 Extend Bd of Psychologist and Psych. Assoc. passed unanimously in the House and was transmitted to the Senate on March 30, and was read for the first time in the Senate and referred to (S) L&C on March 31. SB 247 Extending Board of Pharmacy was read for the first time in the House, and was referred to (H) L&C on March 26, and is scheduled to be heard on April 7. SB 248 Extend Bd of Marital & Family Therapy was read for the first time in the House, and was referred to (H) L&C on March 26, and is scheduled to be heard on April 7.

HB 314 Workers' Compensation was moved from (H) RLS to Calendar on March 30, and transmitted to the Senate on March 31. HB 354 AK Capstone Avionics Revolving Loan Fund was read for the first time in the Senate, and referred to (S) L&C on March 26. HB 361 CPR Training for 911 Dispatchers was heard for a second time in (H) HSS and moved out of committee on March 30, and referred to (H) FIN on March 31. SCR 13 Supporting Senior Caregivers is scheduled to be heard in (H) HSS on April 1. 

The following is a list of all health-related bills recently proposed or sitting in various legislative committees. For a description of the process of selecting and tracking health policy bills, as well as the full names of committees and their abbreviations, refer to the end of the Bill Watch section.
 
Bill information is current as of April 1 at 10:00 AM.

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HB 314 Workers' Compensation
Sponsor: Labor and Commerce Committee
Committee(s) and date of last action: Moved from (H) RLS to Calendar, 03/30/10; transmitted to the Senate, 03/31/10
Description: This bill is "An Act relating to fees and charges for medical treatment or services, the crime of unsworn falsification, investigations, and penalties as they relate to workers' compensation; and providing for an effective date.

HB 346 Workers' Compensation Advisory Board
Sponsor: Rep. Olson
Committee(s) and date of last action: Heard and held in (H) FIN on 03/22/10
Other Information: This bill proposes that a Workers' Compensation Advisory Board be established, with a variety of members who would be required to meet every six months. If established, the bill would take effect immediately, and the Board would be in place until June 30, 2015.

SB 20 Worker's Comp Medical/Rehab Records
Sponsors: Senators French and Thomas
Committee(s) and date of last action: Read and referred to (S) L&C, then (S) JUD, 01/21/09
Description: This bill proposes that any documents containing personal and confidential information of an employee that is receiving, or has received, worker's compensation, are kept in a confidential location away from the public's view.

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Sponsors: Representatives Holmes, Dahlstrom, Millett, and Kawasaki
Committee(s) and date of last action: Heard in and moved out of (H) JUD, 03/15/10, referred to (H) FIN, 03/17/10
Description: This bill amends a previous statute by adding that a health care facility will not be subject to civil or criminal liability in the event that they act in reliance to an advance health care directive or fail to check an advance health care directive registry for a patient in their facility. In addition, HB 71 proposes the establishment of an advance health care directive registry within the Department of Health and Social Services, where individuals or their guardians can file advance health directives. This registry would be confidential and may not be used for another purpose.
 
HB 168 Trauma Care Centers/Fund
Sponsor: Rep. Coghill
Committee(s) and date of last action: Heard in (S) HSS, 02/22/10 and referred to (S) FIN, 02/24/10
Description: "An Act relating to state certification and designation of trauma centers; creating the uncompensated trauma care fund to offset uncompensated trauma care provided at certified and designated trauma centers; and providing for an effective date."

HB 304 Ban Smoking in Public Places
Sponsors: Representatives Salmon and Buch
Committee(s) and date of last action: Read and referred to (H) STA, then (H) JUD, 01/19/10
Description: This bill proposes to amend current laws related to smoking in public places, as well as smoking in any enclosed establishment serving as a place of employment. It includes several specific areas where smoking should be prohibited, including waiting areas for public transportation, facilities providing mental health services, legislative buildings, and health clubs.

HB 354 AK Capstone Avionics Revolving Loan Fund
Sponsor: Rep. Keller
Committee(s) and date of last action: Read for the first time in the Senate, and referred to (S) L&C, 03/26/10
Other Information: This bill proposes an amendment to existing legislation on avionics loan funding, to include both owners and leasers of aircraft. The legislation would apply to medevac carriers who lease their aircraft. Representative Keller proposed the bill to increase air traffic safety, stating on his website, "The program was developed to provide low-interest loans to in-state private and commercial aircraft owners to upgrade their avionics, or on-board navigational aids and computer systems."

HB 361 CPR Training for 911 Dispatchers
Sponsor: Rep. Fairclough
Committee(s) and date of last action: Heard for the second time and moved out of (H) HSS, 03/30/10; referred to (H) FIN, 03/31/10
Other Information: This bill proposes that all 911 dispatchers be required to have certification in cardiopulmonary resuscitation (CPR) prior to their employment.

HB 399 Community Health Assessments
Sponsor: Rep. Cissna
Committee(s) and date of last action: Introduced and referred to (H) HSS, 02/23/10
Other Information: This bill would establish a health impact assessment program within the Department of Health and Social Services, with the goal of creating healthy communities and reducing health disparities, to take effect July 1, 2012.

HB 423 Policy for Securing Health Care Services
Sponsor: House Judiciary Committee
Committee(s) and date of last action: Introduced and referred to (H) HSS, then (H) JUD, 03/31/10
Other Information: This bill is also known as the "Alaska Health Freedom Act." It proposes that the Attorney General enforce a new policy in the Alaska Statutes that states that Alaska residents have the right to choose or decline any form of health care and health insurance, and without a penalty or fine.

HJR 46 Supporting Denali Commission
Sponsor: Community and Regional Affairs committee (CRA)
Committee(s) and date of last action: Transmitted to the Governor, 3/19/10
Other Information: This bill urges Congressional support of the Denali Commission.

HR 14 Oppose Federal Health Reform Bills
Sponsor: Rep. Chenault
Committee(s) and date of last action: Heard in and moved out of (H) RLS, read for the second time, then returned again to (H) RLS, 3/19/10
Other Information: This bill proposes a list of negative consequences to Alaska, and suggests "that the House of Representatives urges the Alaska Congressional delegation to vote against the current health care reform bills and to develop health care reform that is affordable and accessible to all legal residents," and  "that the House of Representatives urges Governor Parnell  and the Administration to review the constitutionality of the special deal for other states contained in the current federal health care reform bills." Once passed, it is requested that the resolution be sent to President Obama.

SB 41 New Driver's/Permit: CPR/First Aid
Sponsor: Sen. Ellis by request of the Governor
Committee(s) and date of last action: Read and referred to (S) HSS, then to (S) STA, 01/20/09
Description: This bill requests that new applications for driver's permits or licenses only be issued to individuals who have completed cardiopulmonary resuscitation and first aid training in the one year prior to the application. This does not apply for individuals who have already obtained a driver's license or permit in Alaska or another state, and is to be effective January 1, 2010.
 
SB 49 Blood Donation Awareness Fund
Sponsor: Sen. McGuire
Committee(s) and date of last action: Moved to (S) FIN, 02/27/09
Description: This bill requests that the opportunity to donate $1 or more to the Blood Donation Fund be made available to all applicants for motor vehicle or identification documents. These donations would be place in the Blood Donation Awareness Fund, and would be used to promote blood donation activities throughout Alaska.

SB 168 Trauma Care Centers/Fund
Sponsor: Health and Social Services, by request of the Governor
Committee(s) and date of last action: Scheduled to be heard in (S) HSS at 1:30 PM on February 10
Description: This is the Senate companion bill to HB 168, and is identical.

SB 169 Approp: Trauma Care Fund
Sponsor: Health and Social Services, by request of the Governor
Committee(s) and date of last action: Heard in (S) FIN, 03/10/10
Description: "An Act appropriating $5,000,000 to the uncompensated trauma care fund; and providing for an effective date."

SCR 13 Supporting Senior Caregivers
Sponsors: Senators Bund and McGuire
Committee(s) and date of last action: Scheduled to be heard in (H) HSS at 3:00 PM, 04/01/10
Other Information: This bill proposes, "Supporting senior caregivers and encouraging the Department of Health and Social Services to provide additional education on the effects of aging and the importance of senior caregivers."

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Bills listed here were selected based on a series of subjective criteria to determine whether they were "health-policy related." All bills currently sitting in the Senate and House Health and Social Services committees were examined, and any that obviously dealt with non-health-related education or social services issues were eliminated. Every other House and Senate committee was then examined for health-related bills, which were included in the final list.
 
After determining the full set of health-related bills still in committee or pre-filed for the new session, they were divided into several general categories. This was done to facilitate finding bills that dealt with certain key health policy issues and to make overall navigation of the list easier. The remaining bills were categorized as "general" health policy-related because of the wide range of subjects they covered.
 
The information listed for each bill includes the bill number, the short title, the primary sponsor or sponsors, the committee in which the last action on the bill took place, and the date on which the last action on the bill took place. A short summary of each bill is also included.
 
Abbreviations have been used for committee names. The committee names and their abbreviations are:

• (H) HSS: House Health and Social Services Committee
• (S) HSS: Senate Health and Social Services Committee
• (H) L&C: House Labor & Commerce Committee
• (S) L&C: Senate Labor & Commerce Committee
• (H) EDC: House Education Committee
• (S) EDC: Senate Education Committee
• (H) FIN: House Finance Committee
• (S) FIN: Senate Finance Committee
• (H) JUD: House Judiciary Committee
• (S) JUD: Senate Judiciary Committee
• (H) STA: House State Affairs Committee
• (S) STA: Senate State Affairs Committee  
• (S) RLS: Senate Rules Committee
• (H) CRA: House Community and Regional Affairs Committee
  

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