Robert Sewell is program manager for Alaska's SHARP program, in the Alaska Department of Health and Social Services Division of Public Health Section of Health Planning & Systems Development. Sewell is a long-time Alaskan and public health advocate. As SHARP program manager, Sewell is working to build support-for-service options for clinicians statewide.
This interview was conducted by Kelby Murphy via phone and email, and it was lightly edited for length and clarity.
Links to selected topics
Please tell the Alaska Health Policy Review
readers a bit about who you are, who you work for, and your role with Alaska's SHARP program
My name is Dr. Robert Sewell. I work for the Division of Public Health in Alaska Department of Health and Social Service, serving as program manager for Alaska's SHARP program, which is a support-for-service effort that provides loan repayment, and now, direct incentive as well for selected health care clinicians throughout Alaska, particularly those providing care for underserved populations. AHPR:
Can you tell us about the key elements and outcomes of SHARP? Sewell:
There are two parts to SHARP. There is our traditional SHARP program, which receives partial funding from the federal Health Resources and Services Administration (HRSA). We have received two federal HRSA grants from a program called the "state loan repayment program" that provides 50 percent support for what we call SHARP-I. This provides support for primary care practitioners only.
To date, SHARP-I has admitted 74 clinicians to the program, of which 62 remain in field. The others have largely graduated or completed their two-year service obligation. SHARP-I practitioners serve across a range of primary care medical, behavioral health, and dental occupations. SHARP practitioners serve across all six regions of the state: Anchorage/Mat-Su, Gulf Coast, Interior, Northern, Southeast, and Southwest. They are tasked to work largely, but not exclusively, with underserved populations, meaning those who are resourced through Medicaid, Medicare, or are uninsured but are assisted [with medical care costs] through a sliding fee or charity care policy. Back to selected topics list
SHARP-II offers more flexibility in support-for-service effort
How is the SHARP program being perceived? Sewell:
From a variety of data, our impression is that the program is off to a very solid start, and it seems to be well received.AHPR:
What factors contributed to the passage in 2012 of state legislation -- HB78 Medical Provider Incentives/Loan Repayment
-- for a loan repayment and direct incentives program in Alaska? Sewell:
There is a 15-member advisory council that provides oversight for our effort; it meets roughly six times per year. The SHARP council is made up of a number of interagency members, some of those are trade associations, and some are umbrella groups. A couple are from the state bureaucracy. Examples would include the Alaska Native Tribal Health Consortium, the Alaska State Hospital and Nursing Home Association, Alaska Medical Association, Alaska Dental Society, Alaska Pharmacists Association, Alaska Primary Care Association, and others.
The council has been key in a couple of things: One is the visibility, advocacy, and consensus around the effort and two, in planning for the road ahead. That new road is "SHARP-II," which came to reality with the passage of HB 78 in the 27th Legislature. HB 78 -- "An Act establishing a loan repayment program and employment incentive program for certain health care professionals employed in the state; and providing for an effective date." -- passed unanimously in both houses in 2012 and was signed by the governor. It picked up numerous cosponsors. This suggests that the general idea for a support-for-service element in our system of care has arrived, has come to maturity.
There are a couple of reasons for that. One is that there are several health care occupations that Alaska simply does not train for, nor is there any plan to do so. An example is dentists. We don't have a dental school. And there is no discussion that we will. It's very expensive and complex to establish one. There are a number of other occupations that we essentially don't train for: Pharmacy would be one. There's a modest partnership program with Creighton.
We do have an excellent WWAMI medical school partnership program with the University of Washington School of Medicine. However, we need to recognize that those medical students also contract a significant amount of debt, whether or not we train them. They respond to national labor markets, and people do buy out of contracts and go elsewhere.
... there is a heck of a lot of people that have a significant amount of debt, I mean some of it is awe-inspiring: $150, $200, $250, and $300,000; I talked to a psychiatrist yesterday with $400,000 of debt.
There is also the issue of maldistribution, which I think is the third rationale for this type of support-for-service effort. It is one thing to have a particular number of practitioners. But it's another thing to ask: Are they in the right locations? Are they serving the priority populations? Those are very different questions. We believe that support-for-service is a policy tool that will help to address the maldistribution question. Which, again, is a little different than the shortage question.
HB 78 did specify that the underserved populations would be a priority for the program, not exclusively, but a tilt in that direction. It also specified a tilt toward rural and remote locations. So HB 78 was different than what we have been able to do under just SHARP-I, and we are excited about the additional flexibility that SHARP-II now has. One flexibility element is that the program is not confined exclusively to federal health professional shortages areas (HPSAs) locations. We see those as too fairly narrowly defined, and in some remarkable circumstances, way too narrowly defined. So, HB 78, and therefore now SHARP-II, provides for additional flexibility in terms of what regulation calls the "health care service shortage areas" that the state of Alaska will identify, or designate. That's exciting.
The second thing is that SHARP-II is not confined to primary care. SHARP-I is, but SHARP-II has more flexibility. Probably many of the positions (slots) will be primary care. But, it is not required by statute or regulation that those be exclusively primary care. There are some locations, there are some practitioner types that are not primary care, but may be a priority.
Third is that it does allow for hospitalists, for instance, for docs that work in the ER, and it allows for specialists. And it allows for other settings, such as long-term care. It was also determined that this can include public health nursing clinics.
This is a new day compared to SHARP-I, which is an excellent option as far as it goes. There are also other terms of contract that we are very excited about regarding increased flexibility. One is that historically, support-for-service efforts such as SHARP-I or the National Health Services Corps, or the Indian Health Services loan repayment program are almost exclusively focused on loan repayment, and that's because of two things. One is that there is a heck of a lot of people that have a significant amount of debt. I mean some of it is awe-inspiring: $150, $200, $250, and $300,000. I talked to a psychiatrist yesterday with $400,000 of debt. Those finishing dental school [have debt that is] often actually higher than physicians and many, many physicians are finishing with well over $100,000 of debt.
That's one of the reasons loan repayment has been around, but if the only policy tool regarding these issues is loan repayment, you are a bit like a child that gets a hammer for Christmas and soon learns everything needs pounding. Meaning, there are a whole bunch of people who finish school who either -- then, or later -- don't have monumental amounts of debt. Therefore, if loan repayment is all that you have for support-for-service, then you are immediately irrelevant to them. Therefore, with the guidance of people like Dr. Donald Pathman at Sheps Center at the University of North Carolina Chapel Hill, we concluded that it would be good to have more flexibility in our support-for-service effort, and thus to include direct incentives. Back to selected topics list
Loan repayment and direct incentives programsAHPR:
Can you explain how loan repayment and direct incentives differ? Are the audiences different? In your mind, is one more successful at recruitment and retention?Sewell:
Direct incentives are not [intended] to repay loans; they increase interest in practicing in those high-need locations, with those high-need populations, even though the person is not saddled with educational debt. We think that has two values. One is that it vastly expands the potential recruitment pool, and by numerous-fold. This is because there are many mid-career professionals here and in the Lower 48 in particular who might consider working in the locations and populations of interest. But they are midcareer -- they are not debt-ridden.
The second important rationale besides increasing the recruitment pool is that there are some health care positions in our state, particularly in rural or remote locations, that may not be [appropriate] for those with new degrees and relatively low levels of clinical experience. Or put differently, there are jobs for which we have been with loan payment confined to the relatively young and inexperienced, simply because they are debt-ridden. There is no indication that those are [necessarily] the best people to be in those jobs. It may be that we need somebody who is more experienced, who is midcareer, and who has been there and done that and has gotten all the T-shirts.
Why? Because some of these involve a fair amount of long on-call hours, some of them involve a fair amount of personal and/or professional isolation, and some of them involve addressing a very wide range of presenting problems. In other words, experience counts. So direct incentives may allow for the state to provide support-for-service for some of those midcareer professionals for whom it is a better match. And that is now codified in regulation that was adopted and finalized. We can offer direct incentives for the more experienced clinician. So, SHARP-II involves both loan repayments and direct incentives.
What else are differences? One key difference is that it also provides a formal and budgetary nod toward very hard-to-fill positions. In other words, you can imagine that there are the default regular fill positions, lots of them in this state. And then there are those that for many reasons may be very difficult to fill, or if filled, to keep filled. Some of it has to do with an overwhelming nature of the work, either in terms of type or amount. Some of it may have to do with geographical or linguistic, cultural, or climatological barriers, or cost-of-living, and cost of travel. All these kinds of things may figure into some positions being difficult to recruit for, expensive to recruit for, and hard to maintain continuous clinical staffing. So, SHARP-II allows for regular fill and very hard to fill. AHPR:
And the three-year contract is for the loan repayment? Sewell:
Well, either route for SHARP-II, loan repayment or direct incentive, the contract is three years. Eligible practitioner categories for Tier-1 include: doctor of Allopathic Medicine (M.D.), doctor of Osteopathic Medicine (D.O.), dentist (D.D.S. or D.M.D.), and pharmacist. Tier-2 practitioners include: nurse practitioner, physician assistant, registered clinical dental hygienist, clinical or counseling psychologist (Ph.D. or equivalent), licensed clinical social worker (master's or doctorate in social work), registered nurse (R.N.), and physical therapist.
In the current Clinician Solicitation-2, there is particular emphasis on finding candidates in the above-listed "Tier-2" occupations. This emphasis is not wholly exclusive of Tier-1 candidates. Rather, the Tier-2 emphasis is due the substantial number of Tier-1 clinicians admitted to the program during Soliciation-1 (Spring 2013).
Loan repayment and/or direct incentive support will be paid up to a maximum annual benefit for the practitioner. This amount is dependent upon whether the occupation is categorized as Tier-1 or Tier-2, and whether the position is full-time or half-time, and whether it's categorized as regular-fill or very hard-to-fill.
The maximum annual benefit amounts are: Tier-1: $35,000 - $47,000 and Tier-2: $20,000 - $27,000. The program can pay a mix of loan repayment and direct incentive, but this yearly payment will not exceed the stipulated maximum annual cap. This loan repayment per se
is exempt from federal personal income tax according to federal regulation governing state loan repayment programs; however, direct incentive is treated as taxable personal income. This support-for-service award is strictly in addition to, and is not supplanting of, the clinician's regular employer-provided wage and benefit.
A wide variety of health care delivery locations are anticipated to become eligible, including selected private non-profit, for-profit, and public (government) health care sites. Potential examples include, but are not limited to, community health centers, hospitals, community mental health clinics, private for-profit clinics, drug treatment facilities, long-term care facilities, and prisons, amongst others. Among the factors considered for eligibility, the site must be identified as, or being within, a state-designated health care services shortage area. An employer matching-payment is required at the rate of: 10 percent at government sites, 25 percent at private non-profit sites, and 30 percent at for-profit sites. A partial waiver of this match requirement is possible in some instances for private non-profit and for-profit sites.
In brief, both individual health care practitioners and individual health care delivery sites must apply. It's kind of a dance, or a match, or dating game.
This loan repayment per se is exempt from federal personal income tax according to federal regulation governing state loan repayment programs; however, direct incentive is treated as taxable personal income.AHPR:
So do they have to connect with one another before applying to you, or do they each apply on their own and then you match them? Sewell:
They can apply individually. We want the sites to continue to apply. And that's an open admission, that's an open application window that will be ongoing. So, a site may have the job they need filled, and we want them to fill out the application and get it in. The clinician window will close on September 30 at 5:00 PM. We believe that there will be other openings for SHARP-II. But we are now moving into more of being able to do more raw recruitment.
It takes a while to find and to solicit and encourage people from distant locations. For example, let's say in Cincinnati there's a dentist who is sick of what he's been doing; he's thinking about life in the last frontier. It will take a while between when he first hears about this opportunity, or any opportunity in Alaska, and him moving here and getting ensconced in a job. But nonetheless, we are moving into more of the opportunity to recruit. Nonetheless, we are getting a lot of interest. What else can I tell you about it? AHPR:
Just a clarifying question, SHARP-I is a federal-state loan repayment program, and SHARP-II is a state-sponsored loan repayment and direct incentive program? Is that correct? Sewell:
Yes. I would have to say [SHARP-II] is a nonfederal sponsor, because most of the support for SHARP-II is from the state general fund, or GF. But for the first time it is required that there be an employer match. That level depends on the type of site. So public or government entities have a 10 percent match. Nonprofits have a 25 percent match. For-profits, which is another category available for the first time -- such as small privately-owned clinics -- have a 30 percent match. Both the nonprofits and for-profits have the opportunity for an application for a partial waiver of the employer match. Nonprofits get reduced to 10 percent, and for-profits could be reduced to 15 percent. That depends on documents that they would submit, but nonetheless, that opportunity is out there for those in harder straits. So, the support for SHARP-II comes mostly from the state general fund, but also required employer match.
For SHARP-I, 50 percent comes from federal HRSA-SLRP and 50 percent from non-federal -- this being state GF and the Alaska Mental Health Trust Authority, which has been very supportive of SHARP.Back to selected topics list
SHARP: Recruitment or retention tool?AHPR:
Are there any quality standards or any other standards that the site or provider has to adhere to in order to get the direct incentive or loan repayment?
Yes, quite a few, as a matter of fact. There is a quarterly report, which is relatively short, and it's not HIPAA-sensitive, but it does have to do with patient counts by payer type and visitation counts. It also has to do with reporting the number of days of clinical work in a quarter, and there is one attestation regarding the portion of the work week that is in direct care. That's not for administration; it's for direct care clinical employees. There are a number of things that they have to assert, [for instance,] that they will take clients with Medicaid, Medicare, and clientele on a sliding fee or charity care basis for those unable to pay.
There are a number of requirements about how the contract is maintained, for example, the kinds of records available for inspection. In terms of the application itself, we do require that the site applicant be busy developing a recruitment and retention plan. The state is very interested in doing whatever we can to support development of those site recruitment and retention plans. I think there is a lot of interest in slowing down, by whatever means, the churn and burn that happens in many health care settings. So that's required. We are in a position to work with the individual site over time, so on application day, we may be able to provide some flexibility there and support over time. But they do need to have a recruitment and retention plan.
Early on, retention candidates are by far the most likely. The longer the program is in place, and the more visibility the opportunity, the more word gets around, and the more people can be plan-ful.AHPR:
Related to that -- recruitment and retention -- do you see SHARP-I or SHARP-II as being more of a recruitment tool or a retention tool? Or can we not separate them? Sewell:
I think it's a developmental and timing issue. I think it is part of the life cycle of the program. Early on, retention candidates are by far the most likely. The longer the program is in place, and the more visibility the opportunity, the more word gets around, and the more people can be plan-ful. I'm getting a bunch of contacts now from fourth-year dental students, from fourth-year pharmacy students, people still in WWAMI. Why? Because those professional associations are getting the word out while people are still in school.
You see, [the momentum] that recruitment type of effort takes a while to build. Retention is a little different. If somebody is already in one of those jobs, then they may be contacted by their employer, who you know, has to be at the dance. And their HR department, which is already in place, gets that word out in a heartbeat to everybody in the joint. So that kind of person is going to be more likely to be contacted early, and they are more likely to respond pronto; they already have licenses as an example, they are already in Alaska.
But as time goes by and we have more of a horizon -- SHARP-II allows for a significant horizon. That gives us time to build relationships with professional schools, with national trade associations, that kind of thing. So more retention today, more recruitment tomorrow. But both are necessary, people talk about it as one or the other, but that's fallacious.
For instance, if you wanted to fill a tub with water, you've got to do two things: you've got to turn on the spigot, and you have to put in the drain plug. Otherwise you're not going to fill the tub. You have to do both. Back to selected topics list
Potential impacts of the Affordable Care Act on the health workforceAHPR:
What do you know about the Affordable Care Act and the measures to address the health care workforce system and shortage? Will you speak about that?Sewell:
In terms of the impact of the Affordable Care Act (ACA) on workforce, I think it's a two-edged sword. On the one hand, ACA is anticipated to identify and help to resource something like 40 million more Americans. Most of those frankly are in lower income categories, not all but a lot. It may be that 17 million more will be added to Medicaid. At least. Those people, now more enfranchised in the system will be, reasonably, looking more for health care that they can get into, that they can afford. That, by all accounts, is expected to increase demand. Or actually, present demand that has always been there. Where will those people go? A lot of them will go to places like community health centers, not exclusively, but we are expecting that the impact of the ACA per se
is going to be a big case finder; it's going to increase presenting demand. And therefore, we have to be more concerned, more interested in enhancing primary care in our state, because that's happening right now, and it's going to accelerate nationally.
Apart from demographic changes or any of the other stuff, that would be an overlay, for instance, on the arrival of large numbers of people in their later years in our demography. That means more comorbidity, more polypharmacy, and more chronic conditions. So that the ACA will be a case finder piece is an overlay on other things that are already moving. That means that we need to be more focused on workforce development, recruitment and retention, and support-for-service. Second thing is, on the other side in terms of resource, the ACA made it absolutely crystal clear through its passage and attendant regulation, loan repayment at the state level is exempt from personal federal income tax. That is a tax exempt benefit, not for direct incentives but for loan repayment. That's very helpful.
Another thing is that, depending on how this current federal budget cycle goes, we expect that the augments in loan repayment programs nationally through the National Health Services Corp will continue. It won't be our stimulus money but we expect that the federal state loan repayment program (SLRP) to continue to be resourced. And it has -- we responded to it in June 2012 and now we have another cadre of 34 clinicians that we brought on board for SHARP-I in fall 2013.
So I see both: it's increasing demand and there are also other kinds of supports that the ACA has provided for. For instance, there has been a doubling -- fairly irrelevant for our state in my view -- but there has been a doubling of the national nurse education loan repayment program, now known as Nurse Corps. That translates to only a few people in our state, but nationally, it's doubled the resources available to that support. And there are many examples like that. Under the ACA, through the National Health Service Corps, we went from roughly 18 practitioners a year, in all of Alaska, to now about 60. So there has been an impact, and we expect it will continue if the federal budget is not too heavily sequestered. Back to selected topics list
The personal side of the storyAHPR:
Thank you very much, that was very informative.
I have been listening to you talk about health workforce professionals and the strategies to recruit and retain them in Alaska, and it strikes me that this is more than just a job to you. Why do you care, personally, about loan repayment and direct incentives for clinicians?Sewell:
Three reasons: One is that I've spent a large portion of my career at university in teaching, advising and administration. From that experience, I am very aware that "training" per se
is only one part of the workforce development system. Over decades, I have worked with thousands of upcoming students, and they have left their mark.
The second reason is that I have worked with hundreds of professionals, both through this support-for-service effort, and through organized labor. It is clear to me that the "skill set" that the individual has is only one part, and sometimes a small part, of general effectuality in the workplace and thus tendency to "stay on." Varied experts in quality management (e.g.,
Deming, Juran, Shewhart) have reported on this in detail.
And finally, I have known many people who have struggled mightily under large education debts, and have seen some of its pernicious side-effects. A support-for-service strategy helps to address this, and it definitely helps interested clinicians stay working with our underserved populations.
I am very excited about the growth and stability, institutionalization of support-for-service programs in Alaska.AHPR: Alaska Health Policy Review
readers probably do not know that we share a background and interest in B.F. Skinner and behavior analysis. It may be apparent to you and I (and other Skinnerians), but could you explain the connection between practitioners' behavior and the success of loan repayment and direct incentives programs? That is, what would B.F. Skinner say about the SHARP-I and SHARP-II programs?Sewell:
B.F. Skinner was one of the very preeminent psychologists of the 20th century, and has left an enduring impact. His emphasis on role of the environment on human action has been very persuasive, especially regarding the consequences of action. Though Skinner has now passed, and I certainly cannot speak for him, the behavior analytic approach to systems relies heavily on examining the "contingencies" within which people act.
When people don't see the hoped for action, such as clinicians coming to practice in, and staying in, Alaska, then Skinner would say that you must examine the contingencies of reinforcement. Are practitioners being encouraged to be somewhere else? Are they facing systematic barriers to "doing the right things with the right populations" here are in our state? Are there accidental mis-alignments in the contingencies of reinforcement that cause clinicians to work with the lesser-priority populations, and/or in low priority locations?
Careful inspection of how we can change some of the financial inducements is bearing fruit, and that experience is similar to that of several other states' experiences and federal HRSAs. AHPR:
That's exactly what I thought Skinner would say about SHARP! Sewell:
As you asked about Skinner, and his colleagues, in some ways, if you want new ideas then read old books. Key examples for me have been: B.F. Skinner's Reflections on Behaviorism and Society
, (especially the article, "The Ethics of Helping People"), his book Science and Human Behavior
and more recently books from two of his later-date colleagues: Tom Gilbert's Human Competence
and Aubrey Daniels Bringing Out the Best in People
Those are great recommendations. B.F. Skinner's Beyond Freedom and Dignity
is one of my personal favorites. And it is always great advice to read old books.
Do you have any final thoughts you'd like to share with the readers of Alaska Health Policy Review
I have three things to say. One is to thank Larry Weiss for his having worked so long and hard in establishing the forum and the nonprofit. So, bravo! Second thing is, I am very excited about the growth and stability, institutionalization of support-for-service programs in Alaska. It is an important additional development in our system of care. And I also want to thank, particularly, all clinicians who have chosen to practice here in Alaska. It is an important thing. AHPR:
Thank you so much for your time, Robert.Back to selected topics listBack to top