1. Health Center Workforce Challenges & One Solution on Alaska’s Horizon: HCPLRIP Presentation for the Association of Tribal Health Directors February 17, 2009

2. Goal – Educate & Activate Re: APCA CHC model Workforce Shortage Challenge CHC Legislative Request Statewide Legislative Request HCPLRIP 2

3. Alaska Primary Care Association 3

4. Community Health Centers CHC Model Medically underserved communities / populations Board governed / advised (51% patients)  Not-for-profit organizations  Local governments  Tribal organizations CHCs are open to all regardless of insurance status or ability to pay – offer sliding fee scale 4

5. CHC Model Quality, comprehensive primary care “Primary Care” includes basic  Medical care  Dental services  Behavioral health care 5

6. CHC network in Alaska is statewide  26 CHCs  13 are Tribal CHCs  141 CHC clinic sites  103 are Tribal CHC clinic sites  80,000+ patients  331,000 patient visits  900+ clinic employees CHC Model 6

7. “…It has been fabulously successful. We have gotten the best treatment we’ve ever gotten in our lives.” -Bob Henrichs, President, Native Village of Eyak Illanka Community Health Center, Cordova 7

8. 13 Tribal CHCs with 103 Sites Aleutian Pribilof Islands Association 1 Bristol Bay Area Health Corporation 7 Council of Athabascan Tribal Governments 9 Eastern Aleutian Tribes 9 Maniilaq Association 11 Native Village of Eyak 1 Norton Sound Health Corporation 15 Seldovia Village Tribe 2 Southcentral Foundation 2 SouthEast Alaska Regional Health Consortium 11 Tanana Chiefs Conference 5 Yakutat Tlingit Tribe 1 Yukon Kuskokwim Health Corporation 29 8

9. CHC Delivery Sites in Alaska 9

10. 78% of Alaskan CHC Patients are Low Income U.S. Department of Health and Human Services, HRSA. Bureau of Primary Health Care Section 330 Grantees Uniform Data System (UDS) Calendar Year 2007 Data Alaska Rollup Report. CHC Patient Income Levels 10

11. Most Alaskan CHC Patients are Uninsured or Publicly Insured U.S. Department of Health and Human Services, HRSA. Bureau of Primary Health Care Section 330 Grantees Uniform Data System (UDS) Calendar Year 2007 Data Alaska Rollup Report. CHC Patients: Insurance Status 11

12. 12

13. 2006 – 2007 CHC Practitioner Numbers 2006 31 48 29 13 2007 Practitioner Type 32 MDs / DOs 48 PAs 32 NPs 16 Dentists U.S. Department of Health and Human Services, HRSA. Bureau of Primary Health Care Section 330 Grantees Uniform Data System (UDS) Calendar Years 2006 and 2007 Data Alaska Rollup Reports. 13

14. Lost in Past 3 Years at CHCs (estimated) # LostPractitioner Type 28 MDs / DOs 46 PAs 28 NPs 6 Dentists 21 LCSWs 16 Other MLPs Alaska Primary Care Association, Workforce Survey, February 2009. Findings are estimates based on convenient sampling. Contact David Wilson for more information: (907) 929-2739 or David@alaskapca.org. 14

15. Current Vacancies at CHCs (estimated) # VacantPractitioner Type 22 MDs / DOs 20 PAs 26 NPs 6 Dentists 10 LCSWs 12 Other MLPs Alaska Primary Care Association, Workforce Survey, February 2009. Findings are estimates based on convenient sampling. Contact David Wilson, APCA, for more information: (907) 929-2739 or David@alaskapca.org. 15

16. High Vacancy Rates Plague CHCs Alaska CHC physicians  2% of state total Alaska CHC physician vacancies  10% of state total 2007 UDS Report, HRSA; and Alaska Health Workforce Vacancy Study, 2007, Beth Landon, Alaska Center for Rural Health. 16

17. Turnover is High / Recruitment is Slow Practitioner is employed2 - 4 yrs MD / DO vacancy 9 -12 mos PA vacancy 6 - 9 mos NP vacancy 9 -12 mos LCSW vacancy 18 mos Alaska Primary Care Association, Workforce Survey, February 2009. Findings are estimates based on convenient sampling. Contact David Wilson, APCA, for more information: (907) 929-2739 or David@alaskapca.org. 17

18. National Shortage: Giant Problem 18

19. The Shortage Problem: Impacting CHCs 2% U.S. medical students choose primary care¹ 9% of physicians practice in rural areas – But 20% of the population resides in rural areas² 150,000 general dentists in practicing in US – But only 14% practice in rural areas² CHC patients grew 57% from 2000 to 2006³ 19 ¹Journal of the American Medical Association, September 2008. ²DHSS Heath Planning & Systems Development, Robert Sewell. ³HRSA, Bureau of Primary Health Care Section 330 Grantees Uniform Data System Calendar Years 2000-2006.

20. A Problem that Must Be Resolved Incentives elsewhere have stronger pull Routinely lose candidates Question of incentives and loan repayment often first question Alaskan CHCs can’t compete Alaska can’t compete 20

21. 2 Legislative Solutions to Address Immediate Problem 1. CHCs2. Statewide HCPLRIP CHC State Support 21

22. CHC State Support Federal dollars have not kept pace Cost for uncompensated care is significant All but a dozen states support CHCs Wise investment Nationally, medical expenses for CHC patients are 41% lower compared to patients seen elsewhere. 22

23. FY10 CHC State Support Request Workforce  $1.5 million – local recruitment (O)  $120,000 – statewide tools (C) Energy  $5.6 million – energy assistance Senior Access  $155,000 – added to $350,000 line item (O)  $500,000 – outreach infrastructure (C) 23

24. HCPLRIP Health Care Professions Loan Repayment & Incentive Program

25. Shortages are Statewide Estimated Vacancies Estimated Vacancies  10.3% Statewide  16.5% Tribal Health Organizations  13.9% Behavioral Health  29% of all vacancies  Shortages: all 119 occupations 25 Alaska Health Workforce Vacancy Study, 2007, Beth Landon, Alaska Center for Rural Health.

26. Shortages are Serious Without intervention, shortage will become a public health crisis. Without intervention, shortage will become a public health crisis. 26 Rod Betit, Alaska State Hospital and Nursing Home Association, discussion at ASHNHA Annual Meeting, Talkeetna, Alaska., Fall 2008.

27. Tribal / Rural Recruitment is Tough Remote locations Cost of living Lack of housing Competing salaries Shrinking pool NHSC &IHS loan repayment issues Lack of state-sponsored incentives 27

28. Case in Point: Dental Shortage $35K recruitment cost Vacancy rate  10% all  15% rural  42% tribal Average vacancy  19 months 28 Alaska Health Workforce Vacancy Study, 2007, Beth Landon, Alaska Center for Rural Health.

29. Statewide vacancy rate of 24% (51% tribal) Average vacancy length is 15 months 29 Case in Point: Pharmacist Shortage Alaska Health Workforce Vacancy Study, 2007, Beth Landon, Alaska Center for Rural Health.

30. $126K recruitment cost (family medicine) Vacancy rate  11.7% all  28.4% tribal Average vacancy  17.8 months 375 FTE shortage 30 Case in Point: Physician Shortage

31. Occupational Groups Statewide Estimates PositionsVacancies Vacancy Rate Tribal Vacancy All Occupations34738352910.2%16.5% Physicians193122611.7%27.1% Professional Nurses71396969.8%15.5% CNA/LPN/PCA/HHA17621116.3%14.3% Dentist/Pharmacists/ Therapists 228140417.7%42.9% Behavioral Health7450103313.9%14.5% Allied Health55234347.9%17.1% Public Health/Nutrition189ND 15.2% Managers29471605.4%7.6% Health Information/ Reimbursement 44512535.7%11.3% Statewide Vacancy Rates 31

32. HCPLRIP Planning Group  Alaska State Hospital & Nursing Home Assoc  Alaska Primary Care Association  Alaska Native Health Board  Alaska Dental Society  Alaska Mental Health Trust Authority  Alaska Commission on Post-Secondary Education  Health Planning & Systems Development (DHSS)  Alaska State Medical Association  Alaska Pharmacists Association  Alaska Native Tribal Health Consortium  Alaska Geriatric Education Center (UAA) 32

33. Support for Service Options Support for Service Loan Repayments Direct Incentives Scholarships Loans for Service Resident Support 33

34. Prospects Partici pants Trained Professionals AttritionRetirement Trained Professionals (from Elsewhere) Active Practitioners AK HC Workforce ______________________________________________________ Direct Care _____________________________________________________ Non-Direct ______________________________________________________ Possibles Support- for-Service Programs target those who are farther along in their careers. 34

35. When Practitioners Make Commitments 22 23 24 25 26 27 28 29 30 31 32 33 34 35 -7 - 6 - 5 - 4 - 3 - 2 - 1 0 1 2 3 4 5 6 Years before and after service begins Medical SchoolResidency Scholarship Programs & Service-Option Loans Loan Repayment Programs & Direct Incentive Programs Service Post-Service Retention Typical Ages Residency Support Programs 35

36. HCPLRIP Program Elements Program Elements (see handout) 1. Oversight Entity 2. Fiscal Agent 3. Practitioner Eligibility 4. Site Eligibility 5. Payment Details 6. Program Evaluation 7. Resources & Funding 36

37. 2 Components: Loan Repayment & Direct Incentives 37

38. 10 Occupations included in HCPLRIP Tier-1 Dentists Pharmacists Physicians Tier-2 Dental Hygienists Nurses (RN) Nurse Practitioners Physician Assistants Physical Therapists Psychologists Social Workers 38

39. Payment Details Placement Types: Regular & Hard-to-Fill Amounts  Tier 1 Up to $35,000/year (Regular) Up to $47,000/year (Hard-to-Fill)  Tier 2 Up to $20,000/year (Regular) Up to $27,000/year (Hard-to-Fill) 39

40. Payment Details (cont’d) 3-year period of service Quarterly payments following service May re-apply for a 2nd period of service Lifetime participation cap is 6 years 40

41. Funding & Resources Employer or community match 0% - 100% May not offset current or expected provider supports Proposed funding for FY10 $7.5 million $7.5 million: 90 participants (9 in each category) 41

42. Even in tough economic times of low oil revenues… Economic impact of rural physician Turnover costs Locums: high cost & discontinuity of care Pay-offs  Costs avoided  Continuity of care 42 …HCPLRIP is worth the cost.

43. Questions? Thank you for inviting the APCA! We are happy to partner with you as we work together to promote access across Alaska. Shelley Hughes Government Affairs Director Alaska Primary Care Association Shelley@alaskapca.org 907-841-1634 43