[Senate Hearing 110-26]
[From the U.S. Government Publishing Office]
S. Hrg. 110-26
THE PHYSICIAN SHORTAGE CRISIS IN RURAL AMERICA: WHO WILL TREAT OUR
PATIENTS?
=======================================================================
FIELD HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
ON
EXAMINING THE PHYSICIAN SHORTAGE CRISIS IN RURAL AMERICA, FOCUSING ON
ACCESS TO HEALTH CARE IN ALASKA
__________
FEBRUARY 20, 2007 (ANCHORAGE, AK)
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut MICHAEL B. ENZI, Wyoming,
TOM HARKIN, Iowa JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland BILL FRIST, Tennessee
JAMES M. JEFFORDS (I), Vermont LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico RICHARD BURR, North Carolina
PATTY MURRAY, Washington JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island MIKE DeWINE, Ohio
HILLARY RODHAM CLINTON, New York JOHN ENSIGN, Nevada
ORRIN G. HATCH, Utah
JEFF SESSIONS, Alabama
PAT ROBERTS, Kansas
J. Michael Myers, Staff Director
Katherine Brunett McGuire, Minority Staff Director and Chief Counsel
(ii)
C O N T E N T S
__________
STATEMENTS
TUESDAY, FEBRUARY 20, 2007
Page
Murkowski, Hon. Lisa, a U.S. Senator from the State of Alaska,
opening statement.............................................. 1
Jackson, Karleen, Commissioner, State Department of Health and
Social Services, Juneau, AK.................................... 4
Prepared statement........................................... 6
Hatch, Rita, Older Persons Action Group, Incorporated, Anchorage,
AK............................................................. 10
Prepared statement........................................... 11
Appel, Frank, Chair, Alaska Commission on Aging, Anchorage, AK... 11
Berger, Carl, Executive Director, Lower Kuskokwim Development
Council, Bethel, AK............................................ 13
Tanner, Ross, President-Elect, Alaska State Medical Association,
Anchorage, AK.................................................. 17
Johnston, Harold, Director, Alaska Family Practice Residency,
Anchorage, AK.................................................. 20
Neubauer, Richard, Internal Medicine, Anchorage, AK.............. 23
Perkins, Byron, American Osteopathic Medical Association,
President of the Alaska Osteopathic Medical Association,
Anchorage, AK.................................................. 27
Prepared statement........................................... 31
Coombs, John, Associate Vice-President for Medical Affairs,
Associate Dean for Regional Affairs, Rural Health and Graduate
Medical Education, Seattle, WA................................. 41
Prepared statement........................................... 44
Perdue, Karen, Associate Vice President for Health, University of
Alaska, Anchorage, AK.......................................... 49
Prepared statement........................................... 51
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Report of the Alaska Physician Supply Task Force (August
2006)...................................................... 72
(iii)
FIELD HEARING
THE PHYSICIAN SHORTAGE CRISIS IN RURAL AMERICA: WHO WILL TREAT OUR
PATIENTS
----------
TUESDAY, FEBRUARY 20, 2007
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Anchorage, AK.
The committee met, pursuant to notice, at 9 a.m., at the
Loussac Public Library, 3600 Denali Street, Anchorage, Alaska,
Hon. Lisa Murkowski, presiding.
Present: Senator Murkowski.
Opening Statement of Senator Murkowski
Senator Murkowski. We'll call to order the field hearing
for the Health, Education, Labor, and Pensions Committee.
I'd like to welcome you all here this morning to talk about
an issue that is of great concern to us here in this State, and
truly to Americans across the country, particularly in those
more rural areas.
Just a little bit of process here before we begin this
morning. We do have a set witness list of invited participants
that we have asked to address this issue. I do believe that you
should have received a copy of that when you signed in. I do
understand this morning that there are some individuals who
would like the opportunity to give their perspective on
physician access here in the State of Alaska. While we had not
anticipated that, I would welcome the opportunity to hear your
comments. So, the revised plan--if you will--this morning, is
that we'll have the opportunity for individuals to make a short
statement at the conclusion of the panelists' testimony.
If you chose not to provide your statement orally here
today, we would encourage you to submit your statements in
writing. They will be made part of the Health, Education,
Labor, and Pensions Committee record. So, that will be part of
the committee's deliberation as we take the issue up back in
Washington, DC.
So, whether you choose to submit your comment here this
morning, or in writing--your choice--we'll hold the record open
on this for a 2-week period, so if you would like to submit
those comments, you may do so in writing.
Maggie Elehwany, who is just walking off here, is my
legislative assistant on healthcare matters, and she would be
the contact person for those of you who might have any
questions as to the process.
As I've indicated, this is a HELP Committee Field Hearing,
I do believe it's probably the first such hearing that we've
ever had in this State. I am the first of Alaska's Senators to
serve on this committee, a committee of very important
jurisdiction to all of us. So, to have the opportunity this
morning, as Alaskans, to put our comments on the record for my
colleagues back in Washington to see and understand our
situation, I think is very important. And I am most
appreciative to the Chairman of the committee, Senator Kennedy,
and the Ranking Member, Senator Enzi, for allowing us to have
this, this morning.
Now, some have asked me, ``Well, why are we even having
this field hearing up here? What's going on up in Alaska?''
And, I will start off by reading just a few snips from some e-
mails that I have received from constituents, and this is just
kind of random sampling out of the correspondence files as they
come in.
Over the past year, the volume of e-mails, faxes, letters
saying, ``I can't find a doctor to care for me. I cannot find--
I cannot get an appointment as a Medicare-eligible patient,
what do I do?''
I've got one here from a constituent here in Anchorage, who
says,
``My mother has returned to Alaska to retire near her
grandchildren, and has had difficulty in the extreme in getting
a doctor who will take her, as she is a Medicare patient. My
mother has made in excess of 100 calls to physicians in
Anchorage.''
Another woman from Anchorage writes,
``During the past year, I've tried to find a doctor that
accepts Medicare. I used the Anchorage Yellow Pages and called
over 100 doctors, only to be told that they won't accept any
more Medicare patients. I'll tell you ahead of time, we'll be
going to the hospital emergency rooms to receive even the basic
medical care for colds and flu and other basic needs that could
have been treated by seeing a doctor at their established
practice. This doesn't sound like good fiscal management.''
Another letter, one that was actually reprinted in the
Anchorage Daily News from a person here in Anchorage, says ``My
friend's telephoned more than 80 doctors recently, and no one
was accepting new Medicare patients.'' Another constituent from
Kenai writes,
``My mom has Medicare, and she had to wait 5 months to be
seen by a neurologist, because she'd been put on a waiting list
to be seen, due to the fact that she was a Medicare patient.''
E-mail after e-mail, fax after fax, phone call after phone
call, saying, ``What do we do? Whom do I go to? How long is the
list? What can we do?'' And so, it's comments like these from
constituents all over the State that has precipitated the need
for this hearing today.
And I will tell you, we will focus here today on the Alaska
situation, but we must also keep in mind that, as we face the
challenges here, in Alaska, Americans across the country in
rural parts of the Nation are facing similar concerns.
Patients cannot access healthcare because of the
dangerously low shortages of healthcare providers. In just 20
years, 20 percent of the U.S. population will be 65 years, or
older, and this will be a larger percentage than in any time in
our Nation's history. And just as this aging population places
the highest demands on our healthcare system, we've got some
experts that are predicting a national shortage of 200,000
physicians. If that becomes a reality, 84 million patients will
be without a doctor's care.
There's already a dozen States--including Alaska, now--that
report physician shortages. And the shortages exist in
radiology, cardiology, neurology, just to name a few, but the
greatest shortages persistently have been in primary care. In
fact, the shortage of primary care physicians in rural areas of
the United States represents one of the most intractable health
policy problems of the past century.
So, the question is, Where are the doctors going? What's
happening out there? And we're losing our doctors through
attrition--one-third of physicians are 55 years or older, and
are likely to retire just as this baby boom generation moves
into its time of greatest medical need. Additionally, for the
last quarter of a century, medical schools have kept their
student enrollments virtually flat, so we're not seeing the
medical students coming out.
But, we're also losing our doctors to frustration. Low
Medicaid and Medicare reimbursement rates, coupled with complex
regulations and paperwork, leave physicians aggravated and
disappointed with the practice of medicine.
We'll hear from one of our witnesses this morning that
Medicaid--which covers nearly one in five Alaskans, and one in
three Alaskan children, once again, will receive cuts in
Federal dollars if the temporary formula is not extended or
made permanent.
The recent Federal reductions in Alaska Medicare
reimbursement rates have been so severe, that our physicians
report reimbursement rates are only about 40 percent of the
actual cost of treating patients. Losing money by seeing
Medicare patients has meant that many, many physicians have
stopped accepting Medicare patients entirely. And, this was
reflected in the frustration of some of the e-mails that I read
to you.
We hear the stories from seniors all over the State who
call physician after physician, but they can't find a doctor
who's willing to accept them. And, if you are lucky enough to
find a physician, it often may take weeks or months to get an
appointment. And, when faced with that kind of a delay,
patients essentially have one of two options--they go to the
emergency room, or they don't go at all.
In rural America, patients have long gone without care.
Despite the fact that one-fifth of the U.S. population lives in
rural America, only 9 percent of our Nation's physicians are
practicing in these areas. Over 50 million of these rural
Americans live in areas that have a shortage of physicians to
meet basic needs.
Physician recruitment in rural America is a problem. High
student debt often forces many students away from rural
practice, and into urban-specialty medicine. In Alaska, we know
that the definition of rural here is a little bit different
than in the Lower 48. But, our definition of rural, and how we
deal with that, and you compound that with the physician
shortage crisis, and the situation is just magnified.
Right now, Alaska has the sixth lowest ratio of physicians
to population in the United States. Once you go outside the
Anchorage area, we're dead last. In other words, outside of
Anchorage, the physician to population ratio is the worst in
the Nation.
Now, while we don't have a medical school here in this
State, we do have two successful programs that have helped
train Alaskans as physicians, or to help bring doctors to the
State. This is the University of Washington Medical School
program, known as WWAMI, we also have the Alaska Family
Physician Residency Program.
But, despite the success of these two great programs, we
recognize the inadequacies in that each of them are far too
small to meet the population's needs. In fact, the State has
clearly recognized the crisis that we are facing, and last year
the University of Alaska, in conjunction with the State,
established a task force. We'll hear some of the details from
that task force presented to us today, and we greatly
appreciate that.
The challenge that we face, that our seniors face, and
others face, who don't have access to a doctor--it's an
unacceptable situation. We must help current physicians stay in
the practice of medicine, and we must vastly increase our
healthcare workforce.
Senator Stevens and I have been working together to fight
for fair Medicaid and Medicare reimbursement rates for Alaskan
providers. I've introduced the Rural Physician Relief Act; this
is a bill that provides tax incentives for physicians to
practice in our most rural and our frontier locations. I'm also
going to be introducing a bill when we get back to Washington
after this President's Day recess, this will be the Physician
Shortage Elimination Act, and what this will essentially
provide for is to double the funding for the National Health
Service Corporation.
It will equally allow rural and underserved residency
programs to expand, by removing barriers that prevent the
programs from developing rural training rotations, and will
create programs that target disadvantaged youth in rural and
underserved areas. Essentially, it will create a pipeline to
careers in healthcare. And finally, to bolster the cornerstone
of rural healthcare, which is the community health center,
through grants, and by allowing them to expand their residency
programs.
There's a great deal that we must do, but today, this is my
opportunity to hear from you about the specifics on the ground
here in this State, and again, so that I can take that back to
Washington to help explain to others why we need to act, and
act quickly, as we address access to healthcare here in this
State.
And with that introduction, I would like to bring up on the
first panel, we have Karleen Jackson, who is the Commissioner
of the State Department of Health and Social Services.
Commissioner Jackson has been very instrumental, as we have
worked on Medicare and Medicaid issues, and I appreciate you
coming this morning, Commissioner, up from Juneau to provide
the perspective.
And, with that, if you would like to proceed.
STATEMENT OF KARLEEN JACKSON, COMMISSIONER, STATE DEPARTMENT OF
HEALTH AND SOCIAL SERVICES, JUNEAU, ALASKA
Ms. Jackson. Thank you, Senator Murkowski. I'd also like to
thank the committee for allowing Alaska to host this important
field hearing to talk about healthcare access in rural America.
My written testimony provides references to several
important facts that are in the written materials, many of
which are out on the table, that outline the issues that
compound the rural healthcare crisis in Alaska, as you so
eloquently explained in your introduction.
Some of the facts, for example, there are just over 670,000
people living across more than 570 square miles in Alaska. One
hundred and fifty-two thousand people in 230 villages and
communities--including our capital city--only are able to
access services outside their area by air or water
transportation, weather and conditions permitting.
The annual cost of recruitment of healthcare workers in
Alaska was over $24 million in 2005-2006, with $15 million
attributable to rural facilities. Average cost per physician
hired were over $74,000, with rural costs per hire 44 percent
higher than urban.
Healthcare costs in Alaska are 70 percent higher than those
in the Lower 48. In 2004, 16 percent of rural Alaskan physician
positions were vacant, and shortages are expected to increase
over the next 20 years, as the State's population ages, and
physicians retire.
As mentioned, the number of people 65 and older in Alaska
is projected to increase from 43,000 to 124,000 people between
2005 and 2025. This will exacerbate the problems created by the
expiration on January 1, 2006 of the Medicare Physician
Reimbursement Formula, that had helped encourage Alaskan
physicians to accept Medicare patients.
Medicaid provides healthcare coverage for nearly one in
five Alaskan residents, including almost one in three children,
making Medicaid the second-largest healthcare insurance payer
in the State. Alaska has the largest Native American population
served by Medicaid in the Nation, with 52,000, or nearly 40
percent American Indian or Alaskan Native enrollees in fiscal
year 2005.
Alaska's frontier and rural areas have the largest number
of people requiring Federal healthcare assistance. As a result,
several Federal funding issues will significantly compound the
problems, with access to healthcare in Alaska, unless they're
addressed by Congress.
The Deficit Reduction Act of 2005, set the Alaska Federal
Medicare Assistance Formula, or FMAP percent rate, at 57.58
percent until September 30, 2007, at which time it reverts to
the formula-derived rate of 52.48 percent. However, the formula
reduction does not take into account Alaska's high cost of
care, especially for those Alaskans living in areas of the
State that experience Third World conditions, and for which
physician recruitment issues are exacerbated.
It is critical to the success of the Alaska-Denali Kid Care
Program, not only that Federal SCHIP be reauthorized, but also
that the funding formula be changed, so that Alaska is not
dependent on the redistributed funds from other States to
ensure access to healthcare for the one in three Alaskan
children who rely on this program.
And the Federal Continuing Resolution has had a negative
impact upon tribal healthcare corporations, by reducing funding
for some at a time when already high fuel prices are rising,
resulting in some corporations actually securing short-term
loans to maintain services.
In conclusion, the shortage of physicians in Alaska,
particularly in our rural and frontier areas of Alaska, must be
addressed within the context of our larger healthcare system
challenges, including shortages of other healthcare
professionals and para-professionals, and funding decreases
across several Federal sources.
We appreciate Congressional support for efforts such as the
Dental Health Aid Therapist Program that helps Alaska meet our
healthcare needs, and Senator Murkowski, with you, to solve the
physician shortage crisis in our Nation and in our State.
Thank you for allowing us an opportunity to bring this
issue to the attention of the HELP Committee.
[The prepared statement of Ms. Jackson follows:]
Prepared Statement of Karleen Jackson
Thank you for allowing Alaska to host this important field hearing
to discuss access to healthcare in rural America. And, thank you,
Senator Lisa Murkowski, for your strong support for finding solutions
to meet the healthcare needs of Alaskans, particularly those living in
rural and frontier areas of our vast State.
According to data from the Alaska Department of Labor and Workforce
Development, there are 670,053 people (Census Bureau and Alaska
official estimates for 2006) living across the 570,374 square miles
that make up our State. Connected by a road system are 518,000 people--
weather and conditions permitting--while 152,000 people in 230 villages
and communities (including Juneau, our Capital city) can only access
services outside their area by air or water transportation
The Status of Recruitment Resources and Strategies (SORRAS II)
report published in June 2006 found the annual cost of recruitment of
healthcare workers in Alaska was over $24 million in 2005-2006, with
$15 million attributable to rural facilities. Average costs per
physician hired were over $74,000, with rural costs per hire 44 percent
higher than urban.
These facts help to explain some of the reasons the healthcare
costs in Alaska are 70 percent higher than those in the contiguous
States of the United States. However, a number of studies and reports
have been produced in the last few years to help further quantify the
scope of the challenges we face in creating an affordable, accessible
healthcare delivery system in Alaska.
In January 2006, University of Alaska President, Mark Hamilton and
I commissioned the Alaska Physician Supply Task Force to identify the
current and future need for physicians in Alaska, as well as strategies
to meet those needs. The Task Force Report, published in August 2006
identified that 16 percent of rural Alaskan physician positions were
vacant in 2004, with the shortages of physicians expected to increase
over the next 20 years as the State's population ages and physicians
retire. The aging of Alaska's population impacts our physician shortage
in other ways, as well.
According to the 2006 Long Term Forecast produced by the Lewin
Group and ECONorthwest, the number of people 65 and older in Alaska is
projected to increase from 43,000 to 124,000 between 2005 and 2025.
This will exacerbate the problems created by the expiration on January
1, 2006 of the Medicare physician reimbursement formula that had helped
encourage Alaskan physicians to accept Medicare patients. Inadequate
Medicare rate reimbursements for physicians must be addressed both to
encourage physicians to come to Alaska and to support their ability to
care for elderly patients.
The Medicaid Program Review commissioned by the Alaska Senate
Finance Committee and published in January 2007 reported that Medicaid
provides healthcare coverage for nearly one in five Alaskan residents,
including one in three children--making Medicaid the second largest
health insurance payer in the State, while it ranks third nationally.
Furthermore, Alaska has the largest Native American population served
by Medicaid in the Nation, with 52,000 American Indian or Alaska Native
enrollees in fiscal year 2005--representing nearly 40 percent of
Alaskan Medicaid recipients.
Several Federal funding issues will significantly impact access to
healthcare for low-income Alaskans unless they are addressed by
Congress. First, the Deficit Reduction Act of 2005 set the Alaska
Federal Medicaid Assistance Percentage (FMAP) rate at 57.58 percent
until September 30, 2007, at which time it will revert to the formula
derived rate of 52.48 percent. However, the formula reduction does not
take into account Alaska's high cost of care, instead considering only
the relative personal income of Alaska residents compared to the
national average. A reduction in Alaska's FMAP rate would decrease the
Federal Government's ongoing contribution and commitment to Alaska's
Medicaid program--requiring an estimated $37 million in State general
funds for the 9 months of State fiscal year 2008, and even greater
levels of State general funding in future years.
In addition to the FMAP rate decrease, it should also be noted that
President Bush's 2008 budget proposal requests that Medicaid
administrative funding be reduced to 50 percent. Some current
administrative activities, such as Medicaid Management Information
System (MMIS) procurement is funded at 90 percent Federal Medicaid;
with other administrative activities at 75 percent. Estimates are that
a drop to 50 percent in administrative funding would result in an
additional loss of $14 million for Alaska. Widely fluctuating matching
proportions severely impact budget stability for the department and
hinder our ability to plan and fund future healthcare services.
Federal SCHIP funds support Alaska's Denali KidCare program--an
important component of Alaska's healthcare system. However, it is
critical to the success of this program, not only that SCHIP be
reauthorized, but also that the funding formula be changed so that
Alaska is not dependent on the redistributed funds from other States to
ensure access to healthcare for low-income children and families.
Reauthorization that does not address the inequities of the current
funding formula will severely disadvantage Alaska by reducing our
ability to fund Denali KidCare.
The Federal Continuing Resolution (CR) that has funded Federal
programs in lieu of budget bills has had a negative impact upon tribal
healthcare corporations. In a usual year the annual Indian Health
Service grant to tribes would increase by 1 to 2 percent and the
payment would be received such that Alaska tribes could gain interest
on the grant amount. This year the CR provided installment payments to
tribes at Federal fiscal year 2006 level, which included a 1 percent
rescission. This decreased level of funding has resulted in many of the
Alaska tribal health corporations securing short-term loans to maintain
services, thus paying interest rather than earning interest. Certainly,
not all tribal fiscal challenges are a result of the CR process--
however, the current CR situation compounds other challenges such as
the very high cost of energy in rural Alaska.
Several efforts are underway to address the challenges Alaska faces
in recruiting and retaining physicians--especially in rural areas. For
example, workforce development strategies outlined in the Physician
Supply Task Force report (2006) which Congress could support include:
Federal loan repayment programs which play a major role in bringing
doctors and other providers to Alaska; support for the National Health
Service Corps and the Indian Health Service; expansion of medical
school classes, and funding for residency programs and teaching
hospital activities can help improve Alaska's recruitment opportunities
as well as support the national supply; and support for Senator
Murkowski's proposal for a tax credit for physicians agreeing to
practice in frontier areas would improve the situation for Alaska.
The Alaska Senate Finance Committee's recently released Medicaid
Program Review (January 2007) provides useful guidance and information
about policy and funding options including potential 1115 Waiver
options which are currently under development to increase Alaska's
strategies for improving prevention and disease management to save
future healthcare costs.
Governor Sarah Palin, through Administrative Order No. 232 dated
February 15, 2007, created the Alaska Health Care Strategies Council to
develop an action plan for Alaska to ensure access to quality,
affordable healthcare. This Council will compile and analyze the
current components of the healthcare system in Alaska; review the
various planning reports compiled to address the gaps in service;
develop short-term and long-term statewide strategies to improve
healthcare access, control cost, and ensure quality of care; and draft
performance measures to assess the success of implementing those
strategies. Public involvement and input will be included as the
Council prepares an action plan for the Governor and legislature by
January 2008.
Finally, we appreciate the congressional support for the Alaska
Native Tribal Health Consortium's Dental Health Aide Therapist program,
as well as the funding efforts that support the healthcare delivery
system in Alaska including: HRSA funding for the Community Health
Centers program, National Health Services Corps, Rural Hospital
Flexibility Program, Small Hospital Improvement Program, State Office
of Rural Health, Outreach and Network Grants; USDHHS funding from the:
Centers for Disease Control and Prevention, National Institutes of
Health, and SAMHSA. These Federal funds work together to support rural
health facilities, pandemic flu preparedness, obesity and diabetes
management and prevention, fetal alcohol syndrome treatment and
prevention, HIV/AIDS monitoring, oral health, cardiovascular disease
management, tobacco-related illness reduction, EMS services,
Residential Psychiatric Treatment Centers, Behavioral Health Aides,
suicide prevention efforts, disease and risk surveillance, and State
planning efforts to increase healthcare coverage for the uninsured.
In conclusion, the shortage of physicians in Alaska--particularly
in our rural and frontier areas must be addressed within the context of
our larger healthcare system challenges--including shortages of other
healthcare professionals and para-professionals and funding decreases
across several Federal sources.*
*Sources: Alaska DHSS, Status of Recruitment Resources and
Strategies 2005-2006 (SORRAS II). June 2006; Alaska Physician Supply
Task Force, Securing an Adequate Number of Physicians for Alaska's
Needs. August 2006; Alaska Department of Labor and Workforce
Development, Alaska Population Estimates online at
www.labor.state.ak.us.; Lewin Group and ECONorthwest, Medicaid Long
Term Forecast; and Pacific Health Policy Group, Medicaid Program
Review, January 2007.
Senator Murkowski. Thank you, Commissioner. I appreciate
your comments and the good work that you do in this area.
You've indicated the impact to the State--the financial
impact to the State--as a consequence of the Federal Medicaid
Assistance Percentage, the FMAP. And, as we look, the financial
hit--you've indicated it's about $37 million in State General
Funds this year, but with the potential for an additional $14
million if, in fact, the proposal should go ahead to do further
reductions.
We can understand what the numbers look like on the ledger,
we know that that's going to be a huge hit to the State. But,
what does that do within your Department, should the State have
to assume that financial hit, because of the reduction--what's
that going to do to your budget, within the Department of
Health and Social Services?
Ms. Jackson. Senator Murkowski, what it would do for our
budget in the Department, would have serious consequences for
access to care, and quality of care, for Alaskans. We've done,
I believe, a pretty remarkable job over the last several years
of tightening up, as much as possible, every dollar that we
spend, every Medicaid dollar coming in, and at this point in
time, those kinds of reductions would mean reductions to
services for Alaskans. And when we look at those reductions in
light of the physician supply shortage, and other workforce
development issues, the combination is somewhat the perfect
storm. That would mean that Alaskans are not going to get the
healthcare that they need.
Senator Murkowski. So, in other words, if people think the
situation is bad now, they can anticipate that it will be
worse, should these reductions continue.
Ms. Jackson. That's correct.
Senator Murkowski. Let me ask about the task force that the
State commissioned with the University, to analyze the
physician shortage problems. The report is pretty specific in
its conclusion that there will be significant consequences for
access, and for quality of care. But, do you also see that
costs would continue to increase, as a result of the squeeze,
if you will, or the constriction to access?
Ms. Jackson. Absolutely. One of the biggest problems, and
you mentioned this in your introduction, is when people don't
have appropriate healthcare--don't have access to appropriate
healthcare--they wind up being seen in emergency rooms at a
much higher cost than they would otherwise be seen. And, so
every dollar that we're not able to put into preventive care
costs us more money, in the long run, when people have to be
seen for those higher care costs.
Senator Murkowski. And, I would imagine that many of our
systems are already overwhelmed when it comes to providing that
level of service that is necessary in the emergency rooms.
Ms. Jackson. That would be absolutely true.
Senator Murkowski. As we look at the demographics of this
State, and recognize that we have an aging population--we're
seeing the numbers of physicians dropping--is Alaska prepared
to meet its healthcare needs?
Ms. Jackson. Senator Murkowski, I don't believe we are. I
believe it's critical that we have these kinds of conversations
right now, the Governor is also--through Administrative Order--
created a Healthcare Strategies Council, which I believe will
help us in the next year to look at these issues. But, if we
don't address these issues in the next few months, or at least
the next year, I'm very concerned about what that's going to
mean for health in Alaska. And I know I'm not alone in that,
and you'll hear that from many other people.
But it is a time when many things are converging to create
a crisis of healthcare for Alaskans.
Senator Murkowski. Well, we would look forward to hearing
the outcome from the Council that has been recently formed, and
there are many different entities, whether it's the Task Force,
or the newly appointed Council. We're going to be speaking this
afternoon to the roundtable on healthcare that has been pulled
together by Commonwealth North. There are a great many entities
that are discussing the problem. But, we've got to get beyond
the discussions stage, and say, ``How are we going to be
answering some of these concerns that we are highlighting?''
So, I look forward to working with you on this council, and
sharing some of the information that we gain.
Ms. Jackson. Thank you, Senator Murkowski. I look forward
to that, too, and we hope that that will roll up all of the
good planning that's been done, and come out with an actual
action plan for Alaska.
Senator Murkowski. Thank you. I appreciate you coming here
this morning, and providing us with your testimony.
With that, I would like to welcome to the second panel,
Mrs. Rita Hatch, who is with the Older Persons Action Group;
Mr. Frank Appel, who is Chair of the Alaska Commission on
Aging; and I'm also going to invite up Mr. Carl Berger, who is
the Executive Director of the Lower Kuskokwim Economic
Development Council, out of Bethel, Alaska.
And, you all don't need to crowd on to one table there, if
you want to have more room, you may, but if you want to huddle
together for warmth, I'm okay with that, too.
[Laughter.]
Again, I welcome you all to the committee, and I thank you
for your advocacy on behalf of Alaska's seniors, and with that,
Mrs. Hatch, why don't we begin with you?
STATEMENT OF RITA HATCH, OLDER PERSONS ACTION GROUP,
INCORPORATED, ANCHORAGE, ALASKA
Ms. Hatch. Good morning, Senator, thank you for inviting me
here.
I'm a volunteer with the Older Persons Action Group, and
I'm well-versed in Medicare, Medicaid, Social Security and
other senior issues. And as such, I advocate for seniors in
Alaska.
The most important issue facing seniors in Alaska today, is
finding a physician who will take the most new Medicare
patients, you know that. But what good is having a prescription
drug program, if you can't find a doctor to write a
prescription?
And what good is paying for Medicare Part B, which pays for
doctor's services, if you can't find a doctor to serve you?
With the assistance of some of the staff at OPAG, I have an
ongoing telephone survey of medical facilities in Anchorage, to
find out which ones of them will take new Medicare patients.
And I receive approximately 10 calls a week from seniors who
don't have a doctor, and have tried and tried, and finally get
around to calling me, and the only thing I can tell them to do
is to see a nurse practitioner. I do have a list of nurse
practitioners who take care of new Medicare patients.
There's only one clinic in Anchorage that I know of who is
taking new Medicare patients, and that's the Anchorage
Neighborhood Health Center. The Providence Family Clinic can't
take any more, they haven't taken any more for months now. And,
there are about 20 doctors that I know of, outside of the
clinics, who are taking new Medicare patients, of all of the
doctors in Anchorage.
I have one senior who called me the other day--she's still
working, and she's working for a big company who has insurance.
But she's 65, and her doctor told her he will not take her.
Even though Medicare is secondary, he still won't take her. So,
I don't know what his reasoning is, because the insurance would
pay most of it, anyway.
Then I have another man who just called me the other day,
he's 63, and his doctor said to him the other day, ``When
you're 65, I'm not taking you any more.'' And he just called me
up and said, ``What is going on?''
So, this is the situation, I get people calling who bring
parents up from outside who tell me the same story, they can't
find a doctor. Of course, my temporary solution is the nurse
practitioners, but I think there's got to be something else. It
seems to me the State of Alaska should be offering incentives
for doctors to come up here, to practice up here, and not just
in--well, we need them in the rural areas, but we need them in
Anchorage, too.
I have talked to people in other States, and we seem to be
the worst of them. Montana has the same problem, I don't know
what other States do, but those are the two States who have a
big problem, and it's because of the low population, I guess.
But, it's up to you, to get us some help here, please.
[Laughter.]
There aren't many seniors in the audience today, besides
me, and I really don't have a dog in this fight, because I'm a
retiree from the State, and I have good insurance, and I am a
patient at Anchorage Neighborhood Health Center. But I'm here
to advocate for the people who don't have any help.
[The prepared statement of Ms. Hatch follows:]
Prepared Statement of Rita Hatch
My name is Rita Hatch. I am a volunteer with the Older Persons
Action Group. I am well versed in Medicare, Medicaid, Social Security
and other Senior issues and as such, I advocate for seniors in Alaska.
The most important issue facing seniors in Alaska today is finding
a physician who will take them as new Medicare patients. What good is
having a prescription drug program in Medicare if you can't find a
doctor to write a prescription? What good is paying for Medicare Part
B, if you can't find a doctor to treat you?
With the assistance of some staff at OPAG, I have an ongoing
telephone survey of the medical facilities in Anchorage, to ascertain,
which of them will take new Medicare patients.
I have one senior, who is still working and has insurance and she
still can't find a doctor to treat her, although in her case, Medicare
would be the secondary payer of her bill.
I receive approximately 10 calls a week from seniors who are trying
to find a doctor who will accept them as new Medicare patients. As of
today, there are about 20 doctors in Anchorage, who are still taking
new patients.
Anchorage Neighborhood Center is the only facility still taking new
Medicare patients and that facility is being overwhelmed. Providence
Family Clinic is no longer taking new patients.
My temporary solution is to offer the names of Nurse Practitioners,
who are more than capable of taking care of patients' needs for meds
and other physical problems. I have a roster of about 10 PA's, whom I
currently recommend.
The problem as I see it, is that doctors charge too much for visits
and Medicare pays too little. Obviously Alaska needs more doctors, but
it takes almost 10 years for a new doctor to get into business in
Alaska. One answer might be for the State of Alaska to offer incentives
to outside doctors to come and practice in Alaska. As far as I know,
this problem exists in every city in Alaska.
Senator Murkowski. Well, I thank you. Not only for your
testimony, Mrs. Hatch, but I thank you for all that you do on
behalf of Alaska's seniors. I know that through your efforts,
through Older Persons Action Group, you have provided a little
bit of comfort as you've tried to help match seniors with
providers, and I appreciate that.
I'll come back with questions to each of you, but let's go
to you, Mr. Appel. Thank you for being with us this afternoon,
and for your work on the Alaska Commission on Aging.
STATEMENT OF FRANK APPEL, CHAIR, ALASKA COMMISSION ON AGING,
ANCHORAGE, ALASKA
Mr. Appel. Senator Murkowski, I'm here to testify on the
denial of Medicare services as well, primarily by primary care
physicians. I am testifying as an individual who has been
denied service, and as Chair of the Alaska Commission on Aging.
Last summer, my primary care physician sent me a letter,
stating that he would no longer provide Medicare-reimbursed
services. I had been with that physician for about 15 years.
The reason stated was that the paperwork was too demanding. He
sent along a contract for me to sign, stipulating that I could
continue obtaining service, provided I pay for those services
personally. I have declined to sign that contract.
I have contacted a few primary care physicians, based on
referrals from friends, but I have been unsuccessful in finding
a physician. I haven't searched aggressively, because I had a
physical last May, however, I do have a prescription that
cannot be renewed after April 1st, so I need to get a little
bit more aggressive in my effort. My wife has suggested that
maybe I need to schedule an appointment for a physical at a
clinic in Seattle.
Several weeks ago, a group of us were sitting around the
table at a Senior Advocacy Coalition Meeting, the subject was
Medicare services, service denials came up. I was astonished
when three of the five people who were present, who were over
65, said they had been denied Medicare-reimbursed services, or
were unable to find a primary care physician who would accept
Medicare patients.
During the last year, the Commission on Aging has received
many comments, and much anecdotal evidence that seniors have
been denied service, or have been unable to find a primary care
physician who will accept new Medicare patients.
They have been told by doctors, if they are not receiving
adequate reimbursement to cover their services. Seniors have
told us they have made many unsuccessful phone calls to obtain
primary care services. I have heard that seniors have
increasingly turned to the services of hospital emergency
rooms, nurse practitioners, and the neighborhood health
clinics.
Recently, I talked to the Executive Director of the
Anchorage Neighborhood Health Clinic. She said the Clinic has
been overwhelmed recently by the numbers of seniors seeking
Medicare and Medicaid services.
Incidentally, most of these comments or complaints have
come from the larger communities in this State, the larger
population areas. I don't know why that is occurring. I
understand there's a shortage of primary care physicians in
this State. That shortage may be contributing to the problem.
Under these circumstances, I am concerned that the quality
and availability of Medicare medical services for seniors in
Alaska is declining, that seniors may have difficulty getting
their prescription filled if they cannot find a primary care
physician who will sign off on their refill.
Poor or inadequate healthcare may lead to illnesses, and
more costly long-term care, and the State and the Federal
Government may have to shoulder the burden of these costs.
Seniors with resources may decide to move to the Lower 48,
where they can obtain medical care, thus removing your economic
benefit to the State.
I read a national editorial recently that suggested
Medicare reimbursement rates were a form of price control, but
that so far, it hasn't reduced the supply of medical services.
With the elimination of the Alaskan differential on Medicare
reimbursement rates, we may have reached the point where those
controlled rates are reducing the supply of services in Alaska.
I think the issue is one of many healthcare-related
problems we have facing this Nation. We hear of such large
numbers of uninsured citizens. We also read how increasing
medical costs are becoming a burden to businesses.
I encourage the Senate to not only address the Medicare
issue, but examine some form of comprehensive medical coverage
that will deal with our broader healthcare problems. Thank you.
Senator Murkowski. Thank you, Mr. Appel.
And, let's next go to Mr. Carl Berger, the Executive
Director at the Lower Kuskokwim Economic Development Council.
Welcome, good morning, and your comments, please?
STATEMENT OF CARL BERGER, EXECUTIVE DIRECTOR, LOWER KUSKOKWIM
DEVELOPMENT COUNCIL, BETHEL, ALASKA
Mr. Berger. Thank you, Senator Murkowski. And thank you for
the opportunity to speak at this meeting this morning.
I didn't come with any prepared statement, I, in fact, just
found out about the location of this hearing about an hour ago.
But, I wanted to come because I've recently turned 65, and I
had looked forward to getting on to the Medicare program, I'm
also a retired State employee, although I continue to work at
another job, and I have a good medical coverage plan for
working for the State of Alaska, but I don't have a G.P., I
don't have a physician. My physician that I have gone to for
over 20 years, here in Anchorage, retired, Dr. J. Caldwell. And
I have not been able to find anybody else to take his place.
I guess I have to say, lucky for me--I have a heart
condition. So, I'm seeing another physician whose specialty is,
you know, seeing me for my heart condition. But I'm just
baffled by the fact that in this State, you know, what
physician in their right mind would want to see me when they
can only be reimbursed 40 percent of their usual cost. That's
just, you know, it doesn't jive at all with the way things
should be.
I was pleased to see that there was a program in place, up
until the beginning of this year, I believe, or last year, to
allow for better reimbursement to physicians. I pointed this
out in a letter to you and to the other members of the
congressional delegation, that we must do something about this.
I'm not speaking only for myself, I'm actually in pretty good
shape, I do have medical insurance, but there are other people
in the bush who do not.
It's difficult to find a physician, even at the Yukon-
Kuskokwim Health Corporation, because they are fully booked, as
well. And as a non-Native person, I'm not really eligible to be
seen there, except as an emergency situation. So I don't think
that's the solution, either. I'm willing to pay my way into
Anchorage to see a physician. But right now, I can't find one,
and that's wrong, that needs to be fixed. Not just for me, but
for a lot of other people around the State.
So, I guess I'll leave my comments at that, and be happy to
answer any questions you may have. Thank you for the
opportunity to speak.
Senator Murkowski. Thank you. I appreciate the comments
from all three of you.
It's one thing to have statistics, it's another thing to
have the real stories on the ground. And whether they're as
unscientific as a group of folks sitting around a kitchen table
talking about what has happened, in terms of denial to access--
these are real-live stories, these are Alaskans that do not
have access. And, it makes our statistics all that more
compelling.
Mrs. Hatch, let me ask you--you'd indicated that you kind
of conducted a telephone survey of the facilities in Anchorage
to kind of determine who was accepting new Medicare patients.
How long ago was this? Or, are you still doing it now?
Ms. Hatch. This is ongoing.
Senator Murkowski. You're still doing it now. And, that's
how you have come to your number of----
Ms. Hatch. Well, there's three questions we ask. We ask,
Are you taking new Medicare patients now? Are you taking new
Medicare patients? Do you take assignment of Medicare? And we
generally try to get the billing person, or whoever's in charge
of the bills in the office. And we can call at 1 a.m., and they
say, ``yes, they are taking new Medicare patients,'' and you
can call them back in the afternoon to get another telephone
number, or an address, and they say, ``no, we're not taking
them.'' So, it's incredible.
Senator Murkowski. And, as you're kind of acting as a
facilitator for some of the seniors that you're working with,
you've suggested that if they can't get into a practitioner,
that a nurse practitioner is the next best option. But, what
happens if their medical needs go beyond what a nurse
practitioner can provide?
Ms. Hatch. Nurse practitioners usually work with a doctor,
and they can usually get them in to see a doctor.
Senator Murkowski. So, we're not seeing the same wall,
then?
Ms. Hatch. There's not the same wall. Because if a nurse
practitioner asks you to, you know, refers you to a doctor,
they'll generally take them.
And that's the same with specialists, too. If a doctor
refers you to a specialist, that specialist will generally take
you.
Senator Murkowski. Right.
Ms. Hatch. As a Medicare patient.
Senator Murkowski. Mr. Appel, you've mentioned that you
have--through the Commission--been in conversation with many
seniors that are focused, and very concerned, on this same
issue. Is it fair to say that the situation that we're seeing
here in Anchorage is replicated around the State? Or, do you
have conversations with folks outside the Anchorage area?
Mr. Appel. Well, we've had conversations with people in
some of the smaller communities of this State--Ketchikan,
Juneau, specifically--because we've held meetings there
recently. And, it doesn't appear to be as much of an issue in
those communities. And I can't speculate why that is, but it
could be that those communities are more insular or more
intimate, and so physicians may be reluctant to refuse services
in a smaller community.
But, most of our comments come from the Rail Belt area--the
Matsu, Anchorage, and Fairbanks--the larger population areas.
But, we have not explored this issue in the rural community, so
I would hesitate to comment and say----
Senator Murkowski. Does the Commission on Aging do a
similar thing that Mrs. Hatch has described, in terms of trying
to do an assessment of who is available to take new Medicare
patients? Are you involved in that at all?
Mr. Appel. Well, we examined some of the State
organizations. At a meeting we had in November, one of the
Medicare-coordinating agencies for the State suggested they had
a list of physicians that accepted Medicare, but we found out
that that was not the case. And so we couldn't--because we
wanted to advise seniors where they could obtain services. So,
we have been unsuccessful in finding any kind of a list, or any
kind of a method of identifying physicians who take Medicare.
Senator Murkowski. Mrs. Hatch, do you want to weigh in on
that?
Ms. Hatch. Just another----
Senator Murkowski. If you can put the microphone----
Ms. Hatch [continuing]. That list that Frank is talking
about, it's on the Medicare web page. And it's doctors who have
taken Medicare, or are enrolled in Medicare. But that doesn't
mean they're taking new Medicare patients. So, the list is
really worthless.
Also, I don't know if you've had anything to do in
Fairbanks, but I've gotten reports in Fairbanks that doctors
are asking for a $300 ``retainer,'' just to take you on as a
Medicare patient.
Senator Murkowski. Well, I had a series of Town Hall
Meetings last year on this issue of the physician shortage--one
up in Fairbanks, one on the Kenai Peninsula, and one down in
Juneau--and heard very similar comments and concerns about the
access issue.
Mr. Berger, from the Bethel area--you've pointed out that
your situation might, perhaps, be a little bit different, but
in terms of access in the more rural parts of this State, I'm
assuming that you're not an isolated instance, that many are
faced with the same issues that you have described here this
morning.
Mr. Berger. I think they are. One thing I didn't mention in
my earlier comments was the importance of the continuity of
care. Having a general practitioner for almost 25 years before
he retired was important to me. I worked hard to get my medical
coverage with the State of Alaska, it's good coverage. But,
it's not much use to me if I can't find somebody who will see
me on a regular basis. I don't want to have to skip around,
from one doctor to a nurse practitioner, to a physician's
assistant. I want to establish a relationship with a doctor
that I can see on a regular basis. And if he's in Anchorage, so
be it. If he's somewhere else, that's fine.
But I don't want to have to be forced to go from one person
to another who doesn't really know me, and never really does
get to know me and my medical situation. I think that's very
important. And, as somebody who has established a career, and
is now getting ready to retire--having just turned 65--I'd like
to look forward to having good, reliable, steady care from a
person, a physician, that I can get to know and feel
comfortable with, and who will take better care of me than
somebody who sees me once and never sees me again. Or, maybe
twice, or three times, and then I'm jumped to somebody else,
and then somebody else after that. And I think there are other
people in the bush that are in that same situation that I am
in.
Senator Murkowski. I'm going to ask one last question of
all of you, and it will be the same question.
Given the array of issues and concerns that face us in
Alaska and in the Nation regarding healthcare, what is the
biggest problem? What's the biggest problem--is it access? Is
it the cost? Very briefly--what's the biggest problem with
healthcare from your perspective?
Mrs. Hatch, if you can speak into the microphone.
Ms. Hatch. Access to doctors, I think, is the most
important thing. Because if you can't find a doctor, what are
you going to do?
Senator Murkowski. Right. Thank you.
Mr. Appel.
Mr. Appel. Well, I think, certainly access to doctors by
seniors over 65 is a huge problem, but I think medical costs,
in general, having been spiraling, and so I see that as a
problem as well.
Senator Murkowski. Mr. Berger.
Mr. Berger. I think it's access to physicians, but I also
think the insurance companies who provide coverage to Alaskans,
need to have a better understanding of the cost of care here,
and that it's higher. I often get my charges rejected, because
they're above the usual customary charges. And then I ask my
doctor--the heart doctor that I can see--he says, ``Oh no,
there's nobody in Alaska who will provide this service at the
rate they're willing to reimburse.'' And that kind of makes me
angry, you know, I pay for my health insurance through my
employment, and so I've challenged the insurance company to
say, ``Wait a minute, your usual and customary charge isn't
really the usual and customary charge in Alaska,'' and you know
what? They back right down. And so far I've had pretty good
results on getting them to reconsider and pay.
But that shouldn't be necessary. Insurance companies that
are based in Seattle or somewhere else should be willing to pay
what physicians charge here, or what a service like an
echocardiogram costs in this State. Yes, you can get an
echocardiogram done in Seattle, but do they really want to fly
me down there? Oh, no, they surely do not. But they want to pay
for what an echocardiogram costs in Seattle, not what it costs
in Anchorage, or somewhere else here in Alaska. So, that needs
to be addressed, too. Thank you.
Senator Murkowski. Very good. I appreciate again the
testimony, the perspective that you bring, and all that you are
doing individually, collectively, to help make a difference. As
you point out, we've got some real problems when it comes to
access, when it comes to costs, and how we explain our higher
costs in the State. So, thank you for what you're doing, we'll
keep working on it as well. Thank you for serving on the panel.
And with that, we will bring the next panel forward, and
this is the panel that has been asked to speak to the potential
solutions to the patient access crisis.
Having heard from users within the system about the
problems that we face, we now want to hear from some who would
offer some suggestions.
We will have Dr. Ross Tanner, Dr. Harold Johnston, Dr.
Richard Neubauer, Dr. Byron Perkins, Dr. John Coombs and Ms.
Karen Perdue join us at the table.
And for the audience, I'll give a little bit of background
on each of our panelists this morning. Dr. Ross Tanner is the
President-Elect of the Alaska State Medical Association; Dr.
Harold Johnston is the Director of the Alaska Family Practice
Residency program; Dr. Richard Neubauer here in Anchorage is a
doctor in internal medicine; we have Dr. Byron Perkins, who is
the President of the Alaska Osteopathic Association; we have
Dr. John Coombs, who is the Associate Vice-President for
Medical Affairs, and the Dean for Graduate Medical Programs
there, the WWAMI program; and we have Karen Perdue, Associate
Vice-President for Health at the University of Alaska, and the
one who will explain to us the details and the findings from
the Alaska Physicians Supply Task Force.
So with that, if we can move from you, Dr. Tanner, on down
the line and I will reserve my questions until all of you have
had an opportunity to present.
So, thank you for being here.
Dr. Tanner.
STATEMENT OF ROSS TANNER, PRESIDENT-ELECT, ALASKA STATE MEDICAL
ASSOCIATION, ANCHORAGE, ALASKA
Dr. Tanner. Good morning, Senator.
Senator Murkowski. Good morning.
I'm going to ask everyone to make sure that that mike is
pulled pretty close up. I understand it's been tough for some
of the folks in the back to hear. So----
Dr. Tanner. As the first physician to testify, I'd like to
request Secret Service agents to protect my well-being before I
leave here today.
[Laughter.]
But I am the President-Elect of the Alaska State Medical
Association, and as many of you know, the Alaska State Medical
Association, or ASMA, represents physicians statewide, and is
primarily concerned with the healthcare of all Alaskans, and
that's all Alaskans--young, old, and middle-aged. And I don't
know how to define old age, other than saying Medicare-age.
ASMA is also federated with the American Medical
Association. Welcome back to Alaska, it's nice to see you
again, and thank you for the opportunity to address you today.
It is, indeed, an honor to be able to address the Senate
Committee on Health, Education, Labor, and Pensions.
Last week, I participated and represented the State of
Alaska at the AMA National Advocacy Conference in Washington,
DC., which addressed many of the concerns which we will discuss
here today.
As President, I receive no remuneration for my services, or
the time away from my busy medical practice. So, why would
anybody want to become involved in organized medicine?
It is the progressive deterioration of access, as well as
inefficiency of delivery of healthcare to the citizens of this
State, and also of people of other States, that--in the last 15
years, I believe that this is continuing to worsen, and I
believe the prognosis is poor. This is shameful, given our
intellectual and financial resources we have as a Nation.
Today, I would like to provide you with a current
assessment regarding Alaska's chronic, and currently acute,
shortage of physicians, and to provide you with ASMA's
recommendations on how you can help us address this critical
situation that endangers the healthcare of every Alaskan.
Currently, Alaska has a shortage of 30 percent of
physicians, or nearly 400 physicians. Alaska has 10 slots per
year at the University of Washington Medical School program,
participation with the collaborative effort between the five
States, the WWAMI program, which is Washington, Wyoming,
Alaska, Montana and Idaho.
Alaska has only one residency program, the Alaska Family
Medicine Residency, which would train a maximum of 12 residents
per year. Alaska has a physician workforce that has more age
than most other States, and over the next 20 years, Alaska will
need to nearly double the number of physicians, just to keep
pace with the expected population growth. This requires a net
increase of 50 physicians per year, given the projection of the
number of physicians who will leave practice, which will
require approximately 100 physicians per year to be added to
the workforce currently.
Alaska has experienced a large number of retired military,
Medicare-eligible people, seeking treatment by private
physicians due to the deployment of Alaskan military physicians
to the Middle East. These numbers were developed by the Alaska
Physicians Supply Task Force that we heard about earlier. This
Task Force was convened by the University of Alaska President,
Mark Hamilton, and Alaska State Commissioner of the Department
of Health and Social Services, Karleen Jackson.
The Task Force reported their findings after working for at
least 6 months in its report, ``Securing an Adequate Number of
Physicians for Alaska's Needs.'' ASMA was represented on this
Task Force by our Executive Director, Mr. Jim Jordan, who is
with us today, and I believe that you all have been provided
with this report.
For Senators and people of this committee that come from
larger States, some of these issues may not seem that large, at
face. However, when put in perspective to other States, the
Alaska picture is, indeed, grim. Alaska has the sixth lowest
physician to population ration in the Nation, as you earlier
stated. Most physicians practice within 100 miles of where they
will complete their residency or specialty training.
Alaska has only one residency program with 12 slots of
family medicine residents. By contrast, as reported by the
Texas Medical Association, Texas has nearly 6,400 resident
slots in multiple specialties. New York has over 15,000 slots,
California has nearly 9,000 slots, and Pennsylvania has almost
7,000 slots--just for residencies. If 12 slots were sufficient
for Alaska's roughly 650,000 population, that would mean in
comparison, that Texas' 6,400 slots would be adequate for a
population of 325 million people--very much underserved.
Alaska has only 10 slots at the University of Washington
Medical School, coupled with the 12 family medicine residency
slots, cannot come anywhere near the growing need that our
public and our citizens of this State need. Alaska's current
physician workforce is not sufficient to provide the clinical
teaching resources necessary to expand the residency program
itself, for a wide variety of needed specialists.
An increase in the WWAMI Program, or additional slots
through other medical schools, will not provide any help for a
minimum of 10 years, because of the duration of medical
training that all of us went through that are sitting at this
table.
Recruitment costs in Alaska range anywhere from $60,000 to
upward to $200,000 per physician. I think you will agree that
the current physician workforce environment in Alaska is in a
crisis, as we've heard from patients, as well as you're hearing
from physicians today. This is particularly true when taken in
the context that Alaska needs to recruit physicians from other
parts of the country at a time when there is also a nationwide
shortage of physicians, and it's projected to be between 80,000
to 200,000 physicians--truly, alarmingly large numbers.
Before I outline what ASMA recommends for ways in which you
can help Alaskans get the healthcare they need and deserve, I
would like to briefly describe what we are doing at a State
level.
For the past 10 years, ASMA has been instrumental in
advocating for legislation that would create and maintain an
environment conducive to attracting, and most importantly,
retaining physicians. Those successful measures include major
liability reform in 1997, and again in 2005--and I want to
thank you for that--enacting an Alaska Bill of Rights,
protecting patients, enacting fair contracting provisions for
relationships between physicians and health insurers, enacting
Health Insurance Prompt Payment Law, and enacting legislation
that allows physicians to jointly negotiate with insurers for
everything but their fees.
These measures, as well as others, were critical for my
decision to come to Alaska. If you think it's bad in Alaska, go
to Washington State--it's worse. Since I've last left the area
around Olympia, there's been 40 physicians leave since I've
been here, for 2 years, just in that one community. And before
I got there, there were 50 physicians left in the preceding
year. It's worse.
Currently, ASMA--along with other key organizations, such
as the Hospital and Nursing Home Association, and the
University of Alaska--is acting as the catalyst to enact a bill
to double the WWAMI class size from 10 to 20 medical students.
The State legislature is expected to act on the bill in early
2007, so that in the fall, a total of 20 qualified Alaskans can
enter medical school at the University of Washington.
ASMA is also exploring ways to develop long-term,
sustainable funding mechanism for physician education for
qualified Alaskans.
Here's what I think you can do too at the national level to
help Alaska--and patients in Alaska--and really, across the
Nation. No. 1, enact a legislation that permanently, and I
stress, permanently, fixes the Medicare physician payment
system so that it realistically reflects the physician practice
cost. With rising costs, coupled with shrinking reimbursements,
this leaves less quality time with your doctor, if you even get
it.
In general, I will need to see approximately 45 Medicare
patients in a day, that produces about the same revenue as 20
insured patients to equal each other. As an internist, I lack
the ability to generate revenue by procedures, and am
compensated for cognitive and diagnostic abilities.
No. 2, if a patient is new to Alaska, or my patients turn
65 years of age, it will be nearly impossible to find a primary
care physician, as we've heard today, eloquently placed by
patients and our Commissioner. My own mother and father
encountered this problem. It is certainly nobody's fault for
turning 65 years of age.
Alaska reportedly has the second-fastest growing elderly
population, second only to Nevada. Continued year to year,
uncertainty created by the flawed sustainable growth rate, or
SGR formulate, has caused a lack of access to care for Alaska
Medicare beneficiaries. Medicare payments to physicians in
Alaska represent 37 to 40 percent of the cost of opening our
doors each day.
No. 3, we ask that you support and enact legislation that
provides tax credits for young physicians to practice in
frontier States, such as Alaska. Your bill, S. 290, is such a
bill. This will help Alaska, and other frontier and rural
States, to attract physicians.
No. 4, support and enact legislation that revamps the
funding of graduate medical education. Reforms need to be made
that recognize residencies, like the family practice residency,
in Alaska, and make them eligible for Federal funding support,
as well as other mechanisms that would encourage regional
residencies between States such as Alaska, Wyoming, Montana and
Washington State. Furthermore, the latitude to work with Canada
is needed. Alaska could work in conjunction with Canadian
medical schools, or with residencies in Western and
Northwestern Canada to develop joint residencies.
No. 5, develop programs to help medical students cope with
the enormous debt of going to medical school. Our best and
brightest students are being disincentivized from going to
medical school due to the tremendous educational debt
associated with medical training. For public medical schools,
it is an average of $125,000 per student, and for private
medical schools, it is approximately $200,000 to go to school.
For those bright students not deterred by the debt, it is
impacting their choice of specialty training. Many physicians
are choosing their career path, based on potential future
income.
So, now students are often going into more lucrative sub-
specialties, than going into family practice or general
internal medicine. A way to remove these disincentives must be
found.
Others here today will speak to many of these same issues
that I've mentioned, such as Dr. Johnson, on graduate medical
education, Dr. Neubauer on the practice of internal medicine,
Dr. Perkins with primary care and family practice, and I hope
the testimony today by myself, and others, does not fall on
deaf ears.
I would also imagine that it is a rare occasion when a
specific occupation, business, or trade comes and asks you to
increase competition. And, as I stated in the beginning, the
physicians are genuinely concerned with the healthcare of all
Alaskans.
I'd be happy to address any questions you may have. Thank
you.
Senator Murkowski. Thank you, Dr. Tanner.
Dr. Johnston.
STATEMENT OF HAROLD JOHNSTON, DIRECTOR, ALASKA FAMILY PRACTICE
RESIDENCY, ANCHORAGE, ALASKA
Dr. Johnston. Thank you, Senator. It's a great pleasure to
be able to offer testimony to the committee. And I congratulate
you on all of the work that you've done to help us so far, here
in Alaska, with our healthcare crisis issues.
I'm the Director of the Alaska Family Medicine Residency,
the only graduate medical education program in Alaska, and I
also have had the distinct privilege to be the co-chair of the
Alaska Physician Supply Task Force, whose report has been cited
several times so far today.
I appreciate the remarks of Dr. Tanner, much of what he
said were things that I had intended to say, as well, so I'm
not going to repeat those. But, I want to emphasize a couple of
points about things that he said.
One, about physician education in Alaska--indeed, Alaska
has the lowest, per capita number of medical school slots in
the United States, we have the lowest number of residency slots
in the United States, we have the lowest acceptance rate of
Alaskan medical students, Alaska students into medical school,
of any population in the United States. And, the fact that we
are so far behind is contributing to our crisis----
Senator Murkowski. Can you repeat that last one? We have
the lowest number of----
Dr. Johnston. We have the lowest----
Senator Murkowski [continuing]. Number of students being
accepted into medical schools?
Dr. Johnston. We have the lowest acceptance rate of
students going into medical schools. In other words, of all of
the Alaska students who apply to medical school, we have the
lowest rate of acceptance.
Senator Murkowski. Thank you.
Dr. Johnston. Those facts are contributing greatly to the
crisis that we have in physician supply here. As has been
stated, rural areas are in tremendous shortage. In rural areas,
and nonrural areas, we have a lot of specialties that are in
shortage, primary care is in major crisis, particularly in
Anchorage, general internal medicine is in extreme and dire
shortage, although many specialties are in shortage here, as
well.
I believe that these problems are related to the
consequences of national trends. Many of those national trends
are things that can be affected by Congress, especially in the
Medicare program, but also in other ways.
One of the national trends is the national shortage. Years
ago, in the 1980s, multiple specialties societies, and the
Council on Graduate Medical Education--using flawed
methodology--concluded there would be a surplus of physicians.
As a consequence of that analysis, the Association of American
Medical Colleges reduced the number of medical student slots
that they were producing--or reduced their growth rate, anyway,
and Congress in 1997, capped the number of residency positions
that were available for funding in the United States.
About a year after Congress capped the number of residency
positions, the light started to dawn that the analysis had been
flawed, and actually, in 2005 COGME reversed its position, and
stated that its previous analysis was wrong, and that actually
we were facing a shortage of physicians, and that the caps were
a mistake. The Association of American Medical Colleges around
the same time, advocated an increase of medical student
positions of 30 percent over what currently exists in the
United States, in order to start the valve--open the valve on
the pipeline of physician production.
Well, in Alaska, we have always been a net importer of
physicians. We don't have much training capacity, as I stated
before, and so in order to supply ourselves with physicians, we
have had to recruit them from the Lower 48. Well, when the
Lower 48 has a shortage of physicians, that makes the
recruitment to Alaska increasingly difficult, and part of the
reason that we're seeing the cost of recruitment go up, and the
cost of absent physicians go up so high across the State, is
because it is becoming more and more difficult to get doctors
in here. It used to be that the Indian Health Service would
assign commissioned officers to Alaska, and the military had a
different process of assigning physicians to Alaska--many of
Alaska's physicians came from doctors who were in the
commissioned corps of the military, and then in their assigned
rotation, here, fell in love with Alaska and decided to stay
after their obligations expired.
Currently, that process is no longer effective in Alaska,
because the presence of the Indian Health Service in the
commissioned corps, and the military, has been reduced. The
commissioned corps has been reduced, the military has changed
its policies, and so the assignments are in a different
mechanism that I don't fully understand, but it effects the
ability of military physicians to enter private practice in
Alaska.
So, on one hand, the recruitment problem is partly due to
the national shortage. That can be traced back to the training
limitations that have been posed by Congress.
Second, primary care shortage is due partly to the general
physician shortage, but also to a great degree to the problem
of getting doctors to go into primary care. Student debt is
very high, graduating from medical school. And nonprimary care
specialties pay much better than primary care. Students are
responsive, to some degree, to the financial incentives that
they experience as they enter practice. And the effect of that
has been to diminish the interest in primary care by graduating
medical students.
Part of the reason is the debt--part of the reason is that
payments to primary care doctors are lower than payments to
nonprimary care doctors. The testimony earlier today from
people who have been trying to get Medicare patients into
doctors has stated that they don't have much trouble getting
patients into specialists. But they have a terrible time
getting patients into primary care doctors. As a practicing
physician, that's my experience, as well. When I have--as a
primary care doctor--made a diagnosis, and advised the patient
to seek surgery, or a specialty services, I can refer them to
one of my specialty colleagues, and unfailingly get that
patient in to be seen. But, getting the patient in the door of
the primary care office is the big, big problem.
One big problem for Alaska, now, is related to these caps
on residencies. We know what works. Our family medicine
residency program has been a stunning success. We graduate 12
residents per year--we will be graduating 12, we're in the
growth phase now, right now we're graduating 10 per year--but
in another 2 years, we'll be graduating 12 per year. Seventy-
five percent of our graduates practice in Alaska. Fifty-five
percent of them practice in a rural community. If you count
Alaska practice, rural practice, or underserved practice--such
as an Indian health service, or community health center as a
target--95 percent of our graduates practice in one of the
socially desirable target practices. We know how to do it. And
we're doing a good job of it. But, we can't do enough, because
they have caps. Our residency program, in 2 years, we'll be
training 36 residents at a time, but our cap for Federal
payment is at 22. We can't get that cap lifted, and
consequently, the program is running at a very large deficit,
which has been sustained by the private business that sponsors
it, not by the government or the society as a whole.
We also need lots more residencies in Alaska. Family
medicine is not the only specialty we need. We desperately need
residencies in several other specialties which could easily be
started in Alaska. There are plenty of talented doctors to
teach, and plenty of interesting patient cases to learn from. I
think our experience in the family medicine program indicates
we could be very successful in recruiting students from other
schools to come to Alaska to train, but none of these programs
can start in this State, because there's no Federal money to
pay for the resident FTEs.
Most of the other specialties, besides family medicine, can
only be well-trained in a large community, like Anchorage. And,
hospitals in large communities like Anchorage are capped. So,
we need to have relief of these resident FTE caps, in order to
initiate a funding stream that can start training programs for
the other doctors.
I think that as we look into the future of physician
shortages in Alaska, we have to move forward on all fronts--the
Physician Supply Task Force identifies a number of them, and
Dr. Tanner has identified most of them in his comments. We have
to move forward on the front of retention so that we can keep
the doctors we have practicing longer, and happier, we need to
move forward on the front of recruitment, because that's the
short-term way of getting doctors into the State--if we start
recruitment efforts now, we'll be able to get doctors soon.
But, those two efforts are not going to be enough, in the
long run. We have to also start training our own doctors in
much larger numbers, because as the competition for physicians
gets tighter and tighter around the United States, unless we're
training our own, we are always going to be unable to attract
the doctors that we need for this State.
With that, I'll conclude my testimony, and answer your
questions.
Senator Murkowski. Very interesting comments, thank you,
Dr. Johnston.
And next, let's go to Dr. Richard Neubauer. Welcome, and
good morning.
STATEMENT OF RICHARD NEUBAUER, INTERNAL MEDICINE, ANCHORAGE,
ALASKA
Dr. Neubauer. I'm very pleased to give this testimony.
Besides being a general internist here in Anchorage, I also
serve on the Board of Regents for the American College of
Physicians, which is the second-largest physician group in the
country, representing about 120,000 general internists, and
other internists. Second only to the American Medical
Association.
As I listen this morning, it struck me that one thing that
hasn't been said is how much joy there is in being a doctor.
You know, I really love my job, I enjoy being a general
internist, it's a wonderful job--perhaps the best job in
medicine. And it's a real tragedy that we have to be here
talking about the delivery of medical care, or the lack of
access to medical care, in the way we are.
So, just prefacing my remarks, I think that this is very,
very important.
While there are shortages in many specialties in medicine,
it's the shortage of primary care physicians--and,
specifically, general internists--that concerns me the most. In
my view, these areas of medicine are actually near collapse,
both here and nationally. And are critically threatened, unless
there are prompt actions that are taken to reverse these
current trends.
When I graduated from medical school at Yale University in
1976, and then did my internship and residency at the
University of Michigan from 1976 to 1979, the majority of my
classmates wanted to be internists of one sort or another.
Nowadays, that's very different. And, the majority of
medical school graduates want to pursue careers in radiology,
ophthalmology, anesthesia or dermatology, because these areas
of medicine have a kindlier lifestyle, better pay, and are
perceived to have better prestige than what I do right now.
This is especially tragic, I think, because with an increasing
elderly population, the need for general internists who are
skilled in the management of complex medical problems is
increasing, and will continue to increase. And, I think the
testimony that's been given earlier today testifies to that, as
well.
After leaving my residency training and completing a
scholarship obligation with the Indian Health Service in
Wyoming, I came to Alaska in 1981, and have been in practice
here since. When I started my career, I typically cared for 10
or 15 hospitalized patients, took many admissions from the
emergency room, and worked, as well, full-time in my office,
and didn't get home until really late at night.
Over 25 years of practice, I've watched as many of my
colleagues in internal medicine have retired, moved away, or
moved on to other things. With very few exceptions, as these
physicians have left their practices, they have been unable to
find young physicians to take their place, and have simply
closed their doors. And, with that, their patients have been
scattered to the wind, hopefully to find other doctors,
oftentimes not being able to.
And, nowadays, when this happens here in Anchorage--
especially if these patients are covered by Medicare, they
can't find doctors to care for them.
An example of that was, a physician in my office who
retired earlier this year, and we've literally had patients
coming to the front desk in tears, trying to find a physician
to care for them. And we try to help with that, as much as we
can, but it's very limited, given limited manpower
capabilities.
The reason for this is because these patients have very
complex problems, that take a lot of time to take care of
properly. And frankly, the reimbursement for seeing them does
not even cover the overhead of operating an office.
So, as has been said by others, these patients are destined
to use the emergency room for their primary care, and that's
both inexpensive and inefficient. And, oftentimes, these
patients may also neglect their problems until they become more
far advanced, and are thus either harder, or impossible, to
treat.
Right now, unfortunately, there's virtually no financial
incentive for a young primary care physician, in internal
medicine, to come start a private practice in this city. The
remuneration for their efforts would simply not be enough to
justify the work involved, and the overhead of operating an
office.
Starting in the mid-1990s, in Anchorage and elsewhere,
there was an advent of a new area of medicine called
``hospitalice medicine,'' this is internists who only work in
the hospital, and this even further changed the dynamics of
care in Anchorage, and around the country.
Right now, in general, internists who are coming out of
training programs are only interested in getting hospitalice,
and not operating in an office. This is, again, due to the high
overhead of office practice, the burden of unreimbursed work in
an office, and the threat of punitive audits, the long hours,
constant need to be on-call, and low compensation, in general,
for the work in our current reimbursement system.
With the ascendancy of hospitalice practice, this has
certainly benefited functionality of inpatient care, but it
has, unfortunately, come at the expense of promoting a further
decline--critical decline--in the interest of providing long-
term management in ambulatory or outpatient settings.
Right now, in Anchorage, by my count--and I could be off a
little bit on this--there are about 18 general internists
working in office settings, and by comparison, there are
approximately 30 cardiologists in Anchorage. And this is just
not a healthy mix.
A sad truth is that if I--at age 57, not quite 65, but
getting there--were to become incapacitated, or otherwise leave
my practice, it's highly unlikely that anyone would be around
to take my place, and my patients would be without a physician.
Let me just present an example from my own practice of how
coordination of care of a patient by primary care physicians
can result in better outcomes, and lower costs, but is actually
not reimbursed by the current system.
I currently care for a man in his fifties who, tragically,
has had a series of strokes and heart attacks at a very young
age. He suffers with congestive heart failure, but with modern
medical management, has lived with these conditions for a
number of years, whereas in the past, he probably would have
been dead by now. He also has diabetes, hypertension, many
psychological issues that have complicated his care. And I
share his care with a cardiologist, but for quite some time, he
was visiting the emergency room on a regular basis with chest
pain, was often admitted to the hospital at great cost, and
with no particular benefit to his care.
By intervening and allowing him open telephone access to my
nursing staff, to the physician assistant, who I recently hired
to help me, and having him come to my office for frequent
reviews of his medications with my staff, we've been actually
able to avert most of his emergency room visits.
This was done with low-cost office visits, unreimbursed
time in person and on the telephone with him, and the monetary
savings to the system were tremendous. Whereas the monetary
benefit to my office was modest.
What can be done about these problems? I think both here
and in Alaska and nationwide, a further study of the manpower
needs for primary care services is sorely needed. In my view,
the current methods that CMS uses to track access to care are
very blunt tools that, just frankly, don't reflect reality.
It's my view that a robust, primary care presence in our
country will require a restructuring of the payment systems in
a way that reflects the importance of primary care services,
with recognition that much of what we currently do is
unreimbursed.
I think management fees, above and beyond traditional fee-
for-service reimbursement, would be one step, at least, in
recognizing the value of primary care of the patient, and needs
to be strongly considered.
I think new models of care, such as the advanced medical
home concept proposed by the American College of Physicians,
has promised to increase the attractiveness of internal
medicine as a career. This model relies heavily on electronic
medical records to improve the functionality and accountability
of practices, and to improve the delivery of preventive
services, but the implementation of this technology, namely
electronic health records, has been hampered by high cost, and
difficulty of deployment in busy offices.
We do have an HER, Electronic Health Record alliance here,
that has been formed by the APS, the Alaska Physicians and
Surgeons, the Alaska Chapter of the American College of
Physicians, and the State Medical Association to try and
address this, and we're trying to get funding for a pilot
program here to see how we could implement these records
better.
I think medical training programs need to be re-designed to
encourage students to consider careers in internal medicine,
and primary care, but that has not been happening in a
concerted fashion, partly due to entrenched interests, and
perverse incentives. And this certainly needs to change.
As has been said, students are burdened with so much debt
coming out of medical training, that they're pushed into higher
paid specialties by necessity. In an effort to fill positions
that graduates of American medical schools are not interested
in, as a Nation, we've been robbing other countries of their
own talented physicians, but importing foreign graduates, and
this is certainly not a good, long-term global strategy.
In summary, I think we stand at a critical time in the
design of delivery systems within our medical communities.
Certainly, inaction at this time will have very predictable
results. A lopsided supply of physicians in very high paid
specialties, coupled with access to care problems for patients
who want the guidance of a physician to coordinate their
medical care.
There are things we can do to positively shape the future,
but this will require, I think, courage and conviction, and I
certainly applaud your efforts in this regard.
I'll conclude by asking that the HELP committee require a
study and report on ways that the Federal Government can
increase the attractiveness of primary care, including
consideration of programs to eliminate or reduce student debt,
for those who go into primary care, redesigning Federal support
for medical education, to expose medical students to well-
functioning models of community-based primary care, and changes
in Federal reimbursement policies to support the value of
primary care.
Thank you very much.
Senator Murkowski. Thank you, Dr. Neubauer. I appreciate
your testimony.
And, let's move over to the other table here, we have Dr.
Byron Perkins, the President of the Alaska--I was going to say,
it's not the American Osteopathic Association, you're the
Alaska rep for the American Osteopath.
STATEMENT OF BYRON PERKINS, AMERICAN OSTEOPATIC ASSOCIATION,
PRESIDENT OF THE ALASKA OSTEOPATHIC MEDICAL ASSOCIATION,
ANCHORAGE, ALASKA
Dr. Perkins. That's correct. Thank you, Senator Murkowski.
Senator Murkowski. Thank you, and welcome.
Dr. Perkins. I am Byron Perkins, and I am a practicing
osteopathic family physician here in Anchorage, and I am the
President of the Alaska Osteopathic Medical Association, AKOMA.
I've had the privilege of working in Alaska 4 years in
Nome, and 7 years with the Alaskan Native Medical Center, and
now in primary care/private practice in Anchorage.
I'm honored to be here today representing the American
Osteopathic Association, and AKOMA. The AOA represents the
Nation's 59,000 osteopathic physicians, and over 12,000
osteopathic medical students, and we applaud your interest in
this very timely discussion, and important issue.
Much of my testimony will echo the findings of the Alaska
Physician Supply Task Force Committee. We applaud their work,
we were able to participate in testimony on their efforts. Much
of my testimony will echo some of the testimony already
presented.
The AOA recognizes that many communities in the United
States face limited access to physicians, and physician
services. We've heard that today, this is especially true in
rural and frontier communities, and really so in Alaska. And
for more than 130 years, AOA has been dedicated to training and
educating the future physician workforce. We have a tradition
of turning out primary care physicians. More than 65 percent of
our students, physician graduates, practice in primary care,
and that trend has been historical.
In Alaska, there are 115 licensed osteopathic physicians,
77 of those physicians practice in primary care, roughly 69
percent. They practice in diverse communities, from places like
Barrow, and Bethel and Craig and Klowak, Nome, Gotsebu, and
Anchorage/Fairbanks, Juneau.
Over the past 15 years, the osteopathic profession has
enjoyed tremendous growth. We are currently one of the fastest-
growing professions in healthcare. Since 1990, the osteopathic
physician numbers have increased 67 percent, there are
currently about 59,000 osteopathic physicians in the United
States, we are still a minority in physician groups. About 6
percent of all physicians in the United States are osteopathic
physicians.
As our membership grows, the AOA is refocusing our efforts
on our core mission, which is training physicians who are
capable and willing to provide high-quality care to our
Nation's neediest populations, particularly in primary care.
Many experts believe that we are in a shortfall, we in
Alaska have made the same conclusion--we are in a physician
shortage. If we begin to work on that effort now, we can make a
difference, as we begin to educate and train a larger number of
physicians in the immediate near future.
The time it takes to educate and train a physician is
anywhere from 7 to 14 years, and that means anybody starting in
school today won't be available to serve for at least 7 years,
particularly in primary care. And due to the time education
requirements for future physicians, we believe a concerted
effort must be made now, and that is what most of my testimony
is referencing today.
Today, one in five medical students in the United States is
in osteopathic medical school. Currently, there are 23 colleges
of osteopathic medicine, operating on 26 campuses. There are
two additional colleges that will open within the next 2 years,
bringing the total number of colleges to 25, operating on 28
campuses. In 2007, those colleges will graduate approximately
3,000 new physicians, by 2008, approximately 3,500 physicians,
and by the year 2015, we are projecting 5,000 new physicians
per year.
We, in Alaska, are especially proud of the Pacific-
Northwest University of Health Sciences, projected to open in
the year 2008 in Yakima, Washington. This has been a
collaborative effort, and by the five Northwestern States, and
the associations in those States, we believe the opportunity to
participate in this will give us more direct influence on the
number of students, and the type of students that will be
referring and matriculating to this facility. I'm optimistic
that when it begins operating, it will be a direct contributing
factor to Alaska's physician workforce, in the future. And that
recommendation did come forward in the Physician Supply Task
Force recommendations.
Medical schools, and colleges of osteopathic medicine
traditionally place significant emphasis on an applicant's
academic achievement. We agree with this, but we also believe
that medical school should be looking at the whole person, that
is something that is traditionally done in the osteopathic
applications process. Particularly, when a student from Alaska,
or from a rural community, is evaluated--they should meet all
of those academic requirements, but at the same time, there is
something desirable about placing a student from a rural
community into a medical school.
If two students are equally qualified, we would encourage
schools to matriculate students from the rural communities.
Much of the same testimony has come forward.
Additionally, our medical education system must increase
its efforts to promote both primary care specialties, and
experience in rural practice locations. It's already been
testified to by Dr. Johnston and Dr. Neubauer. The role of the
family physician and the internal medicine physician generalist
is less glamorous, less rewarding financially, and yet I would
echo what Dr. Neubauer said, this is the greatest thing in the
world to do. I love my work, I wouldn't trade it for anything,
I am blessed to be an osteopathic physician.
The issues facing our Nation's rural healthcare system are
complex, and there are no easy answers. The AOA recommends five
policy changes that we believe will lead to improved access to
physician services, and increase the availability of U.S.-
trained physicians. And, I would like to list those now.
No. 1, the Congress should consider eliminating the cap on
available, and funded, residency positions in the United
States. Dr. Johnston spoke to this, there are currently,
approximately 96,000 funded residency positions. The number of
funded residency positions has been static since the 1990s,
when the Balanced Budget Act of 1997 put a cap on residency
positions. This severely limits our ability to increase the
residency positions available here, in Alaska--not just Alaska,
all of the Pacific Northwest.
The AOA encourages Congress to either remove or increase
the caps on the number of funded, graduate medical education
training slots, as established by the Budget Act of 1997. This
past week, legislations were introduced in the Senate that
would accomplish this goal. The Resident Physicians Shortage
Reduction Act of 2007, increases the cap adjustments for
teaching hospitals in eligible States, where there is a
demonstrated shortage of resident positions. Alaska is 1 of 24
States that would benefit from this legislation, and AOA
supports this legislation, and urges all Senators to go sponsor
this important bill.
We would, in that vein, support the Physician Shortage
Elimination Act that you referenced in your opening statement.
I think it's the right direction to move.
No. 2, in addition to expanding the training capacity at
existing teaching hospitals, we feel desperately, the need to
create new training hospitals at new hospitals. There is the
known adage that most physicians will end up practicing within
100 miles of where they do their postgraduate training. With
the limited number of postgraduate sites--not only in Alaska,
but in the Pacific Northwest, that limits the number of
recruitment opportunities we have in bringing qualified
physicians to Alaska. And, as previously testified, we are
always recruiting from outside, we can't produce enough at our
current levels to sustain our needs.
Currently, a majority of allopathic and osteopathic
residency training programs exist in or near the major
metropolitan cities. Dr. Tanner talked about the large number
in the State of Texas. And, while those current programs
continue to excel at producing high-quality physicians, they
don't adequately distribute physicians to communities across
the Nation, and particularly to places like Alaska.
A major obstacle often preventing the establishment of new
residency training programs, are the costs associated with
startup. The AOA proposes the creation of a new program that
would assist communities, and rural hospitals, in their efforts
to establish new residency training programs.
Under the Physician Workforce and Graduate Medical
Education Enhancement Act, the Secretary would be directed to
establish an interest-free loan program, whereby hospitals
committed to starting a new allopathic or osteopathic residency
program, would secure startup funding to offset the initial
startup costs. Congress would be asked to allocate adequate
money to establish and fund the program. To be eligible, a
hospital would demonstrate that they do not currently operate a
residency training program, and they must commit to operating a
residency program in one of the five medical specialties of
primary care--family medicine, internal medicine, pediatrics,
OB/GYN, and possibly, general surgery. Hospitals securing a
loan under the program would be obliged to repay the total sum,
without interest, to the Secretary.
I was just at a meeting last weekend in Portland, the
Northwest Osteopathic Conference of States, and there's a small
hospital in eastern Oregon who is attempting to start a rural,
community-based family practice residency program. And they
were there with their CFO, and their hospital administrator,
and two of their physicians, basically trying to find out how
they were going to come up with the funding to make this work.
The desire is there, the need is there. They can't supply their
physician staff resources, and they thought with residency
training, not only could they grow their own, but they could
help offset some of the local physician shortages that already
exists. Startup costs are prohibitive. As Dr. Harold Johnston
said earlier, our residency program has been operating at a
deficit since its inception.
I would say that the Alaska Family Medicine Program has
been very kind to us, as an osteopathic professional. They have
sought our participation from the beginning, and just last
year, hired an osteopathic Physician Director of Medical
Education, and that program is now a dually-certified program,
so osteopathic medical students can do their residency training
at the Family Practice Program and get dual certification from
the AOA. And, we are currently, the only operating osteopathic-
approved training program in the entire Northwest, at
Providence Hospital.
No. 3, Congress should enact legislation that would
establish, in statute, clear and concise guidance on the use of
ambulatory, nonhospital sites in graduate medical education
programs. While the majority of physician training takes place
in the hospital setting, it should not be limited to this
setting. We need to do more to expose medical students--and
resident positions--to different practice settings during their
training years. And the Alaska Family Medicine Residency
Program has done an excellent job of providing that
opportunity.
In 2002, the Centers for Medicare and Medicaid Services
began administratively altering the rules. Began denying the
time that residents spend in nonhospital settings. As a result,
hospitals are being forced to train all residents in the
hospital setting, eliminating the valuable, educational
experiences offered in the non-hospital training sites.
Additionally, some teaching hospitals may be forced to
eliminate programs, as a result of the current CMS policies.
Allowing hospitals to receive payments for the time
resident physicians train in a nonhospital setting is sound
educational policy, and a worthwhile public policy goal that
Congress clearly mandated. Additionally, it would be good for
us in rural communities.
No. 4, Congress should amend the tax code to allow
practicing physicians in rural communities an annual tax credit
equal to the amount of interest paid on their student loans.
Last year, Senate bill 2789 was introduced, directly addressing
tax credits in that regard. I believe you sponsored that
legislation. We supported that as an association, and we would
support that type of legislation in the future.
We believe this proposal is a direct incentive to young
physicians, and would assist in the recruitment and retention
of physicians in rural communities.
Additionally, Congress should revise current scholarship,
and loan payment programs, to allow physicians to fill their
commitment on a part-time basis, as with the National Health
Service Corps.
No. 5, Congress should reform the Medicare Physician
Payment Formula, by eliminating the sustainable growth rate,
and replacing it with a more equitable, and predictable,
payment structure. This testimony has already been brought
forth. Additionally, Congress should make permanent provisions
that establish a floor of 1.0 for their work, geographic
practice cost indices, and provide a 5 percent add-on for
services provided by physicians, in recognized Medicare-
scarcity States, which Alaska certainly is.
Again, we thank you for focusing your attention on this
important issue. The AOA, and the AKOMA and our members stand
ready to assist you and the committee, as you develop policies
aiming at improving access to physicians and physician
services. I look forward to your questions.
[The prepared statement of Dr. Perkins follows:]
Prepared Statement of Byron Perkins, DO
Senator Murkowski and distinguished members of the committee, my
name is Byron Perkins. I am a practicing osteopathic family physician
in Anchorage and currently serve as the President of the Alaska
Osteopathic Medical Association. I am honored to be here today
representing the American Osteopathic Association (AOA). The AOA, which
represents the Nation's 59,000 osteopathic physicians and over 12,000
osteopathic medical students, applauds the committee's interest in
examining this very important issue. Access to physicians and other
healthcare services for people residing in rural and other underserved
communities is a serious problem. The AOA believes that access to
physician services in rural and other underserved communities can be
improved by increasing training and workforce opportunities along with
developing new programs that aid in the recruitment and placement of
osteopathic and allopathic physicians.
We recognize that many communities in the United States face
limited access to physicians and physician services. This is especially
true in rural and frontier communities. We applaud the efforts made by
State governments, the Federal Government, Members of Congress, and
rural communities to increase physician access for their citizens.
However, like you, we believe much more should be done.
For more than 130 years the AOA and the osteopathic profession has
been dedicated to educating and training the future physician
workforce. Consistent with our mission, we remain committed to
producing primary care physicians who will practice in rural and other
underserved communities. This mission has been a tenet of the
profession since it's founding in the late 1800's. Today, more than 65
percent of all osteopathic physicians practice in a primary care
specialty (family medicine, internal medicine, pediatrics, and
obstetrics/gynecology). In Alaska, there are 112 osteopathic
physicians. Seventy-two of these osteopathic physicians practice in a
primary care specialty, 59 are family physicians [Maps 4 and 5].
Nationwide, more than 100 million patient office visits are made to
osteopathic physicians each year.
Over the past 15 years the osteopathic profession has enjoyed
tremendous growth. We are one of the fastest growing professions in
healthcare. Since 1990 the number of osteopathic physicians has
increased 67 percent. Currently, there are 59,000 osteopathic
physicians in the United States. The number of osteopathic physicians
in the United States is projected to exceed 90,000 by 2015. Osteopathic
physicians represent 6 percent of the current U.S. physician workforce
and over 8 percent of all military physicians.
Throughout our history, the osteopathic profession has placed an
emphasis on primary care and rural service. Our commitment to these
goals is reflected in our membership and in the mission statements of
the Nation's colleges of osteopathic medicine. Our emphasis on primary
care and rural practice is reflected by the fact that currently 22
percent of osteopathic physicians practice in a designated medically
underserved area (MUA) (Map 1). As our membership grows, the AOA is
refocusing its efforts on our core mission--training physicians who are
capable and willing to provide high quality care to our Nation's
neediest populations.
The issues facing our Nation's rural healthcare system are complex.
We do not suggest that there are easy answers, but we do believe that
change in some policies would increase our ability to meet these needs.
The following pages outline several recommendations. These
recommendations would improve the ability of the AOA and our allopathic
colleagues to meet the needs of rural and other underserved
communities. We believe that the implementation of these
recommendations will allow the U.S. medical education system to meet
its responsibilities of training physicians who will provide quality
healthcare to all populations regardless of their geographic location.
PHYSICIAN WORKFORCE
Many experts now believe that the United States will face a
shortfall in its physician supply over the next 20 years. While
academic and policy experts debate the needs and expectations of the
future physician workforce, the AOA recognizes that we must begin to
educate and train a larger cadre of physicians, now.
The time it takes to educate and train a physician is, at minimum,
7 years. This means that a student accepted in the matriculating class
of 2007 will not enter the physician workforce until at least 2014. Due
to the time required to educate and train future physicians, we believe
a concentrated effort must be focused on increasing the Nation's
physician education and post-graduate training capacity over the next 5
years. If handled appropriately, the country could increase the
physician workforce dramatically by 2020.
Reliance upon the J-1 Visa program is neither the most effective
nor the most desirable way to increase physician supply in rural
communities, although we recognize that the program can provide short-
term relief. The J-1 program is not capable of meeting the physician
workforce needs of our Nation and should not be promoted for this
purpose. Yes, a few States and communities have physician services as a
result of the J-1 program. However, thousands of rural communities
remain without physician services. The AOA supports increasing our
capacity by adopting policies that encourage larger numbers of U.S.-
educated and trained physicians to practice in rural and underserved
areas. An increase in U.S.-educated and trained physicians, if properly
selected and trained, will lead to a more predictable and reliable
physician workforce and is more likely to produce larger numbers of
physicians who will practice in rural communities.
Today, one in five medical students in the United States is
enrolled in a college of osteopathic medicine. Fifty percent of the
students enrolled in the Nation's colleges of osteopathic medicine are
women. Currently, there are 23 colleges of osteopathic medicine
operating on 26 campuses (See Map 2). There are two additional colleges
that will open within the next 2 years, bringing the total number of
colleges to 25 that are operating on 28 campuses. In 2007, these
colleges will graduate approximately 3,000 new osteopathic physicians.
In 2008, the number of graduates will increase to 3,500. By 2013 the
number of osteopathic physicians graduating from colleges of
osteopathic medicine is projected to reach 4,500. Assuming a
predictable growth pattern, the osteopathic profession should produce
approximately 5,000 new physicians per year beginning in 2015.
The current colleges of osteopathic medicine, and those set to open
in the future, are located in regions that historically have had
limited access to physician services. Currently, there are three
colleges of osteopathic medicine in Appalachian region, one in Las
Vegas and one developing in Denver--two of the Nation's fastest growing
communities, three colleges in the States of Missouri and Oklahoma, and
Yakima, Washington--which aims to meet the needs of several Northwest
States including Alaska. The location of current and future colleges of
osteopathic medicine reflects the osteopathic profession's commitment
to rural and underserved communities.
In Alaska, we are especially proud of the Pacific Northwest
University of Health Sciences (PNUHS) in Yakima, Washington, which will
begin classes in 2008. Along with my colleagues in Alaska, I am
optimistic that PNUHS will begin contributing to Alaska's physician
workforce in the near future. The AOA urges the Alaska legislature to
develop new programs that encourage a significant number of Alaska
residents to pursue their medical education at the PNUHS College of
Osteopathic Medicine.
INTERNATIONAL MEDICAL GRADUATES
The U.S. healthcare system is widely recognized as the most
advanced in the world. The rapid development of new diagnoses and
treatments outpaces those in other countries. We are the world's leader
in medicine and medical technology. In this role, we should share our
expertise with the world. For this reason, the AOA supports the
continued acceptance of international medical graduates (IMGs) into the
U.S.-graduate medical education system. By training international
physicians, we can improve the healthcare delivery systems around the
world by improving the quality of the physicians. However, this
transfer of knowledge and skills cannot take place if international
physicians do not return to their home countries.
The United States should not be an importer of physicians. The
majority of international physicians should come to the United States
to train and then return home. The ``brain drain'' in many countries is
well documented. Many countries lose their best and brightest young
physicians to the United States and other English-speaking countries.
International physicians should come here to train and should not be
encouraged to stay upon completion of their training. In fact, we
should require that they return to their home countries and practice
medicine for an extended period of time before they are eligible to
petition for a visa, J-1 or otherwise.
In 2006, almost 9,000 IMGs participated in the National Residency
Matching Program (NRMP). Of these applicants, approximately 6,500 were
not U.S. citizens and 2,500 were U.S. citizens who attended a foreign
medical school. Almost 50 percent of all IMGs match to first year
residency positions. In 2006, the total number of IMGs who matched to
first year positions increased to 4,382.
Of the 6,500 IMG participants who were not U.S. citizens, 3,151
(48.9 percent) obtained first year positions. 2006 was the fifth
consecutive year that the number of non-U.S. citizen IMGs matching to
first year positions increased. Of the 2,500 U.S. citizen IMG
participants, 1,231 (50.6 percent) were matched to first year
positions. 2006 was the third consecutive year that the number of U.S.
citizen IMGs matching to first year positions increased. The total
number of IMGs filling first year residency positions will be much
higher than the approximate 4,400 who secured positions through the
NRMP. Many IMGs are able to secure residency training positions outside
the match.
RECRUITMENT AND PLACEMENT
Medical schools and colleges of osteopathic medicine traditionally
place significant emphasis on an applicant's academic achievement--
grade point average, undergraduate degree program, and scores on the
Medical College Admission Test (MCAT). While we would never suggest
that the academic standards required for admittance be lowered, we do
recommend that the Nation's medical education institutions begin
evaluating ``other'' factors. An evaluation of the student's life,
including an evaluation of where the student was raised, attended high
school, and location of family members, provides an indication of where
a future physician may practice. For example, an applicant from
Manhattan, New York is less likely to practice in a rural community
than an applicant from Manhattan, Kansas. If the two applicants are
equally qualified, we should encourage our schools to matriculate the
student from Manhattan, Kansas, an individual more likely to return to
rural Kansas once education and training is completed.
Our medical education system must increase its efforts to promote
both primary care specialties and experience in rural practice
locations. Over the years, the role of the rural family physician
became less glamorous than that of the urban subspecialist. Far too
many medical school students want to be an ``ologist'' instead of a
general surgeon, family physician, general internist, or pediatrician.
Our Nation's healthcare system needs specialists and subspecialists,
but we need far more primary care physicians. Our medical education
system must place greater emphasis on educating and training primary
care physicians and general surgeons. These physicians are more likely
to practice in a rural or small community hospital and are far more
likely to practice in rural America.
The AOA believes that programs funded and operated under Title VII
of the Public Health Service Act are essential to achieving the goals
outlined above. Over the past 5 years, title VII programs have seen a
dramatic decrease in both support and funding. We urge Congress to
reverse this trend and place greater emphasis on these important
programs.
INCREASE TRAINING CAPACITY
Currently, there are approximately 96,000 funded residency
positions in the United States. The number of funded residency
positions has been static since the late 1990's when Congress, as part
of the Balanced Budget Act of 1997, placed a limit or ``caps'' on the
number of funded residency slots any existing teaching program may
have.
The residency caps were established at a time when the general
consensus was that the country had an adequate supply of physicians. We
now recognize this is not correct. The residency caps established by
the BBA limit the ability of teaching hospitals to increase training
programs, thus preventing responsible growth capable of meeting our
future physician workforce needs. The AOA encourages Congress to either
remove or increase the caps on the number of funded graduate medical
education training ``slots'' as established by the Balanced Budget Act
of 1997.
This past week, Senators Harry Reid and Bill Nelson introduced the
``Resident Physician Shortage Reduction Act of 2007.'' This legislation
authorizes the Secretary of the Department of Health and Human Services
(HHS) to increase the number of residency cap positions for which
Medicare payments will be made if certain criteria are met. The
increases or cap adjustments target teaching hospitals in eligible
States where there is a demonstrated shortage of resident physicians.
States would be considered to have a shortage of resident physicians if
its ratio of allopathic and osteopathic physicians training in ACGME or
AOA approved residency and/or fellowship programs is below the national
median number per 100,000 population. According to current statistics,
the national median number of resident physicians per 100,000
population is 25. Teaching hospitals in 24 States would be allowed to
increase their FTE cap under the proposed formula.
The AOA supports this legislation and urges all Senators to
cosponsor this important bill. Furthermore, we call upon the Senate to
approve this legislation this year.
IMPROVE RURAL TRAINING PROGRAMS
There is an old saying in medical education circles that physicians
will practice within 100 miles of where they train. While the validity
of this saying either in a world that is limited to the United States'
borders or alternatively in an era of globalization is unproven, its
message rings true. Physicians are more likely to practice in settings
where they have the most experience. While a majority of physician
training takes place in the hospital setting, it should not be limited
to this setting. We need to do more to expose medical students and
resident physicians to different practice settings during their
training years.
A valuable component of graduate medical education is the
experience of training at nonhospital ambulatory sites. These sites
include physician offices, nursing homes, and community health centers.
Ambulatory training sites provide an important educational experience
because of the broad range of patients and conditions treated and by
ensuring that residents are exposed to practice settings similar to
those in which they ultimately may practice. This type of training is
particularly important for primary care residency programs since a
majority of these physicians will practice in nonhospital ambulatory
clinics upon completion of their training. This training also is
essential to improving access to care in rural communities.
Congress has long recognized that a greater focus should be placed
on training physicians in rural and other underserved communities. In
the 1990s, Congress began to fear that the current graduate medical
education payment formula discouraged the training of resident
physicians in ambulatory settings. This opinion was based upon the fact
that the payment formula only accounted for the resident training time
in a hospital setting.
Through the Balanced Budget Act of 1997, Congress altered the
payment formula, removing the disincentives that existed for training
in nonhospital settings. We accomplished this goal by allowing
hospitals to count the training time of residents in nonhospital
settings for the purpose of including such time in their Medicare cost
reports for both indirect medical education (IME) and direct graduate
medical education (DGME) payments.
This change in the payment formula was designed to increase the
amount of training a resident physician received in nonhospital
settings, enhance access to care for patients in rural and other
underserved communities, provide an additional education experience for
residents who are considering practicing in rural communities, and
provide a recruitment mechanism for rural and underserved communities
in need of physicians.
The program appeared to be working as intended. However, in 2002
the Centers for Medicare and Medicaid Services (CMS) began
administratively altering the rules and regulations in respect to this
issue. As a result, CMS intermediaries began denying the time residents
spent in nonhospital settings. In many cases, hospitals were forced to
repay thousands of dollars as a result of this administrative change in
regulations.
Many Members of Congress urged CMS to work with interested parties
to resolve this issue by developing new regulations that clarify the
appropriate use of nonhospital settings. Unfortunately, these
conversations have not produced policies that meet the original intent
of Congress as established in 1997. As a result, hospitals are being
forced to train all residents in the hospital setting, eliminating the
valuable educational experiences offered in nonhospital training sites.
Additionally, some teaching hospitals may be forced to eliminate
residency programs entirely as a result of current CMS policies.
Allowing hospitals to receive payments for the time resident
physicians train in a nonhospital setting is sound educational policy
and a worthwhile public policy goal that Congress clearly mandated in
1997. Additionally, it is good for rural communities.
DEVELOPMENT OF NEW TEACHING HOSPITALS
In addition to expanding the training capacity at existing teaching
hospitals, we desperately need to create new training programs at new
hospitals. Currently, a majority of allopathic and osteopathic
residency training programs exist in or near the major metropolitan
cities on the east coast, west coast, and Great Lakes region. While the
current programs continue to excel at producing high quality
physicians, they do not adequately distribute physicians to communities
across the Nation.
As we outlined previously, it is well documented that physicians
establish practices near the location of their training program.
Assuming this to be true, the Nation desperately needs new training
programs in many States, especially those in the Midwest, Southwest,
Northwest, and Rocky Mountain regions. By providing greater number of
residency training programs in these areas, the physician workforce
shortage could be reduced greatly for many States.
A major obstacle often preventing the establishment of new
residency training programs are the costs associated with the creation
of such programs. Under current law, a hospital starting a new
residency program is not eligible for direct graduate medical education
(DGME) or indirection medical education (IME) funding until they have
filed their initial cost-report with the Centers for Medicare and
Medicaid Services (CMS). Initial cost reports are filed following the
completion of the first year the residency program is in operation. The
first payments from CMS to hospitals with new residency programs
typically occurs around 16 to 18 months after the program is started.
This financing arrangement presents challenges for hospitals that
operate on narrow margins, especially community hospitals that lack
adequate reserve funds to offset the financial commitments associated
with starting a new residency program.
The AOA is working with Members of Congress to develop a new
program that would assist community and rural hospitals in their
efforts to establish new residency training programs. Under the
``Physician Workforce and Graduate Medical Education Enhancement Act,''
the Secretary would be directed to establish an interest-free loan
program whereby hospitals committed to starting new osteopathic or
allopathic residency training programs could secure startup funding to
offset the initial costs of starting such programs. Congress would be
asked to allocate adequate money to establish and fund the program.
To be eligible, a hospital must demonstrate that they currently do
not operate a residency training program, have not operated a residency
training program in the past, and that they have secured preliminary
accreditation by the American Council on Graduate Medical Education
(ACGME) and/or the American Osteopathic Association (AOA).
Additionally, the petitioning hospital must commit to operating an
allopathic or osteopathic residency program in one of five medical
specialties or a combination of these specialties: family medicine,
internal medicine, emergency medicine, obstetrics/gynecology, or
general surgery.
A hospital may request funding to assist in the development of a
residency training program. We suggest that the financing be limited to
no more than $1 million. Funding could be used to offset the costs of
residency salaries and benefits, faculty salaries, and other costs
directly attributable to the residency program.
Hospitals securing a loan under the program would be obligated to
repay the total sum, without interest, to the Secretary. Hospitals
would have two repayment options--repayment in full or repayment
through a financing mechanism. The AOA looks forward to working with
Members of the U.S. Senate on this concept and is optimistic that this
type of a program would enhance the disbursement of physicians to
communities in need.
EXPAND PROGRAMS THAT PROVIDE INCENTIVES FOR RURAL PRACTICE
There are numerous existing programs that provide scholarships and
loan repayment for physicians who choose to practice in rural
communities. These programs include the National Health Service Corps,
Public Health Service, Indian Health Service, and many programs
operated by State governments. The AOA supports these programs and
encourages Congress to continue funding them at levels that facilitate
greater numbers of physicians practicing in rural and other underserved
communities.
Additionally, we believe that some consideration should be given to
allow physicians to participate in the programs on a part-time basis.
There are numerous communities that need physician services, but they
may not need them full time. We believe that modifications should be
made to Federal loan repayment and scholarship programs that allow
participants to repay on a part-time basis in exchange for a longer
term of service. For example, if a physician participates in the
National Health Service Corps and agrees to a 3-year commitment in a
rural community--why not allow the physician the option of committing
to 4 or 5 year's service on a part-time basis. We believe this would
encourage more physicians to participate in these valuable programs
without jeopardizing the underlying mission.
The AOA also proposes a change in the tax code that would provide
physicians practicing in designated rural communities with a tax credit
equal to the amount of interest paid on their student loans for any
given year that they practice in such a community, or until their loans
are paid in full. Under current law, individuals may deduct up to
$2,500 in interest paid on student loans from their Federal income
taxes. However, the income thresholds associated with this provision
often prevent physicians from qualifying. Our proposal would provide a
direct link between practice location and the tax credit. A physician
practicing in rural Wyoming who pays $8,000 in interest on her student
loans in year one would get an $8,000 tax credit for that year. The
program would continue until the physicians had retired her student
loan debt or when she departed the rural community. We believe that
this proposal provides a direct incentive to young physicians and would
assist in the recruitment and retention of physicians in rural
communities.
IMPROVE THE ECONOMICS OF MEDICINE
The current practice environment physicians face is challenging.
Over the past decade escalating professional liability insurance
premiums, decreasing reimbursements, and expanded regulations have made
the practice of medicine more frustrating for all physicians. These
issues are compounded in rural communities where physicians are often
in solo practice or small group practices, unable to benefit from
economies of scale that larger group practices in urban areas enjoy.
According to a 2004 Health Affairs study, more than half of all
practicing physicians are in practices of three or fewer physicians.
Three-quarters are in practices of eight or fewer. They face the same
economic barriers as every other small business in America. Costs
associated with staff salaries; health and other benefits, basic
medical supplies, and technology, all essential components of any
business, continue to rise at a rate that far outpaces reimbursements.
When facing deep reductions in reimbursements at the same time that
their operational costs are increasing, it is safe to project that most
businesses will not be able to continue operation. While most
businesses increase, or have the ability to increase, their prices to
make up the differential between costs and reimbursements, physicians
participating in Medicare cannot.
Physician Payment--Since 2001, Medicare physician payment
rates have fallen greater than 20 percent below the Government's
measure of inflation in medical practice costs. In 2002, physicians'
payments under Medicare were cut 5.4 percent.
If the projected cuts are implemented, the average
physician payment rate will be less in 2007 than it was in 2001.
Additionally, two provisions included in the Medicare Modernization Act
(MMA), which provide increased reimbursements for physicians in rural
communities, will expire over the next 2 years.
In 2002, physician payments were cut by 5.4 percent.
Congress acted to avert payment cuts in 2003, 2004, 2005, 2006, and
2007 replacing projected cuts of approximately 5 percent per year with
increases of 1.6 percent in 2003, 1.5 percent in 2004 and 2005, and 0
percent in 2006 and 2007. Even with these increases, physician payments
fell further behind medical practice costs. Practice costs from 2002
through 2006 were about two times the amount of payment increases. The
long-term projections are even more startling. Under the current
formula, physicians face cuts of greater than 30 percent over the next
8 years.
Since its inception in 1965, a central tenet of the
Medicare program is the physician-patient relationship. Medicare
beneficiaries rely upon physicians for access to all other aspects of
the Medicare program. This relationship has become compromised by
dramatic reductions in reimbursements, increased regulatory burdens,
and escalating practice costs. These projected cuts come at a time when
the number of Medicare beneficiaries is projected to grow from the
current 43 million to more than 71 million. Additionally, since many
healthcare programs, such as TRICARE, Medicaid, and private insurers
link their payments to Medicare rates, cuts in other systems will
compound the impact of the projected Medicare cuts. Medicare cuts
actually trigger cuts in other programs.
Additional cuts in Medicare physician payments threaten
Medicare beneficiaries' ability to access to physician services. These
access problems are compounded in rural communities where the loss of a
single physician can equate to no access for beneficiaries in that
community. These problems will only increase if additional cuts are
implemented.
Furthermore, reduced payments hamper the ability of
physicians to purchase and implement new technologies in their
practices. According to a 2005 study published in Health Affairs, the
average costs of implementing electronic health records was $44,000 per
full-time equivalent provider, with ongoing costs of $8,500 per
provider per year for maintenance of the system. This is not an
insignificant investment. When facing deep reductions in
reimbursements, it is safe to project that physicians will be
prohibited financially from adopting and implementing new technologies.
Physician payments should reflect increases in practice
costs. Now is the time to establish a stable, predictable, and accurate
physician payment formula that reflects the cost of providing care.
Congress must act to reform the Medicare physician payment
formula. Continued use of the flawed SGR formula will have a negative
impact upon patient access to care. Additionally, Congress should act
to extend expiring provisions that provide incentives to physicians in
rural communities. The Medicare Modernization Act (MMA) altered the
Medicare physician payment formula by establishing a 1.0 floor for the
work geographic practice cost indices (GPCI) under the Medicare
physician fee schedule and created a 5 percent add-on payment for
physicians practicing in recognized Medicare physician scarcity areas.
The MMA reversed years of inequities in payments between rural
physicians and those in larger urban communities. Congress extended the
1.0 floor for the work GPCI as part of the ``Tax Relief and Health Care
Act of 2006'' (H.R. 6111). However, both the GPCI and Medicare scarcity
provisions expire on December 31, 2007 unless Congress acts. We believe
that these are essential and positive Medicare payment policies that
should be extended, if not made permanent. Both provisions will enhance
beneficiary access and improve the quality of care available.
Medical Liability Reform--As you know, the Nation's
medical liability system is broken. In recent years physicians across
the Nation have faced escalating professional liability insurance
premiums. According to the National Association of Insurance
Commissioners (NAIC), between 1975 and 2002 medical liability premiums
for physicians increased, on average, 750 percent. These premium
increases are related directly to an explosion in medical liability
lawsuits filed against physicians and hospitals and the rapid increase
in awards. The Government Accountability Office (GAO) confirms this. In
a 2003 report, the GAO stated that losses on medical liability claims
are the primary driver of increases in medical liability insurance
premiums.
As a result of a broken medical liability system patients
face reduced access to healthcare, the overall costs of healthcare
increases, and the future supply of physicians is threatened. Many
physicians no longer provide services that are deemed high-risk, such
as delivering babies, covering emergency departments, or performing
certain surgical procedures. This crisis also impacts primary care
physicians, especially those in rural areas who are often the only
physician practicing in a community. As a result, patients have seen a
decrease in the availability of physician services. Additionally, the
medical liability crisis has a significant impact upon the career
choices of future physicians. In a recent poll conducted by the AOA, 82
percent of osteopathic medical students stated that the cost and
availability of medical liability insurance would influence their
future specialty choices, while 86 percent stated that it would
influence their decision on where to establish a practice once their
training was complete. This trend in career choices is disturbing and
will have a long-term impact upon the healthcare delivery system in the
years ahead.
SUMMARY
Again, the AOA appreciates the opportunity to share our views on
this important issue. We remain committed to working with Congress to
enact legislation that will ensure access to quality physician services
for all Americans, regardless of where they reside. In closing we would
like to highlight five recommendations made in our testimony that we
believe will lead to improved access to physician services, increase
the availability of U.S.-trained physicians, improve the quality of
training for future physicians, and improve the recruitment and
retention of physicians in rural communities.
1. Congress should consider eliminating the cap on available and
funded residency positions in the United States. This cap hinders the
ability of osteopathic and allopathic medical schools to educate and
train larger numbers of physicians. To meet the healthcare needs of our
growing population we must have the capacity and financing to train a
larger number of physicians. The AOA supports the ``Resident Physician
Shortage Reduction Act of 2007'' and urges the Senate to approve this
legislation in 2007.
2. Congress should establish and fund a new interest-free loan
program to assist in the creation of new residency training programs at
hospitals that have not operated teaching programs previously. By
expanding opportunities to new hospitals, Congress can facilitate the
training of physicians in new geographic regions that currently have
limited access to physicians.
3. Congress should enact legislation that would establish, in
statute, clear and concise guidance on the use of ambulatory
nonhospital sites in graduate medical education programs. If enacted,
it will preserve the quality education of resident physicians
originally envisioned by Congress in 1997.
4. Congress should amend the tax code to allow physicians
practicing in rural communities an annual tax credit equal to the
amount of interest paid on their student loans. We believe that this
proposal provides a direct incentive to young physicians and would
assist in the recruitment and retention of physicians in rural
communities. Additionally, Congress should revise current scholarship
and loan repayment programs to allow physicians to fulfill their
commitment on a part-time basis.
5. Congress should reform the Medicare physician payment formula by
eliminating the sustainable growth rate and replacing it with a more
equitable and predictable payment structure. Additionally, Congress
should make permanent provisions that establish a floor of 1.0 for the
work of GPCI and provide a 5 percent add-on for services provided by
physicians in recognized Medicare scarcity areas.
Senator Murkowski. Thank you, Doctor.
Next, let's go to Dr. Coombs, University of Washington
School of Medicine. Tell us a little bit about WWAMI this
morning.
STATEMENT OF JOHN COOMBS, ASSOCIATE VICE-PRESIDENT FOR MEDICAL
AFFAIRS, ASSOCIATE DEAN FOR REGIONAL AFFAIRS, RURAL HEALTH AND
GRADUATE MEDICAL EDUCATION, UNIVERSITY OF WASHINGTON, SEATTLE,
WASHINGTON
Dr. Coombs. Thank you, Senator Murkowski. And I want to
also express my appreciation on the part of the HELP
Committee--Health, Education, Labor, and Pensions--for inviting
testimony today from the WWAMI program. I want to try to
summarize some of my written comments that I have brought
forward, in the interest of also having questions that you
might bring forward, and to address beyond what we have said
today.
What is really remarkable to me is that when I began at the
WWAMI Program at its inception, actually, 35 years ago, I was a
practicing rural family physician in a very small community in
north-central Washington, a National Health Service Corps
volunteer, and someone who now has built upon that experience
to continue to pledge our efforts, in terms of the University
of Washington School of Medicine and WWAMI, into meeting future
needs for physicians practicing in those areas.
In your opening comments, you mentioned that the size of
the rural population in the United States is roughly about 21
percent of our total population. In the WWAMI area, that
number, actually, is 35 percent, and in Alaska, it's greater
than 50 percent of the population of the State of Alaska, who
live in rural communities, and in Wyoming, Montana and Idaho,
the number is even greater than 50 percent. So, this is a
significant issue, in terms of the WWAMI Program.
The thing I want to emphasize today, is the success of the
WWAMI Program has been, really, predicated by partnership. The
partnership that has existed between the Alaska State
legislature, and the other legislatures across the five States
among the institutions of higher education, such as the
University of Alaska, Anchorage. Also, among practicing
physicians, such as the Alaska State Medical Association and
the volunteerism that goes forward to teach our students and
residents. Also, among the hospitals within the State, who have
put forward resource and energy to allow for the training of
future physicians within those areas, as well as direct support
for programs such as residency training. And also, among the
partnership that exists between WWAMI and the Federal
Government. And that really is the issue that I'd like to
specifically center on today.
Over the course of the past decade, the number of
physicians entering family medicine from the WWAMI Program has
gone from 36 percent of the graduating class, to this year, an
anticipated 12 percent. Similarly, during that time, primary
care has dropped from over 60 percent, to now just greater than
38 percent. As a consequence, as you can see, the shortage that
we're facing, we're not directing physicians in the way that we
intend to, which is toward careers in primary healthcare.
And why is this? Many of these issues have been mentioned
today, but the mounting student debt, the shortage of really a
critical unit in terms of being able to have adequate
physicians within isolated communities, as well as large, urban
communities. In addition to the absence of adequate applicants
to residency programs who have done their training in the
United States, which now, across the Nation, is less than 49
percent of U.S. medical school graduates now fill our Family
Practice Residency Programs, as an example.
This is a significant issue. What can we do about this, in
terms of the restoration of this in terms of the Federal
partnership that we have within WWAMI? First of all, we need to
restore and enlarge support for student debt relief. I think
the National Health Service Corps--and particularly, I was
pleased in your opening comments to hear you say, ``the
relationship between academic training programs, and community
health centers''--there needs to be a stronger community/
academic partnership which is developed that will allow for the
training of family physicians, primary care internists, general
pediatricians, general surgeons, and psychiatrists within
settings such as that, to meet future needs, and access to care
for people in isolated areas.
The second thing is, that we need to fix the overall
healthcare delivery system to create greater incentive for
primary care physicians, and this has been mentioned by my
colleagues who have testified before.
At the present time, the financial incentive, or
disincentive, to enter into primary care is very remarkable, in
terms of the onus that this places upon medical students who
are now facing, on our situation, $94,000 debt from people who
graduate from the WWAMI Program who are from Alaska, in
comparison to $125,000 that was mentioned earlier from public
medical schools, and between $150,000 and $200,000 from private
medical schools.
We need to maintain and to incent training for primary
care, and the essential specialties. And to do this, I want to
make 8 points from the Federal perspective, that would help.
First, is to eliminate caps for these primary care
specialties in areas such as the critical things such as
general surgery, and psychiatry. To enable hospitals and people
who support graduate medical education, to build additional
capacity in that respect.
Second, not to allow for further reduction, and to restore
reductions in Medicare and Medicaid that support graduate
medical education, and medical education in general. This also
includes the appropriated funds for pediatric training, and
graduate medical education, which are currently scheduled for
substantial reduction in this year's considerations.
We need to increase the training for opportunities for
residents in the critical needs specialties, and to build upon
things--even in States like Alaska that do not, perhaps, have
their own programs--we need to be innovative in terms of
placing general surgeons, psychiatrists and internists, such as
we have done in the State of Idaho, for instance, through the
WWAMI Program, to bring them to Alaska as well, and to create
innovative programs that will allow us to do that.
We need to restore title VII funding. Currently that is
pegged with the budgetary considerations to basically be
eliminated this year. And this is something which supports our
residency training, our medical student training, our faculty
development, and a number of other areas which are essential,
as far as the success that WWAMI has created over the course of
the past 35 years.
We need to restore the Health Careers Opportunities
Program, HCOP, so that we can take people who come from
underserved communities such as many of the areas in Alaska, to
bring them to medical school, and to bring them into the health
professions. Currently, in Dr. Johnston's program, there are
two people who have participated in the HCOP Program within
WWAMI who are now residents here. But, that program now has
been eliminated. And so, what are we going to do to reach out
to Alaska's communities, to bring people to healthcare careers
in the future, and to just tell them, simply, ``You can do
it.'' And we're here to help them make that happen.
We need to expand funding for the National Health Service
Corps Scholarship Program, which has been very effective. Dr.
Johnston was also a National Health Service Corps volunteer,
and someone who was brought into medicine through that
mechanism. We need to restore funding for the Bureau of Health
Professions, for the Center for Health Workforce Studies across
the country, such that we can evaluate innovative programs and
estimate the needs. That has now been eliminated over the
course of the past 2 years, through the Bureau of Healthcare
Professions.
And, finally, I want to come back to creating this academic
community health center alliance, where we can begin to have
training programs within these CHCs, to be able to bring
trainees to them, and to actually create the success that I
think can be done in that respect.
This is a long list of things, in terms of the Federal
support. But, it is something that I want to return to the fact
that, partnership has been the thing that has led to the
success of WWAMI.
I've provided in my written testimony, information which is
available to you, and other members of the HELP Committee,
including our continuum of medical education, which really
brings out all of the programs which rely upon Federal support
in terms of their continuance. Much of which, now, has been
eliminated.
Finally, now, I just want to briefly touch upon the success
that WWAMI has created. The Program has been successful, not
only because of this partnership, but it's bringing incredibly
capable students from States such as Alaska into the
opportunity to achieve publicly-supported medical education.
We're joined today, if they could stand, by the students who
are currently in the pipeline of WWAMI from Alaska, who are
going to be the future of healthcare delivery in Alaska.
[Applause.]
For every student who just stood, there are six other
qualified students who could be here today, if there was just
the resources to be able to bring them into the pipeline. And
also, to be able to enlarge upon the graduate medical education
programs that exist within the State.
The student return rate for WWAMI is 61 percent who return
to WWAMI to practice medicine. This is a remarkable thing,
especially when you look at the State of Alaska, where 47
percent of those who start in the State of Alaska return, but
84 percent of the positions, the 10 positions per year, are
filled by students who have graduated from WWAMI, who return to
the State to practice.
The second thing is that WWAMI is very cost-effective. Our
tuition, the $15,900 per year, is $4,000 below the National
average for public medical schools. And so, not only is that
something that is cost-effective, but also, the total cost of
educating students of--what seems like an enormous amount of
money--of $57,000, is far below the average of $60,000 to
$120,000 nationally, to educate medical students.
We've been fortunate to be named the number one primary
care medical school in the United States by U.S. News & World
Report, for the last 13 years. No. 1 in family medicine, number
one in rural health. But, I think the critical issue is, we
need to have the support of all of the partners to be able to
continue to do this.
We've been fortunate that through the program, such as Dr.
Johnston's Family Practice Residency Program, 77 percent of the
350 residents who are part of that Program, have returned to
practice in WWAMI. And, among those, 30 percent in communities
of less than 25,000, 15 percent in communities of less than
5,000. So, we need to continue to be able to innovate.
So, I'd like to just conclude by saying, again, thank you
very much to the HELP Committee for allowing me to come and
testify, and share with you some of the success of WWAMI, but
also, to encourage us to return to the partnership that has
made us successful, and has benefited the people of, not only
the State of Alaska, but across the WWAMI region, and the
Nation, in terms of the preparation of future family
physicians, and physicians in other specialties.
Thank you.
[The prepared statement of Dr. Coombs follows:]
Prepared Statement of John B. Coombs, M.D.
My name is John Coombs and I am a physician on the faculty at the
University of Washington School of Medicine. As a family physician and
pediatrician and as a member of the Dean's office, my responsibilities
include the oversight of the WWAMI Program.
Today it is my privilege to testify before you from my leadership
position in the WWAMI Program. As I will outline below, WWAMI
(Washington, Wyoming, Alaska, Montana, Idaho) has accomplished much in
its nearly 35 years of serving the region. From a Federal perspective,
I can say that we have only been able to accomplish this record with
continuing Federal support. We have partnered with the Federal
Government all along the way and I want to begin by thanking this
committee and the programs it funds for the support you have given to
WWAMI over the years.
At the end of my testimony, I will suggest specific ways that we
together can reinvigorate our partnership. Recent years have seen a
decline in Federal support for what we do. While we appreciate the
realities of the Federal budget, I hope to convince you that your
investments in support of medical education are key to managing the
physician crisis in rural America, the subject of this hearing.
WWAMI stands for Washington, Wyoming, Alaska, Montana and Idaho.
The University of Washington School of Medicine is the only medical
school and academic medical center within this five-State area. The
region comprises approximately 27 percent of the total land mass of the
United States. The approximately 10 million people in the region
constitute 3 percent of the population in the United States. Thirty-
five percent of the people living within this five-State region live in
rural communities. This year we are celebrating the 35th anniversary of
WWAMI, and are acknowledging the remarkable interstate partnership that
has been developed to allow for public access to medical school for the
citizens of the five States. This has only been possible through the
cooperative relationship between the people of the five States and the
medical school. This is a relationship which has evolved between
institutions of higher education, physicians in practice, hospitals,
and the State legislatures as we work together to support, in an
enduring fashion, this remarkable partnership.
In each of the past 14 years, the University of Washington School
of Medicine and the WWAMI Program have been recognized by U.S. News &
World Report as the No. 1 Medical School in the United States in
primary care as well as in rural health and Family Medicine. Though the
program began with a focus solely on training medical students, our
evolution has been toward the development of a continuum of educational
services (represented in the attachments as the ``WWAMI Educational
Continuum'') that begins before medical school and extends into
community service. It has also evolved into the creation of graduate
medical education programs that have allowed for graduates of WWAMI to
continue on with their training within the five-State area in family
medicine, pediatrics, internal Medicine and psychiatry. In 2002, the
Association of American Medical Colleges recognized WWAMI with its
prestigious Outstanding Community Service Award, applauding the
partnership between the UWSOM and communities within WWAMI.
The material that I have provided to you as part of this testimony
is the current Executive Summary of Activities in the States of Alaska
and Wyoming over the past 12 months. The insert to both of these
reports provides a State map, which allows for visual representation of
communities where the WWAMI program is based within the States. In
addition, on the back of the map page is a pictorial representation of
the WWAMI Educational Continuum. This material will give the reader an
in-depth glimpse of exactly what WWAMI does within the States of Alaska
and Wyoming.
Overall, the outcomes of the program are substantial. Sixty-one
percent of our medical students have returned to practice within the
five-State WWAMI area. This compares favorably to the national average
return rate (for all medical schools) return rate of 41 percent. In
addition, over the course of the past 20 years, approximately 40
percent-55 percent of graduates have entered into residencies in
primary care (national average, 7 percent-10 percent). Over a similar
timeframe, 15 percent-30 percent of WWAMI graduates have chosen to
establish practices in rural and medically underserved areas. Hence,
WWAMI ranks highly among the States with regards to return of graduates
to practice within the communities where they trained. Similarly, WWAMI
ranks highly in providing well-trained physicians ready for primary
care careers in rural and medically underserved communities. The Family
Practice Residency Network, which is affiliated with the University of
Washington and brings together 17 Family Practice Programs across the
five States (one of which is here in Anchorage), has a return rate of
77 percent of graduates to practice within the five-State area. Of
these graduates, 30 percent practice in communities of less than 25,000
and 15 percent in communities of less than 5,000 people--most often in
communities that are medically underserved and/or rural. Additional
information is provided on the State-specific Fact Sheets that are
attached to this testimony in conjunction with the Executive Summary
Reports.
The WWAMI Program is remarkably cost-effective. The total cost to
States averages between $45,000-$55,000 per student, per year for
medical student education within WWAMI. This compares favorably to
national averages of $60,000 and $120,000 per student, per year in
medical schools in States outside of the WWAMI region. In addition, the
tuition that is paid by students at the University of Washington School
of Medicine is $15,900 per year, approximately $4,000 less than the
national average among publicly supported medical schools. This cost
effectiveness is consistent with one of the original 1970 goals of the
WWAMI Program which was to assist WWAMI States in avoiding duplicative
capital costs and the expenses of hiring new faculty. The WWAMI Program
would not have been able to accomplish this without cooperation of
universities such as the University of Alaska-Anchorage and the
University of Wyoming in Laramie. It truly has been an enduring and
effective partnership.
The above summarizes the accomplishments of WWAMI. Now let me focus
on some of the challenges we face in preparing the future rural health
workforce.
Over the course of the past 5 years, WWAMI has seen a drop in
student interest in selecting residencies in primary care. We have gone
in 1996 from approximately 36 percent of students entering into family
practice to approximately 12 percent estimated this year. This
remarkable decline has resulted from a variety of factors including
rising student debt, student interest in assuring that there will be
adequate time for personal as well as professional pursuits and changes
in the healthcare delivery system. As we look to the future, the effect
of this decline in student interest in primary care will be devastating
for rural and medically underserved communities.
Looking deeper into the underlying reasons as to why this drop has
occurred, we cite the following issues:
Reduced student interest in primary care.--Long hours,
limited pay, and reduced personal time have discouraged students from
pursuing careers in primary care. There is frustration among many
students that the current healthcare delivery system does not allow the
students, once they become doctors, to pursue the principals of primary
care, which include continuous patient-centered, comprehensive,
compassionate, and coordinated care. The prevailing practice of primary
care at the present time also discourages students away from primary
care because of the limited time and infrastructure upon which to
implement exceptional management of chronic diseases. This is of
particular concern with an aging population and the increased incidence
of chronic disease among the elderly population. Contributing to this
reduction in student interest is also the increasing requirement for
more positions in the current healthcare delivery system in the United
States. The Association of American Medical Colleges now recommends
that there be a 30 percent increase across the country in the number of
medical students we train. With this increased demand, students now
have many other options in healthcare that allow them to direct their
interests away from primary care.
Increasing Student Debt.--Over the past decade there has
been a remarkable increase in student debt upon graduation from medical
school. The national average is currently $125,000 per student from
public schools, and $150,000+ from private schools. Students in WWAMI
from Alaska currently graduate with $94,000 debt per student, with 100
percent of graduating students incurring debt. Over the past 6 years,
this is up from $50,000 per student with approximately 75 percent of
students graduating with debt.
Loss of Federal funding at the University of Washington
School of Medicine/WWAMI.--The following factors have contributed to
undermining of support for our programs that are aimed at enhancing
student interest in careers in primary care.
Loss of title VII funding. This loss has led to cuts
in residency training in programs in Alaska and Wyoming,
reduced support of Family Medicine Student Training Programs,
the loss of residency faculty development fellowships, and
reduced support for the underserved pathway within WWAMI.
Loss of the Health Careers Opportunity Program (HCOP)
Grant funding ($1.2 million over 2 years) at the University of
Washington. This has led to a severe reduction in our summer
UDOC Program which is designed to encourage students from
medically underserved areas to follow their interests in health
careers.
Loss of Center of Excellence for Native American and
Native Alaskan funding. Over the past 2 years, $647,000 has
been cut from this program. At the present time, three WWAMI
graduates from this program are residents at the Anchorage
Family Practice Residency Program, an affiliate of the
University of Washington Family Practice Network. A similar
loss in Center of Excellence funding in Montana occurred in
Pharmacy.
Loss of funding for the WWAMI Center for Health
Workforce studies and the Rural Health Research Center. These
programs fund the creation of vital sources of information
(across WWAMI and the Nation) concerning the programmatic
effectiveness in rural programs. In addition, they inform us
concerning workforce needs in rural areas. Funding here has
been reduced in the last 2 years from approximately $2 million
per year to $0.6 million per year. This has resulted in our
staff declining from 21 researchers to six within our
Department of Family Medicine.
Reduction of support for National Health Service Core
Scholarships.
The creation of caps on Graduate Medical Education (GME)
funding as a result of the Balanced Budget Act of 1996.--This has
imposed a freeze on GME positions within the WWAMI area. Across the
five States, the number of GME positions per 100,000 population is far
below the Nation's average per State of 34 positions per 100,000
population. In WWAMI, this number is closer to 15 positions per
100,000. Currently the State of Alaska has only 4 residency positions
per 100,000.
Perpetuations of GME losses currently proposed in the
President's fiscal year 2008 budget.
Medicare IME (Indirect Medical Education) payment
reduction, a proposed cut from the GME payments that are
attached to the Medicare Advantage Plan payments. There is also
a potential proposed cut (as recommended by MedPac) of an 18
percent reduction in the IME portion going from 5.5 percent to
4.5 percent.
Proposed Medicaid cuts, including the elimination of
GME payments currently provided within Medicaid payments to
hospitals. If this is allowed to occur, the anticipated impact
will be a loss across the country of $1.76 billion over the
next 5 years.
Nearly complete elimination of title VII--The
President has proposed that title VII funding be reduced from
$185 million in fiscal year 2007 to $10 million in fiscal year
2008. This is a perpetuation of significant reductions in title
VII over the past 6 years.
Reduced support for payoff of student debt by
reduction of funding for the National Health Service Core from
$125 million in fiscal year 2007 to $116 million in fiscal year
2008.
Children's Graduate Medical Education appropriation
reduction from $297 million to $110 million (a 63 percent
reduction).
All of these reductions (and proposed reductions) have
significantly influenced the ability of WWAMI and other similar
programs across the country to continue to support the preparation and
training of physicians to practice in rural and medically underserved
areas and to achieve our remarkable outcome record. To successfully
turn this around, interventions will be required in which we enhance
student interest in primary care and support the continuation and
expansion of programs like WWAMI.
I would strongly recommend that this committee consider support of
the following Federal initiatives as a way to restore efforts on the
part of programs such as WWAMI. This will assist us in continuing to
provide effective medical education programs that are consistent with
the workforce needs within the five States, and across the Nation.
Specifically, I would recommend the following measures be
considered and taken:
Address the reduction in student interest and create
financial incentives to entering primary care residencies and practice.
To successfully do this over time, the reimbursement for primary care
physicians and physician practices will need to be enhanced far above
where it is today. This reimbursement and support for primary care
practices (such as the institution of measures to create medical homes
for all patients, electronic medical records, and the establishment of
evidence-based approaches to disease management among others) will need
to occur. Specifically,
Encourage the increased number of medical students in
training by increasing the Nation's medical school capacity
consistent with the AAMC's recommendation of a 30 percent
increase. Within the WWAMI States, we are currently
anticipating an increase of 22 percent in seats for medical
students over the course of the next 2 years. This includes 10
additional seats from the State of Alaska, 6 seats from the
State of Wyoming, and 20 seats within the State of Washington.
In addition, discussions of increases in seats for medical
students are currently underway in Montana, and to a lesser
degree in Idaho.
Encourage students to enter primary care residencies
through tuition support programs like the National Health
Service Core to offset the increasing amount of student debt,
and to reduce financial disincentives to entering into primary
care.
Restore Federal support for educational programs for
physicians in training, giving particular attention to those
programs that address the shortage of doctors in rural and
medically underserved areas. This can be best done by
restoration of title VII, HCOP and Center of Excellence
Funding. We should also direct assistance to medical schools
and residency training programs that promote (and are held
accountable for) physicians entering practices in primary care
and other needed specialties (such as general surgery and
psychiatry) particularly in medically underserved areas.
Eliminate caps within the Medicare Program for
primary care residency positions and rural track programs in
specialties needed in rural America. Besides family medicine,
general internal medicine and general pediatrics, this should
also include innovative programs in rural track training in
general surgery and in psychiatry. Many of these programs may
be urban-based in addition to having rural locations in the
program.
Expand training opportunities in rural and medically
underserved communities. This should include the support for
graduate medical education programs which combine urban and
rural training (such as in rural track training). Enhance the
supply of future accountable rural practitioners and increase
access to rural and medically underserved citizens to top
quality healthcare. Current examples of this in WWAMI include:
1. The continuation of rural track training with the
WWAMI Family Medicine Network.
2. The development (currently being considered) for
rural track training in general surgery.
3. Support for rural-track psychiatry programs such
as our programs based in eastern Washington, Idaho and
Wyoming. This last example is of particular importance
given the burgeoning problems in mental health,
including meeting the needs of veterans who have
returned from National Guard duty to rural communities
over the past 10 years.
Continued support for Area Health Education Center (AHEC)
funding and programs that promote recruitment of high school students
into health careers.--Programs such as the AHEC currently in place
within WWAMI provide infrastructure and allow physicians in training to
do community-based rotations in rural and medically underserved areas.
This support needs to continue.
Encourage programs that promote educational relationships
between Community Health Centers (CHCs) and academic medical centers.--
Within WWAMI we are currently exploring community academic linkages
that would allow for increased educational opportunities within CHCs
that serve rural and medically underserved populations. CHCs are
rapidly becoming the greatest provider of primary care in rural and
underserved urban communities, yet the supply of physicians to meet
this need is far below demand. This would allow for greater
opportunities to train students and residents within CHCs, and would
help to alleviate the workforce shortages that challenge the CHCs.
Restore funding for the Office of Rural Health Policy,
Rural Health Research Centers and the Bureau of Health Profession
Centers for Health Workforce Study across the country.--The absence of
funding for these programs has severely limited our ability to evaluate
and assess efforts that are currently in place to craft innovations
that address many of the needs that I have addressed today. In
addition, funding for the Nation's Centers for Health Workforce Studies
(CHWS) (which has been completely eliminated within the Bureau of
Health Professions) needs to be restored such that regions can have at
hand the ability to assess current workforce needs.
In conclusion, it has been my privilege to present this information
to you today and to provide, in a short period of time, advice to
policymakers and leaders as to how we might best face the future
challenges of providing for physician needs within rural and medically
underserved communities. The University of Washington School of
Medicine and WWAMI have long appreciated the support provided by the 10
U.S. Senators serving our five-State region, along with your colleagues
from the House of Representatives. WWAMI stands ready to build upon
this remarkable partnership. We will need your continued help and
support in order to accomplish this task.
I look forward to answering questions that you might have around
specific issues. I pledge to you to continue to provide support to this
committee and your staff as we move ahead in the Federal agenda to
support educational solutions to future workforce needs within the
United States.
Thank you for your attention.
Senator Murkowski. Thank you, Doctor, and I appreciate you
making the introduction of the young men and women who are
involved in the program now. It's a delight to have you here. I
hope you're hearing the message that we need you.
And with that, let's go to Karen Perdue, the Associate
Vice-President for Health at the University of Alaska, who has
been coordinating the Task Force Report. And, I would like to
note that a full copy of the Task Force Report will be included
as part of the committee record.
So, with that, Ms. Perdue.
STATEMENT OF KAREN PERDUE, ASSOCIATE VICE PRESIDENT FOR HEALTH,
UNIVERSITY OF ALASKA, ANCHORAGE, ALASKA
Ms. Perdue. Thank you, Senator Murkowski. Again, I echo the
appreciation that you have, the attention that you've given to
this issue. Not only today, but in the last couple of years.
What I want to say, and I want to be brief, myself, because
I do know that we need to have a dialogue, but Alaska has
always had a physician shortage. I think those of us who have
grown up here know that this is not a new phenomenon that we
are facing.
So, the question that we were interested in, at the
University of Alaska, in partnership with the State Health
Department was, what's changed? Why is this--why are patients--
anecdotally, we heard so much more access problems--has there
been a change in the reimbursement climate? Are expectations of
consumers higher? Do we have fewer physicians overall? The
solutions for all of these things are quite expensive. The
public investments that are needed for correcting the problems
are expensive. So, I think it's been important to take the time
to study the issue, and to give policymakers such as yourself,
verifiable information that you can rely on. And, I do believe
this Report does do that.
The Report--the Task Force was appointed by the President
of the University, and the Commissioner of the State, of our
State Health Department. Half of the people on it were
physicians, and half were not. And I think that was important,
because we all came with our own questions, and our own sets of
information.
We spent half of our time looking at the numbers, because--
believe it or not--it's not that easy to determine how many
physicians we actually have in our State, given the fact that
we have many physicians who are retired, or who aren't actively
practicing, this question of the military has been brought up--
you know, so how many people are actually caring for patients?
I think the conclusion of the Task Force was--by the way
that number was about 1,343 physicians was what we determined
were practicing. I think the determination of the Task Force
was that we do have a shortage. Frankly, the shortage wasn't as
great as many of us expected, numerically, when we walked in
the door. But, we are going to have a growing shortage, and
that, I think, was the revelation of the Task Force that was
probably most compelling. If we do nothing, if we do not act in
a very aggressive way, we will have a growing crisis.
It is expensive to do nothing. We have learned from reports
that we saw that--and we've heard earlier, over $24 million in
costs are borne by our healthcare system, just the ones we're
able to document--in recruiting temporary workers, and in the
cost of recruitment and vacancy. One hundred and twenty five
thousand dollars is spent to replace a physician in our State.
Those are costs, those are funds that could be going into the
remedies for the shortage, if we could just get ahead of the
game.
So, the Physician Supply Task Force, of course, concluded
that we needed immediate action, but probably--to reach an
adequate supply by 2025, which was the planning horizon we
used--that we would have to add a net of 59 physicians a year.
Now, that doesn't seem like much when you look at the number,
but it has to be every year. Each year, until 2025. This is a
50 percent increase in what we are gaining now.
So, what do we need to do? We need a sustained and
strategic set of actions, and there's no one thing that will
solve this problem, and that is, of course, a very complicated
thing in public policy, because I think it's a tendency to look
at a problem, address it in one way, and then say, ``OK, I've
got to go on to another issue.'' And, I say to our legislature,
State legislature and our policymakers--this is not a short-
term assignment that we're taking on. It's a very big job.
So, we recommended policies in four areas, and we've
mentioned most of them here, so I won't go over them in detail,
but I will go over them, in general.
We have to increase the in-state production of our Alaskans
who go to medical school. We've heard about the WWAMI Program,
we looked at those numbers, we concur that that program is
extremely effective, and we're very lucky to have it. We need
more slots. We said that we actually wanted 30 slots, 20 slots
is--going from 10 to 20 slots is what's in front of the
Legislature today, but I think, in the long run, we would like
to go beyond that, in the Task Force Report we mention that. I
think there's a need to keep our eye on that ball, because the
University of Washington faces this pressure from every State.
So, we need to act with due diligence on that.
And, of course, the residency program, we looked at that,
those numbers, they were very effective, and we need more
residency training.
Dr. Johnston gave us quite a lot of sobering information
about how hard it is to create a residency program, how many
sick people you need, and how much quality assurance you must
have. So, it's not going to be an easy task, and it's not going
to be cheap. But, it is definitely a highly effective way,
later on in medical training, to get doctors in our State.
And finally, we looked at the issue of other medical
schools, because we do have Alaskans who go to other medical
schools. And Dr. David Head, who was on our Task Force, was
particularly interested in this question, because he went to
school at the University of Arizona. We used to have, through
WHICHE, an arrangement where Alaskan students could participate
in a subsidized way. And we believe that that should, that kind
of an arrangement should come back to our State, but we also
believe it should have a service obligation. And the poor
record of return, in the old days, I think was related--in our
view--to the fact that we didn't have such a service
obligation.
Of course, all of that's a long timeline, so
simultaneously, we must be beefing up the recruitment of
physicians in our State. And, we believe that there should be a
centralized place in State government where recruitment of
physicians is something that people do when they get up every
morning. In other words, they're not actually recruiting the
physicians, but they're assisting the practices, the
communities, the hospitals, and perhaps the legislative bodies
in making this more effective.
Legislation, such as the ones that you sponsored--the loan
repayment or the tax incentives--these are also effective for
that recruitment phase, once the student has finished their
medical school, and we found that was very important.
Also, we have a very strong commitment to mid-levels in our
State--nurse practitioners, and physicians assistants, the
University of Alaska trains them, we feel that that's important
to maintain and to enhance.
And, finally, the area I want to touch on, the third area,
was the medical pipeline that you've mentioned. The University
of Alaska is very serious in assisting in the math and the
science and the interest of young people in getting into
medical careers, and particularly, to become physicians.
We have--the University of Alaska, over the last 5 years,
has beefed up their medical education and pipeline programs.
And through title VII, we gained many different competitive
grants, to work on this area. We lost $1.4 million in effort
last year, when Congress defunded that title VII, those title
VII programs.
These are programs out in communities helping our students,
and also working on rotations, and clinical placements for
students in rural settings.
We are really anxious to work with your office and your
legislation to strengthen title VII funding, I think that will
have a long-term effect. Alaska does now have its own AHEC, and
the partners in that Area Health Education Center include the
Yukon/Kuskokwim Health Corporation, the Family Practice
Residency, and the Fairbanks Memorial Hospital. These are
organizations that will be going out every day and working on
these problems.
So, Senator Murkowski, thank you very much for hearing
about the Physician Task Force Report. We do believe that this
can be turned around. We do believe--we're Alaskans, so we have
to believe that we can solve these problems, that it's not
hopeless. But, we will have to keep our eye on the ball, and we
will have to do many things at one time.
[The prepared statement of Ms. Perdue follows:]
Prepared Statement of Karen Perdue
Thank you for inviting me to participate in this field hearing on
the important topic of the physician shortage and its impact on access
to medical care in Alaska. In my current position at the University of
Alaska, I work on a daily basis to ``grow our own'' healthcare
professionals. These professionals are needed to fill the thousands of
healthcare positions vital to the health of our Alaskan communities.
Recently, I also had the pleasure to be appointed by Secretary
Leavitt as a member of the National Advisory Committee on Rural Health
and Human Services and in that capacity I look forward to working on a
national solution to the growing crisis of the shortage of health
professionals, including physicians, in rural America.
The University of Alaska is playing a critical role in meeting the
workforce needs of one of Alaska's most important industries. My
comments are organized into the following areas:
(1) Documenting Alaska's Health Workforce Needs
(2) Alaska's Physician Supply Task Force
(3) Expanding and Strengthening Health Workforce Programs
(4) Recommendations
DOCUMENTING ALASKA'S HEALTH WORKFORCE NEEDS
The development and maintenance of the health workforce requires
resources--resources to understand needs, develop strategies, and
implement programs.
Federal funding to understand the health workforce, to track
fluctuations and gaps over time, has been limited, but we have
accomplished some important efforts.
Over the past 5 years, the University of Alaska has successfully
partnered with the Alaska Department of Health and Social Services to
support some health workforce assessments. The resultant data clearly
point to huge gaps in Alaska's health workforce. Demand exceeds supply
in almost every health profession.
Through 2010, the U.S. Department of Labor predicts that the top 30
fastest growing jobs in the Nation will be in the field of allied
health. This finding is mirrored in Alaska, where 30 percent of the
jobs created in the past 5 years are in healthcare. Further, the
healthcare jobs in Alaska make up 8.3 percent of the wage and salary
employment, and that may continue to grow as the population ages
relative to the Lower 48 and Alaska develops more comprehensive
services.
The Status of Recruitment Resources and Strategies (SORRAS) study
commissioned by the State of Alaska's Department of Health and Social
Services and conducted by the Alaska Center for Rural Health at UAA
(Alaska's AHEC), documented recruitment expenditures for 13 health
occupations, including oral, behavioral and physical health.\1\
Specific occupations included: physicians, pharmacists, physician
assistants, nurse practitioners, nurses, dentists, hygienists,
psychiatrists, clinical psychologists, masters-level therapists, and
licensed clinical social workers.
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\1\ http://nursing.uaa.alaska.edu/acrh/projects/report_sorras-05-
06.pdf.
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The 2006 study documented a staggering $24 million spent by
Alaska's hospitals, community health centers, and tribal health
facilities in recruiting providers for their most recent fiscal year.
Of that sum, $12.9 million or 54 percent is attributed to itinerant
providers.
This $24 million is lost to direct patient care, driving up the
cost of doing business, compromising continuity of care and forcing
organizations to make decisions on the allocation of precious
resources. Equally important, the salaries to itinerant providers
represent an economic loss to the communities, as itinerant providers
do not buy homes or otherwise invest in the local economy.
Focusing on those occupations in the study that are supported by
the National Health Service Corps, we know that respondent
organizations spent an average of:
$126,782 for the recruitment of each physician (MD or DO);
$25,655 for the recruitment of each physician assistant
and nurse practitioner; and
$35,542 for the recruitment of each dentist.
The University of Alaska is now commissioning the Alaska Center for
Rural Health to conduct a statewide Health Occupations Vacancy Study,
looking at vacancies for over 100 occupations in Alaska's hospitals,
nursing homes, tribal health organizations, behavioral health
facilities, public health nursing, school districts, medical clinics,
dental clinics, pharmacies, rehabilitation (PT, OT, Speech) clinics,
diagnostic imaging clinics and medical laboratories. The resultant data
will inform our program planning efforts.
PHYSICIAN SUPPLY TASK FORCE
Alaska has historically experienced a shortage of physicians, but
stories from patients, providers and health policy experts seemed to
point to a worsening problem.
That is why in January 2006, University of Alaska President Mark
Hamilton, along with Commissioner Karleen Jackson empanelled a group of
experts to take the first ever comprehensive look at Alaska's physician
supply. The report of the panel, issued in August 2006 paints a
challenging picture of the job in front of us: to address a current and
looming physician shortage in our State. If we do not act quickly, we
will face an evergrowing crisis.
The Alaska Physician Supply Task Force called for immediate action
to increase the supply of physicians in Alaska. In order to reach an
adequate supply of physicians by 2025, Alaska needs to add a net of 59
physicians per year, every year, starting immediately. This is a 50
percent increase in new physicians.
While these numbers may seem small at first blush, they are
daunting considering the following:
It takes between 7-10 years to train a physician.
Only 10 Alaskans a year are currently admitted to the
Alaska/University of Washington Medical School Partnership known as
WWAMI. The seats have not been expanded since the program's inception
in 1971.
Alaska has only one Residency program--a common tool for
recruiting new physicians.
Competition for physicians across all disciplines will
increase as shortages occur across the Nation.
Sustained and strategic action is needed to meet the growing
shortage of physicians. No one strategy will meet the need. The Task
Force recommended improvements in four areas (selected strategies
listed):
(1) Increase the in-state production of physicians by increasing
medical school slots and graduate medical education opportunities in
Alaska.
Increase State-subsidized medical school positions
through WWAMI.
Support and enhance residency training in Alaska.
Support, with service obligation, Alaskans attending
other medical schools.
(2) Increase recruitment of physicians.
Create a statewide entity with resources to help
communities with recruitment.
Provide recruitment incentives like loan repayment
and tax incentives to physicians who practice in rural
communities.
(3) Expand and support programs that prepare students for medical
careers.
Support college prep programs in math and science,
internships, scholarships.
Support Alaska's AHEC, which is a system devoted to
attracting and retaining Alaskans into health careers.
(4) Increase the retention of physicians by improving the practice
environment.
Practice environment index.
expanding and strengthening health workforce programs \2\
The University of Alaska recognizes the growing demand for health
careers academic programs and continues to innovate to make programs
available throughout Alaska, and in communities where people reside.
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\2\ University of Alaska Health Programs: Pathways to Alaska Health
Careers.
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Growing Enrollments: In the last 5 years, enrollment in health
programs at the University of Alaska increased by 66 percent and the
number of our graduates has grown by 55 percent.
Expansion of Distance Education: Training Alaskans in their
communities for Alaska's thousands of good healthcare jobs is the only
long-term solution to shortage. However, until recently, Alaska's vast
geography has been a barrier to the creation of learning cohorts. That
changed in 2004 with the formation of the Health Distance Education
Partnership.
In its first 3 years of operation, the Health Distance Education
Partnership has created over 50 distance-delivered courses covering
eight occupational areas, serving over 1,000 students. Distance is not
a barrier to learning. It is the future of its delivery.
National exams show that students taught by distance in nursing
perform equal or out perform their own campus peers.
Doubled Nursing Supply: In 2002, the University/Industry Task Force
established the goal of doubling the number of basic nursing graduates
(AAS and BS programs) from the UAA School of Nursing by 2006. This goal
has been met and exceeded, growing from an annual graduation of 96 to
215 students. Industry partners have given more than $4 million so far
to support the expansion. Further, those industry partners also provide
clinical rotation space in their hospitals. Nursing education is
available in 11 Alaskan communities, enabling students to learn in the
communities where they live.
Alaska WWAMI Program Expansion: Alaska WWAMI students are able to
spend 3 of their 4 years of medical school in Alaska. This corresponds
with the validated research that people practice where they are
trained. The University of Alaska strongly supports the expansion of
the Alaska WWAMI program, expansion from 10 to 20 first-year students
in the coming year. The Legislature is currently considering this
expansion.
Strengthening Mid-level Academic Programs: Alaska has and should
maintain a higher ratio of mid-level providers (advanced nurse
practioners and physicians assistants) to physicians than the national
average. The University of Alaska offers Nurse Practitioner education
through the School of Nursing and a Physicians Assistant Completion
Program in collaboration with the University of Washington's MEDEX
Northwest Physician Assistant Program. These programs should be
strengthened and supported.
Alaska Area Health Education Center (AHEC) Program: Because Alaska
does not have a stand alone medical school, in September 2005, Alaska's
School of Nursing became the first in the Nation to have an Area Health
Education Center (AHEC). All other AHEC programs in the country are
housed in Schools of Medicine. Funded by the DHHS Health Resources and
Services Administration,\3\ the program is responsible for
strengthening the health workforce via collaborations with regional
partners, called AHEC Centers.
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\3\ http://bhpr.hrsa.gov/ahec/
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The Alaska AHEC supports strengthening the physician workforce, and
does so with the following activities:
Support of a summer program encouraging high school youth
into medicine and other fields;
Support of the WWAMI R/UOP Program, a summer experiential
rotation for first year medical students;
Support of clinical rotations for medical students
throughout Alaska;
Representation of the UW WWAMI Medical School on the AHEC
Board of Directors; and
Alaska Family Practice Residency serves as a host
institution for the South Central AHEC Center.
Fairbanks Memorial Hospital and the Yukon Kuskokwim Health
Corporation also house AHEC centers.
RECOMMENDATIONS
The Federal Government has a critical role to play in addressing
the physician supply issue. We make the following additional
recommendations:
First, we applaud Senator Murkowski's Physician Shortage
Elimination Act, which proposes to:
Double funding to the National Health Service Corps;
Expand current medical residency programs;
Reauthorizes some title VII programs; and
Bolster Community Health Centers.
Second, we strongly support the preservation of AHEC funding and
other relevant Federal programs under title VII.
The University of Alaska system is severely hampered in its efforts
to improve the volume and distribution of health workers due to Federal
cuts that occurred in fiscal year 2006 and are being sustained in
fiscal year 2007. Broadly referred to as Title VII of the Public Health
Service Act, and housed in DHHS Health Resources and Services
Administration's Bureau of Health Professions, these competitively
awarded grants to the University of Alaska are collectively valued at
$1.4 million per year and included:
Geriatric Education Centers, to train physicians and other
health workers in the provision of geriatric care;
Health Careers Opportunities Program, to expose youth from
disadvantaged backgrounds to careers in medicine and other health
fields;
Health Education and Training Centers, to expose village
high school students to careers in health, including medicine; and
Quentin Burdick Rural Interdisciplinary Training, to
support interdisciplinary clinical rotations in geriatrics and
behavioral health.
All these efforts came to a halt when Congress defunded large parts
of title VII last year.
Alaska's AHEC provides a golden opportunity to build a statewide
system of programs that work on the ground to recruit, train and retain
Alaskans into health careers. Funds for this program should be
enhanced.
Third, we support Federal legislation to address the rural
physician shortages like the recently introduced Senate bill 498,
Medicare Rural Equity Act, introduced by Senator Collins and Senator
Feingold, which provides:
Rural representation on the Medicare Payment Advisory
Commission;
Funding for quality demonstration projects in health
information technology;
Funding for hospital-based clinical rotations in
underserved areas; and
Elimination of the geographic physician work adjustment
factor in the Medicare physician fee schedule.
Fourth, we recommend the U.S. Department of Labor include the
health industry in list of ``high growth fields.''
Senator Murkowski, we look forward to working with you as you
introduce the Physician Shortage Elimination Act and thank you for your
leadership in addressing the physician shortage crisis in Alaska and
our Nation.
Senator Murkowski. Thank you, Karen. You do point out the
reality, for as long as most of us have been in Alaska, we've
had a physician shortage issue, and it just depended on what
part of the State that you were from, as to how acute it was.
But, I think we're hearing a different level of concern
now. The second panel, listening to Mrs. Hatch's comments, Mr.
Appel, and then Mr. Berger. The need is very immediate. And
very real. When you have to make 100-plus phone calls out of
the Yellow Pages to find somebody that will take your mother,
we have very serious and immediate concerns that we must
address.
In listening to the very distinguished panel we have here
in front of us, we recognize that so many of these solutions
are long-term solutions. We talk about the need to grow our
own, and Dr. Johnston, I so appreciate what the residency
program is doing, Dr. Coombs, what we're able to take advantage
of with the WWAMI Program. But, we recognize that, for these
young people, from the time that they've indicated an interest
in going into medicine, and going into a program, it's going to
be a few years before we're going to see them working for any
of you.
So, the first question that I would throw out to those of
you practicing, currently, or the others--how do we make sure
that Mr. Berger finds a physician? And I know, I appreciate
there are no easy answers, there's no one single solution, but
let's, for discussion purposes at this moment, talk to the
short-term. Is there anything that we can do for the short-
term, while we work harder for the long-term solutions to do
more about growing our own? Mr. Tanner, Mr. Neubauer, Mr.
Perkins, anybody have any good short-term solutions?
Dr. Tanner. I came to Alaska 2 years ago after an inability
to sustain a practice in the State of Washington. So, a lot of
the people have been here a long time, I'm relatively new to
the State, I got nominated to--as President of the Alaska State
Medical Association--things develop very quickly.
My experience within, as a general internists--I specialize
primarily in the field of diabetology, and also lipidology,
which is preventative cardiology, basically, there's not really
a defined specialty within that. But, the complexity of the
patients that I see everyday, it's very time-consuming.
In order to make a practice work in the State of Alaska,
you'd have to average seeing a patient every 7 minutes. I can't
say ``hello'' in 7 minutes, let alone, review medications, and
``Oh, by the way,'' you know, you've got multiple problems.
In 1 year, before I got here, with my mother being my
receptionist, my wife being my office manager, and being very
efficient at managing my office, in 1 year, my net income was
nothing. It's hard to believe that I could make more money
working at Chuck E. Cheese, than I could actually operating in
a practice. There's a conflict between the doctor and the
patient--that the doctor and patient are being thrown into, in
that in some way we're looking like the bad guys--that we're
not accepting patients. And in any trade, when you increase the
cost of doing business--my receptionist needs benefits, my
office manager now needs to have a salary for her children. My
nurse needs to have a salary--as everything is going up and
reimbursements are going down, what that means is, you need to
see more and more patients, and that time--the valuable time
that you spend with your doctor where you sit down and analyze
what is exactly going on--is going out the window.
So, in order for me to stay financially soluble, I need to
be paid for what I do--just like the electrician, just like the
plumber, just like anybody that has a trade that they offer.
And so, as the reimbursements continue to go down, and
continue to be threatened to be cut even further, it's going to
get worse. And, you just have to pay for what you're getting,
and there's a value to things and goods that are delivered in
other professions, but this is a right that everybody should
have, is going to the doctor. And, I'm with the fellow from the
western part of the State, in Bethel, in saying you need to
have that continuity, that's why I went into internal medicine.
I actually was groomed, you know, when I was going through
my program, ``Oh, you're really, you know, you're a good
doctor, we want you to be a cardiologist, we want you to be a
gastroentologist,'' always this push to be a sub-specialist.
No, I want to be a general internist. I like the continuity of
knowing patients over a number of years. But, you do get
disincentivized because you're not being paid. And then you
hear a lot of doctors that are upset, and daily focus on this.
And it's like, you know, I do have the best job in the world.
To sit down with a patient and make a difference in their lives
and saying, if I have the time--and it's not a narcissistic
thing--I can prevent you from having many devastating things
happen in your life.
And it impacts other things, I talked to a fellow coming
back from Washington, DC., when I saw you, he's over 65 years
of age, and I say, ``What do you do for a doctor?'' And he
goes, ``I just go to the emergency room.'' I mean, that is not
an appropriate way of handling--but he says he has no choice.
So, the money's being spent elsewhere, when really, the
money should be spent with the primary care doctors. And, I'm
the cheapest thing that Medicare can spend their money on. Labs
are very expensive. One hour with a cardiologist, doing a
procedure--extremely expensive. Going to the emergency room--
extremely expensive. But, the total cost for me, in a year, is
probably less than $500, and I can prevent a lot of those
things from happening.
So, that's how you immediately can fix it--is we have to be
paid. And, it's not a greed thing, I don't have a bunch of
money in a room, I just go run into and jump in every day----
[Laughter.]
Dr. Tanner [continuing]. It is a problem of being able to
keep the doors open to my practice because I can't pay
everybody, and then the bureaucracy that goes along with
insurance companies, and getting things authorized and those
things--it takes staff, just to get things authorized through
an insurance company. My authorization should be me signing my
name on a prescription, that's my authorization.
Senator Murkowski. You point out that a doctor has the--
certainly the right to be compensated, just as an electrician
or a plumber, and I don't think that if a plumber were to have
expenses of 100 percent, he would accept compensation at 40
percent, and yet that's what we're asking of those docs who do
see the Medicare patients.
Dr. Neubauer, do you want to jump in? Short-term solutions.
Dr. Neubauer. Yeah, I think that partly the answer depends
on what your definition of short-term is. If you mean, in the
next couple of years, I think it's likely that things are going
to get worse before they get better. Because there's--it's
almost like a perfect storm right now--the capacity in private
practice, to add new physicians here who do what I do, is very
limited. And partly that is because general internists in this
town have--as a rule--pared down their practices to bare bones.
You know, they work in small offices that have very little
capacity to add another physician, and they've pared down their
expenses, in an effort to survive, so that they can keep going.
So, the surge capacity in the private world is very limited
right now.
You know, I think that in the sort of longer short-term,
there's more hope. And that is that I think there's a lot of
willingness on the part of young people coming up and training
to do the work. I'd be interested in what the students here
would say, but I think the attractiveness of being a doctor--I
mean, you know, seeing patients, thinking, trying to solve
their problems--is great. And the push to go into fields of
medicine that are highly technical, highly compensated, is
primarily a financial one.
I think there would be a much more even spread of what
people went into, if there weren't these gigantic differences
in what a highly paid technical physician makes, versus
somebody who does what I do, and what Dr. Tanner does, which is
sit in an office and think. You know, it's a lot of fun to
think, and it does a lot of good, and I think there's a lot of
attractiveness to it. It's a different kind of work than
reading an echocardiogram, or sitting and reading x-rays all
day--which is also very important. But, I think there needs to
be a bigger spread of what people go into. And right now,
there's a tremendous push to go into the higher paid things.
One thing that I think needs to happen is for there to be a
continuity of things, that when a physician leaves practice,
that somebody else wants to come and do their work and take it
over, not just have it end. And that, unfortunately, has been
the model here, as I mentioned in my testimony. It's a huge
tragedy, when I see a physician retire here, and, as I said,
close their doors, charts go in storage, patients scattered to
the wind. That's absolutely wrong. There should be a
willingness of somebody young to come and take on that
practice, and right now, there's just no incentive to do that.
It's not looked at as something of value.
And I can cite to you example after example of physicians
who have left here over the last 25 years I've been observing
and that that has happened. It's an extreme tragedy.
Senator Murkowski. Let's just focus on the recruitment
issue for a second, because that's--as you point out, an area
where we're not able to provide for the continuity of care that
I think we would all like to see. When you have somebody who's
retired, or you've got an expanding medical practice, and
you've got room to take on more, if you could find the
physician to come in.
I understand that here in Anchorage, where we've got our
only rheumatologist in the State, we've got one rheumatologist
who's been trying to retire for years, but he can't do it
because there's nobody who will step up and take his practice,
and his commitment to his practice is such that he doesn't want
to leave them in the lurch.
But, yet at some point in time you've got to have that
backfill, if you will, you've got to have those reinforcements
to step up.
When we did the Town Hall meetings last year, the stories
that I was hearing about the medical practices that had been
looking for 18 months to fill a slot for an internist, 2 years
to fill a slot for an internist--what else are we doing wrong
that we can't attract them?
Part of it, as I recall, was the great lure of coming to
Alaska, and the adventure of being here. But, I guess the
adventure of being in Alaska, is outweighed by the fact that
you might not be able to afford your Alaskan adventure, is that
still our situation?
Dr. Neubauer. Well, you know, I think more money is always
good.
Senator Murkowski. Money always helps.
[Laughter.]
Dr. Neubauer. And I think that is one solution, honestly.
But, I think there are a few others. I think that Electronic
Health Records have great promise. I think that if an office
has a robust Electronic Health Record, that's a saleable point
for somebody coming in, wanting that practice. And, I think in
general, across the country, it's almost expected for young
physicians, the few that are going into primary care practices
right now, to want that and have it as a requirement.
So, I think that's very important. And, that's something
that, I mean, this is a wealthy State, we should be supporting
physicians in ways that we can, by giving them subsidies to put
in place Electronic Health Records, and I mean the physicians
who are in practice now. Because I think that would not only be
a recruitment point, but also something that would make it much
more likely that when they leave practice, that somebody would
be there to take their place.
So, more money, and Electronic Health Records, that would
be a good start. And, I think, increasing the pipeline of
people coming in is extremely important. I mean, if there's
nobody interested in taking the job, you're sunk in the water.
So, you have to have people coming up in the pipeline who want
to be there.
But, then you have to incentivize for them to want to do
that, and be able to do that. Because, I think, when you're
saddled with $150,000 to $300,000 of debt, you're not going to
do what I do for a living. It's, you've already bought two
houses before you're going into practice.
Senator Murkowski. Dr. Coombs.
Dr. Coombs. Well, I'd like to make a couple of comments.
First of all, I think we've heard from the panel, but also I
think the students in the audience would agree that they are
going into medicine because of the fact that they want to make
a difference. That they are very happy with a professional life
and the kinds of things that they can do for others, that's not
the issue.
I think the issue is dealing with the stark realities that
we enter into, in terms of both--two things. First of all, once
you have a shortage of people, then you never have enough to be
able to meet the needs, and that is something that preys upon
your private life, in addition to your professional life.
Especially in isolated, small communities.
The second thing is, dollars. Fund it, and they will come.
If you look at, as an example, two things that I'll give you an
example of--in Washington State where I practice, currently
private insurance pays up about $56 per relative value unit to
take care of a patient. Medicare pays about $36. Medicaid pays
about $22. It's impossible to meet the overheads, which are now
60 to 70 percent in a primary care office, to be able to
provide for just the care that you have to provide, and the
staff that you have to provide to achieve that.
In addition to that, you have debt, and other
considerations. So, the unfortunate thing, is that students and
many professionals now run into the stark reality, which is
something where they have to do something which really is
survival mode, in terms of the ability to keep the door open,
to allow patients to come in the door. And that means,
restricting the patients that they see.
It's not something that's part of the Hippocratic Oath. It
is not something that we went into medicine to do. It's just
reality.
Senator Murkowski. I'm going to go a little out of line
here, a little unorthodox for a hearing, but I'm going to ask
some of you students who are part of the WWAMI Program, what
would incentivize you to stay here in the State, to go into the
areas of--as Dr. Neubauer has indicated--into the primary care,
internist areas? What's it going to take to keep you here, to
provide the level of service that we would like to see for
Alaskans? And, if I can just ask you to stand if you want to
share a thought with us, and speak loudly so that we can pick
you up on record.
What have we got? Probably better if you could come up to
the mike; you don't even need to get fancy.
Melissa. My name's Melissa, and part of it for me is, you
know, I'm facing $100,000 of debt, and that's really scary. I
want to know that I'm going to be able to, you know, pay that
back. And, for me, it does come down to money, and being able
to deal with my loans, and sort of having help with assisting
that, and incentive programs to come back here.
Senator Murkowski. Where are you from, Melissa?
Melissa. I'm from Eagle River.
Senator Murkowski. We want you to come back.
Melissa. I want to come back. I mean, Alaska is a great
place to grow up, so I'd love to come back here, so hopefully
it will work out.
Senator Murkowski. OK, we'll work on that.
Who else has a--what would allow you to continue to stay
here in Alaska?
Ross Baldwin. Ross Baldwin from Kenai, Alaska.
I'm actually not too concerned about the whole debt thing,
because I'm interested in surgery, and I'm going to get a lot
of dirty looks right now.
But, one thing that does concern me, as these guys
addressed over here, and I actually got to spend some time
working under Dr. Perkins--he's an amazing guy--but, the lack
of residency programs in the State, or that feed into residency
programs in the State, is a huge concern for me.
If I want to do a surgical residency, which is roughly 7
years, 6 or 7 years from my understanding--I can't be in Alaska
for those 6 or 7 years. So----
Senator Murkowski. So, 7 years, you're gone.
Ross Baldwin. Right.
Senator Murkowski. What happens if you fall in love with
somebody who doesn't want to come back to Alaska? What do we do
to make sure that we can have residency programs for somebody
like you?
Ross Baldwin. I don't have any excellent solutions, because
I don't have enough knowledge about residency programs at this
point.
[Laughter.]
Senator Murkowski. Then we're just going to have to hope
that you find a young woman here.
Ross Baldwin. Right.
Part of the problem is that we have a small population
base, and a lot of the surgical residencies are uncomfortable
with putting forward a residency program with that small
patient base.
I think that there's some innovative solutions out there,
I'm not qualified to offer any of those, but I definitely think
that there could be something done to increase residencies, not
just in the surgical area, but beyond basic family practice.
Internist residency, I think, would be an excellent addition to
the State.
And also, just to kind of give you some additional
perspective from our community. I grew up in Kenai, and I went
to a clinic there where there was a primary care physician, and
he just closed his doors, and there's no one coming in to
replace him. The need is real, it's very, very real.
So, thank you for your time.
Senator Murkowski. Thank you, Ross.
The statistics that we have out there are so troubling,
though, when you recognize that the majority will stay in
practice, what is it, within 100 miles of where they have done
their residency. So, that just automatically precludes so many
of the young Alaskans, if you're going to go outside for 6 or 7
years to do that residency.
What do we do, Dr. Johnston?
Dr. Johnston. Well, I think there's, really logically, only
a couple things that can be done. The range of possibilities is
not huge. We can have residencies here in Alaska, or we can
have branches of residencies here in Alaska. And, really, those
are about the only two ways that you're going to have that
final phase of graduate training in the State.
The data that you cited that depends on specialty a little
bit--but around 70 percent of residency graduates practice
within 100 or 150 miles of where they train--are based upon
graduates of full-fledged residencies, where the resident does
their whole 3 years in that program, such as our program here
in Alaska.
There are other possibilities where residencies in other
States, such as Washington, could have residents rotate in
Alaska for a period of time, as a way for us to make them fall
in love with the State, so that after they graduate from their
residency in Washington they would want to come up here and
practice. I don't know that there's any data on how effective
that is in attracting people to ultimately practice in the
State, maybe Dr. Coombs knows more, because he's involved with
graduate medical education on a larger scale than I am.
But the University of Washington, WWAMI program has
proposed to us, on several occasions, to try to develop those
kinds of programs with the idea that it would allow Alaskans an
opportunity to do at least some of their surgical residency
here in their home State. If that's going to keep them from
falling in love with a woman from Washington, I don't know.
But, maybe we can have a parade of young ladies there that----
[Laughter.]
Senator Murkowski. That's not going to be part of our
medical solution.
Dr. Coombs.
Dr. Coombs. I'd just like to make a comment on Dr.
Johnston's--I was in Boise, Idaho last week, and we were just
establishing a psychiatry residency, actually, in Idaho, that
will be shared 2 years in Seattle, 2 years in Boise, which is a
combination between the Boise V.A. and the two downtown
hospitals in Boise.
We've had success, since 1991, with psychiatry residency
like that model in Spokane, and I know Senator Murray is on
your committee, where we've had 2 years Seattle, 2 years
Spokane--64 percent of its graduates have gone into practice in
the Greater Spokane area, 84 percent in eastern Washington. And
mental health is a huge issue in that respect. I know that's
something that, in Idaho, they're delighted to see that.
In general, internal medicine, we have had a program,
again, in conjunction with the Boise V.A.--I mention the V.A.,
because the V.A. right now is in the process of increasing by
almost 1,000 residency slots nationwide, in terms of increasing
the amount of residency positions which are supported. I'd love
to see that come to fruition here in the Greater Anchorage
area, to engage the V.A. in terms of residency training.
But our internal medicine program, again, based at the
Boise V.A., has been responsible, with over 80 percent of its
graduates going into practice within the WWAMI area, including
within the State of Idaho, 57 percent. So, those are general,
internal medicine, primary care, and total medicine residents.
There are models, it's a matter of having, I think, the
flexibility within the GME process to be able to do that. Not
only in funding, but also in the accreditation cycle.
Senator Murkowski. Now, Dr. Johnston, you had mentioned
that Alaska has the lowest number of students coming, of being
accepted into the medical schools, if I remember that recap.
Ms. Perdue, we recognize, and our Task Force has been
looking at the shortage, is--from the University perspective,
should we be doing more to encourage, at the high school and
the college level, the interest in getting into this healthcare
pipeline? I mean, we acknowledge that we don't have a lot of
folks here in the State, but our reality is that we should be
doing a little bit better about growing our own, but if we
don't have people that are interested in getting in that
pipeline at all, it's going to be tough to achieve what many of
you have suggested. Are we pursuing that, at all, through the
University?
Ms. Perdue. Well, the University, as I mentioned, has been
focusing on beefing up all of its healthcare opportunities,
from nursing to----
Senator Murkowski. You've been very successful with the
nursing component.
Ms. Perdue. Correct. So, we find the interest is there, but
we find that the need for the math skills, and the science
skills and so on, you know, really must be taken care of,
hopefully not after the student starts to apply for the
program. In other words, there are summer opportunities, and if
you can't get those programs in your high school, they can be
supplemented--those are all things that many of the title VII
programs that we talked about, are meant to enhance in our
State. Not that that's solely the responsibility of the Federal
Government--certainly the school districts and the University
working together have a need for that.
Because it's not only for students going into medical
careers, it's engineering, and other areas where we need those
technical skills. But, we need those internships, we need those
summer programs, we need that exposure for rural students, and
urban students alike. And we are very anxious to do more of
that.
Senator Murkowski. I've got a whole host of questions, I
could keep you here all afternoon, but we only have the hearing
room until noon today, and we do have some additional folks
that have indicated they would like a couple minutes at the
microphone, so I want to give them that opportunity.
I think it was you, Dr. Tanner, who mentioned that with the
recent military deployment there has been even further pressure
on the local practitioners to pick up the patients of those who
were being seen by some at the medical unit there at Elmendorf.
Can you give me a little bit more in terms of background on
that, and how it has affected the practice here in the area,
and the pressures?
Dr. Tanner. What I can respond to is what happens in my
office, and people calling my office daily. And it seems, we
get more questions with regard to taking some of the military-
sponsored insurances as they're supplemental insurances, as
well as, the numbers have increased since we've seen the
conflict in the Middle East. The specific numbers, I'm not sure
of.
Senator Murkowski. Any--Dr. Neubauer, are you getting the
same inquiry?
Dr. Neubauer. I'm not sure. What I do know is that my
office gets, probably 10 to 20 calls a day for new patients
that want to come into my practice, and the others in my
office, and we take some of those.
One of the things, just to mention, that I think that
there's a tremendous willingness on the part of doctors to try
and do the right thing. You know, I think there have been a
number of doctors in Anchorage that have opted out of Medicare
altogether, and that's not healthy when you have such a small
number of doctors.
Tri-Care, I'm not sure what's going on with taking Tri-Care
patients right now. But, I do know that between all of the
patients seeking care, there's just no way that primary care
doctors who are here can do all of what needs to be done.
Senator Murkowski. Do I understand correctly that, if you
are going to accept Medicare patients, you basically have to
opt-in or make a statement that you will be accepting those
patients, and you essentially make that statement on an annual
basis. And if you decide at the beginning of 2007 that you are
not going to be taking any Medicare patients, you may not take
any for the duration of that year?
Dr. Neubauer. There's three ways you can handle the
Medicare program. One, is by being a participating physician,
which means that when you see a Medicare patient, you can't
bill the patient at all, you bill the Medicare program and are
reimbursed directly from Medicare.
You can be what is called a nonparticipating physician,
which is kind of a misnomer. And what that basically means is
that when you see a Medicare patient you can bill the patient,
and you're allowed to bill them up to the Medicare-allowable
rate, which is actually a little bit more than you get if you
just get paid by Medicare. And you can collect from the
patient, and then the patient can collect from Medicare to be
reimbursed part of that fee.
And, so it's not really nonparticipation, it's just a
different kind of participation. And then you can opt-out,
which means you do all the things to basically say, ``I'm going
to have nothing to do with the Medicare program,'' and then you
can bill the patient whatever you want. And that's something--
as I say, I think--two physicians that I know of, two
internists in Anchorage have done.
That's pretty extreme, and basically, I know in my patient
population, that would essentially disenfranchise most of my
patients. I mean, I have a few wealthy patients who could pay,
you know, huge fees if I wanted to charge them, but most of my
patients are just struggling along, and so, I just, frankly,
couldn't do that to them.
But, there are a few physicians who have taken that route,
just kind of in disgust, I think, over what's going on.
The 40 percent number is real--I've just looked at what my
charges are versus what I get from Medicare, and it's 40
percent. And, I can tell you, it's very, very difficult. I
mean, we struggle on a day-to-day, month-to-month basis to just
pay the bills. And I don't make an extravagant salary at all.
So, it's just very difficult to run a business that way. In
fact, it's getting more difficult, and it may get close to
impossible, if it gets worse.
Senator Murkowski. Dr. Tanner, and then I want to ask Dr.
Johnston a question.
Dr. Tanner. One thing is that, there are physicians that
can opt out, but the patient can't opt out. If you turn 65
years of age, you have to take Medicare as your primary unless
you are full-time employed.
There are patients that would like to opt-out and use their
State benefits as an insurance, to be their primary carrier,
but they don't have that opportunity.
The other thing is there's a misconception amongst a lot of
patients that, if they have a deductible that it pays the
physician the difference between the routine fees and Medicare
fees. And that's not allowed. There, it's paid at the hospital,
they pay their labs, but the secondary insurance pays nothing
to us. And so, just a couple things where they're, they could--
actually just allowing patients to opt-out of Medicare would
eliminate some patients off the Medicare roll, so to speak, and
then----
[Applause.]
Dr. Tanner [continuing]. And then allowing Medicare to
allow a secondary insurance to pay the difference and just
those two things right there would allow the physicians,
actually, to incorporate Medicare back in their practice.
Because it may come close to what we normally would be paid by
insured patients, but it allows a little bit more flexibility
rather than just making everybody do it. Thank you.
Senator Murkowski. Very good point.
Dr. Johnston, I wanted to ask you about the caps. You had
mentioned that--if we were able, if we could remove those caps
that are in place--were we to do so, how many new residents
could we bring into the residency training program?
Dr. Johnston. Well, currently our residency program is
planned around having 36 residents, that's 12 per year for a 3-
year program, and our cap is about 22. We can't really--we're
already operating at a substantial deficit.
If the caps were lifted so that we could count all 36 of
our residents, that would just about fix the biggest part of
our current deficit.
The controlling factor--if there were no caps at all--the
controlling factor and the size of the residency would be such
things as teaching opportunities, the size of the facility
where the residents practice and train, and those sorts of
things.
You know, just off the top of my head without planning it,
I would say our program could probably go to maybe 15 per year
from the 12 that it is now, which would be a significant
increase. But the interesting thing about lifting the caps,
would be then it would create the opportunity for us in Alaska
to start opening other residency programs. You know I have a
pro forma that I'm going to be discussing about starting a
psychiatry residency program here. A general internal medicine
residency would be something that could easily be done in a
place like Providence, because we have the quality teachers, we
have the quality physicians and we have the patient base. Parts
of a surgery residency could be done here in Alaska. A
pediatric residency would be possible. But we can't do any of
those now because residency education is so expensive, that
without a funding stream to support, no institution is going to
go out on a limb and start a residency program. Right now
Providence Hospital, the only sponsoring institution for a
residency in Alaska, is losing $2 million a year to keep our
program going. They're not going to start another program
that's going to lose them another $2 million a year, so they
have to have a funding stream.
And so the caps--my feeling is that if our residency
program as it is now or slightly larger--operates for a number
of years, we will be satisfying the need for primary care, for
family physicians for Alaska. Because we're the biggest
residency program in the Northwest, in the WWAMI region right
now. We're the biggest family medicine residency program of all
the WWAMI States. But we're not going to solve the physician
problem in Alaska by just pumping out more family doctors. We
have to be able to produce the other specialties that are
really needed in the State and we can't even touch that until
we can get the caps lifted.
Senator Murkowski. Well, and when we figure we need 59 new
physicians a year for--through the year 2025 to just become on
par with the population-to-physician ratio in the Lower 48.
Even adding those additional slots, it just seems like you
can't get ahead of the wave here.
Dr. Tanner. Can I comment briefly on a question you asked
earlier, which is what can we do immediately to fix the
problem? And the problem seems to be that there just aren't
doctors out there that want to come to Alaska, and join Dr.
Neubauer or the other practices that are, that would be able to
recruit and have these physicians if they were around.
I think the problem is that shrinking supply nationally--
and in a world of a shrinking national supply--you have to be
extremely competitive in order to be able to draw the few that
are available to your place as opposed to having them practice
somewhere else. We're not very competitive in recruitment right
now. Because the people who are trying to recruit are docs,
like Dr. Neubauer who are in small offices. They don't have the
resources just to keep their doors open hardly, let alone
advertise, go on trips to residency programs in the other parts
of the United States to solicit, pay recruitment sign-on
bonuses, guarantee the salary for the first couple years, pay
the recruitment trips where they come up and interview and meet
the docs and everything--they don't have the resources to do
that. So we're totally noncompetitive in that.
Some of the hospitals are stepping up to that plate trying
to help out. Their budgets for that are very limited as well.
If you want an immediate solution to the problem of physician
shortage, we have to get organized and get aggressive about a
recruitment process and that has to be done on a much larger
scale than the individual practices. Which is one of the
reasons that the Physicians Supply Task Force made a
recommendation for a statewide office to help support those
activities. But that's going to have to be funded, because
there's a significant amount of cost that goes into those kinds
of activities. And if anything can be done on the Federal level
to help fund that I think that would be very beneficial.
Senator Murkowski. Very constructive.
Excellent comments. I appreciate the input from each of
you. It's quite apparent that there is passion at all levels,
whether within your respective practice or what you're doing to
cultivate those physicians who will be serving us.
But I appreciate, again, all that you have provided us with
here today, in terms of your insight and the possible
solutions, both long- and short-term. I thank you.
And we now will have an opportunity for individuals to make
very brief comments. I'd ask that you try to limit your
comments to no more than a couple minutes. And I realize you
may feel that that's not fair because these folks had a good
opportunity to present theirs, but I do want to be able to hear
from everyone.
I do have a sign in sheet that we will follow off of. The
first person that we will hear from is Diane Holmes. The second
is Diane DeSanto, and then we will go to Jenna Lundy. So if
those of you who are not on a list wish to testify, I would
just ask that you line up there toward the back.
Ms. Holmes, welcome.
Ms. Holmes. Senator, my comments are of course directed to
you, but also if they'll stick around, to the WWAMI students.
I'm a detail person and I do have some solutions that I
hope you will hear me out including how to get or keep people
here, good medical people here.
There's unnecessary shortcomings to this system. The first
situation I'd like to bring to your attention is that Medicare
regulations actually cause higher costs. I am discouraged from
getting lab work at the cheapest, but quality, lab in this town
because Medicare--I can not submit Medicare forms, because my
lab will not submit Medicare forms--and the regulations that
might allow me to be reimbursed are beyond ridiculous.
Why can't the reimbursement procedures be streamlined so
that I can submit my $35 lab fee that gives me three times the
amount of tests than a somewhat similar one at the hospital?
Granted, I was not a Medicare patient at the time. However,
there is a page in the Medicare Web site, and I have an
outdated form that should allow me to submit my claims and be
reimbursed myself, but it is so ridiculous. I can not do this
until 15 months have passed. There needs to be something done
so that I can do this myself.
Regarding the web information, you're not the webmaster and
I won't bore you with the details, but it is inaccurate, and I
could do a much better job, and I hope you will put me to the
right person.
Are you aware about the contracts? There are doctors in
this town who require their Medicare customer to sign a
contract to be seen. I'm told by my secondary insurance----and
by that I mean the company, actually the State, secondary
insurance that pays the paltry 20 percent of the remaining
Medicare allowable fee--that if I sign a contract they will not
pay that 20 percent. I don't know how they're going to find out
if I have paid that or not, but, and I don't even know if I can
submit to Medicare after I have paid that, but these are things
that need to be looked into.
No. 3, the bill. There's a bill that the doctors could
charge me 115 percent of what is allowable for a Medicare CPT
code procedure. Why can't I just pay the difference between
that and the regular bill, as you just heard some of the
doctors say? I could get my miles and submit my own claim.
[Applause.]
I have been doing that for a long time, and as long I have
the grey matter to fill out the forms, why not let me? And if
by doing this, this would allow some Medicare customers to be
seen by the doctors because those of us that may be able to pay
the full difference, can. And we would be, then, a regular
paying customer.
And the last thing I'd like to say, how do you get more
doctors to stay here? I'm afraid you have to look beyond
medicine. You have to look as to what makes a healthy
community, and a healthy person. And that is, we want to make a
livable city so that these--I call them kids, they are pretty
young--will want to come back. We need a walkable city, and we
have to make sure that we have a city that has good northern
climate land use designs.
And it's very appropriate right now because we have title
21 coming up and this Administration and the people in Juneau
can do an awful lot to making good northern city communities,
particularly with the $93 million sitting there now to be given
probably, unfortunately to Anchorage for a bridge to nowhere,
very soon.
Senator Murkowski. Thank you Ms. Holmes.
Diane Santo. Oh, okay.
Welcome Mr. Jesse.
Mr. Jesse. Thank you, Senator. Again, our appreciation for
holding this hearing. Diane DeSanto, unfortunately, had to go
back down to the Mayor's office.
Well, certainly this is an issue for many of us,
particularly around psychiatry and particularly around
children's psychiatry. Listening to the testimony about doing
residencies and partial residencies, all of those opportunities
I think are very positive. If we could set that sort of thing
up in Alaska, particularly now with our Bring the Kids Home
initiative, where we are building in-state capacity and
partnership with the University on workforce issues--I think if
we are able to develop that kind of a connection between those
people that have these skills and are interested in serving
this population--I think this could be a very positive thing.
Certainly the Mental Health Trust Authority would be interested
in partnering and developing that kind of residency program
within the State.
So with that, good luck, and thank you very much.
Senator Murkowski. Thank you, we appreciate what you do
with the Mental Health Trust Authority.
Next we have Jenna Lundy, and following Jenna we have Chad
Whitaker, and then Wayne Westburg.
Ms. Lundy. Senator Murkowski, I'm really nervous, but
thanks for letting me speak. I'd like to respond first of all
that I do not think that there's a quick fix.
I have here a teacher orientation book from 1968 that was
produced by the Bureau of Indian Affairs. My family came to
Alaska at that time and let me just read for a moment, the
section on village health states,
``The teacher plays a major role in disease prevention. Good
health practices are learned chiefly in the school. The teacher
has an obligation to become acquainted with prevalent health
problems, and methods of prevention. Medical personnel should
be consulted, and practical health routines developed, which
can be observed in the home as well as in school. Some common
health problems: eye and ear infections, respiratory ailments,
skin infections, dental cavities, stomach and intestinal
disorders.''
Any of you that practice medicine in this room today knows
that those are the things that the people in our villages face
now. So next year will mark 2008. In 40 years, this list has
not changed. Forty years. Is there a quick fix?
And then this report that, actually I just browsed through
while I was sitting here, but one of the other concerns that I
have just from comments that were made--it says real clearly
here that healthcare workers who grow up in a rural location
are more likely to be recruited to rural practice. Can we,
indeed, bring people from the Lower 48 to places, perhaps
Anchorage, perhaps Girdwood--but can we bring someone to Bethel
where I grew up? Can we bring someone to Hooper Bay? Can we
bring someone to the Village of Napakiak, to Fairbanks, to Tok
where I was last week, but only because I had canceled the
previous trip because it was 52+ below? How do we bring someone
from the States to practice medicine in a place like Tok where
it does, you know, reach 52+ below? Anchorage is pretty mild.
Homer, the Kenai--pretty mild climates.
We have trouble maintaining physicians out in rural Alaska.
We don't have any, at all. The wait time is 3, 4, 6 months out
before someone can see a specialist.
I recently had a very, very close friend who went to ANMC
here, in Anchorage, and was not referred to a specialist,
because her condition wasn't chronic. When Dr. Neubauer spoke
of a person in his practice who retired, that person came to
this lady's aid, and because he was willing to do--come out of
retirement--that woman is alive, today, literally. He saved her
life.
But, that isn't actually what I came to--what I asked to
speak to today. I'm an educator by training, and so I can also
relate to being paid for the services that you're providing,
equitably. And I do understand that there are many physicians
that go into the practice of medicine not merely because of the
amount of money that they're going to make, but because of the
human service that they're going to provide.
Out in the Bethel area, we are blessed with Dr. Carpenter,
who is a dentist. He did fall in love with Bethel, he did fall
in love with the people of the YK Delta, and he chose to stay
there and serve those people.
Dr. Breneman, I'm sure that there are other doctors that
could be listed, from around the State--but those people have
either passed on, or they've retired. And, these young people
that are sitting here--I hope that they are going to step into
those shoes. When I hear of the young man that's from Kenai, I
hope that he chooses to go back to practice in Kenai.
I know the allure of the States, as I keep saying, but the
allure is great. And many of our retirees are leaving, also,
because it's great. But, I would like to say that two of my
colleagues are here with me, and we work with Head Start, and
we work with an organization that has 24 Head Start programs
across the State, and we have five early Head Start programs.
We serve 161 children in the early Head Start program--that's
birth to three. And, of those 161 children, only 64 of them are
up to date on their well-child screenings. And, I have numbers
and statistics that I won't go on and on about, but thank you
for listening.
Senator Murkowski. Thank you, I appreciate it. Thank you
for giving us that rural perspective.
Jed Whitaker, followed by Wayne Westburg.
Mr. Whitaker.
Mr.Whitaker. Thirty-one cents of every healthcare dollar
goes to the paperwork and administrative costs of a healthcare
system convoluted by insurance. The high cost of healthcare is
due to the inefficiency and greed of the insurance industry.
You are quoted as saying we are facing a physician shortage
crisis in Alaska. Your solution, like any good Republican, is
to give a tax cut of $1,000 a month to doctors to entice them
to service Alaska. Doctors, who are already in the highest
income bracket, bribed to practice medicine in Alaska. Solid
Republican rhetoric, because Republicans understand bribes.
Solid Republican rhetoric that asks us to support the war
criminal in the White House, and the trillion dollar costs of
fighting a war that cannot be won, fighting a people who did
not attack America. Rhetoric that says, ``Support the troops,''
with one tongue, while the other tongue cuts Veterans'
benefits, and Medicare. Rhetoric that eliminates the Estate
Tax, a tax which frees just one family, the Waltons, heirs of
Wal-Mart, a $32 billion windfall, with one tongue, while the
other tongue cuts Medicare by $28 billion. Solid Republican
rhetoric that would have us believe that tax cuts for the rich
are good for the country, while the cost of going to college
has risen 35 percent in the last 4 years. Rhetoric that opposes
a living minimum wage, let alone a minimum wage that could pay
for the cost of attending medical school. Solid Republican
rhetoric that equates military might with national security,
while the health of Americans--the real national security--
fails.
The annual cost of the war in Iraq is approximately $120
billion a year. Supplemented by sole-source contracts, to
Christian right private army corporations, like Blackwater, and
friends of Cheney, like Halliburton, who approach a total cost,
to date, of close to a trillion dollars. A trillion dollars to
fight a war that cannot be won, killing a people who did not
attack America. That $120 trillion a year could pay for
universal healthcare, for all Americans, not just Alaskans. It
could also pay for a free college education, and the cost of
medical school for at least two--if not more--people from every
village and city in Alaska.
If you are really serious about solving a physician
shortage crisis in Alaska, stop funding the War in Iraq, and
start funding a program to help the people of Alaska become
doctors.
To have this hearing today, you did not do your job. There
was a nonbinding resolution opposing the escalation of the War
in Iraq. You didn't even--you weren't even there to vote, to
allow that debate to continue. Shame on you.
That is the reason why we have a shortage. We are not
investing in our people. Instead, we are conducting wars that
are illegal and immoral all across this world at a tremendous
cost. Giving tax cuts to the rich, and creating big budget
deficits. And now, with the Democrats pay-go, all the ideas
that were presented to you by all of the esteemed panelists
cannot be funded--cannot be funded--because the Democrats are
going to insist that the budget be balanced. And the only way
that you're going to be able to balance that budget, is to end
the War in Iraq.
Senator Murkowski. Thank you, Mr. Whitaker.
Mr. Wayne Westburg.
Wayne Westburg. Thank you for being here, Senator.
I'm 68 years old, and I work full-time, and I've, in the
last 6 months, had an interesting education. My doctor in--and
I'm sorry, some of this is redundant, but I think it's worth
emphasizing--my doctor informed me he was retiring.
Consequently, I've spent about the last 6 months calling
clinics, doctors all around town, and have found that nobody--
virtually nobody--is taking new Medicare patients.
And, I don't believe it's because of the workload. Being
the individual that I am, I got into some intense questioning
of office personnel and that--I never really did get through to
talk to a doctor--and the reason that they're unable to
accommodate new Medicare patients is pure and simple, money.
That, and a second issue is paperwork, and the bureaucratic
hassle of trying to collect from Medicare, which apparently is
quite a problem, also.
I even offered, naively, to pay the difference. I feel
that's a right that we should have, and they can't legally
accept any additional payment for Medicare-reimbursed services.
Interestingly, I just had a colonoscopy, and I had no
problem finding a specialist to do it, who would handle, who
would take Medicare. I'm in the process of shopping for new
knees, and I have no problem coming up with specialists to do
that stuff. It would appear that the problem is Medicare
payment on general practitioners. And, I hesitate to use the
term discriminatory--I don't know if it's purposeful, but for
some reason, they're just not reimbursing the GPs what they
need, and the constant statement is, ``It doesn't even cover
our overhead.''
Now, I have actually come up with a solution to the
problem, and it may be one that more and more seniors are going
to have to take, and that is, I've gotten with a nurse
provider. And I'm very happy and very satisfied, and they're
enthusiastic, and appear to be very knowledgeable. And that
appears to be a workable alternative.
The only other thing that I would say is, and I've
complained to AARP and whoever else I could think of, but this
is a situation which--I consider myself to be a well-read
individual, and I walked right into it, 3 years after I was 65
years old, not knowing about the issue, and it appears that--
from the calls that I've made around, that the issue, or the
problem, is well-known nationwide, it's just that very few
people are talking about it, or addressing it. And that's all I
have to say. Thank you.
Senator Murkowski. Thank you, Mr. Westburg, I appreciate
that. I think you're right. I think a lot of people get to that
Medicare-eligible age, and realize that this is a problem
that's been out there, but they just were simply not aware of
it, and now they're in the middle of it.
I want to thank all of you for being with us this morning.
We were scheduled to be out at noon, and it's noon straight up,
so again, I want to thank you. There are some others who have
indicated that they would like to submit testimony, and again,
as I indicated this morning, we'll keep the record open here
for several weeks for you to do that. I think we've received
some written testimony already this morning, that will be
included as part of the record.
Senator Murkowski. But, I appreciate the perspective that
so many of you have lent, whether it's from the consumer
perspective, or whether from the provider perspective. And
again, to those of you who are part of the residency program,
part of the training program now, we welcome you, we thank you
for your commitment to serve, and we wish you well. And we do,
plead with you, to come back. We need you here.
And with that, we'll conclude the hearing.
[Additional material follows.]
ADDITIONAL MATERIAL
Acknowledgements
The Alaska Physician Supply Task Force wishes to thank the staff
for their time, diligence, and expertise provided throughout this
project. We also thank all those who contributed their knowledge and
expertise in providing information and comments on our report.
Task Force Members
Richard Mandsager, MD, State of Alaska Director of Public Health
(Co-Chair)
Harold Johnston, MD, Director, Alaska Family Medicine Residency
(Co-Chair)
Rod Betit, President, Alaska State Hospital and Nursing Home
Association
Jan Gehler, Ph.D., Interim Provost, University of Alaska Anchorage
David Head, MD, Medical Director, Norton Sound Health Corporation,
and Chair, Alaska State Medical Board, representing Alaska Native
Tribal Health Consortium
Jim Jordan, Executive Director, Alaska State Medical Association
Karen Perdue, Associate Vice President for Health Affairs,
University of Alaska
Dennis Valenzeno, Ph.D., Director, Alaska WWAMI Biomedical Program
Staff
Patricia Can, Alice Rarig, Joyce Hughes, Stephanie Zidek-Chandler,
and Jean Findley, from Health Planning and Systems Development Unit,
Alaska Department of Health and Social Services, staffed the Task Force
and coordinated production of the report.
Project Funding and Support
Funding to support the Alaska Physician Supply Task Force was
provided by the University of Alaska Statewide, Office of the Associate
Vice President for Health through Federal grants from the Health
Resources and Services Administration, Office of Rural Health Policy,
Special Projects (#D1ARH00052) and Centers for Disease Control (#H75/
CCH024673-01). Additional funding for staff time was provided through
the Department of Health and Social Services: Health Planning and
Systems Development's Alaska Office of Rural Health (HRSA #H95RH00135),
State Planning Grant (HRSA #PO9HSO5505), Primary Care Cooperative
Agreement (HRSA #U68CSO0157), and Rural Hospital Flexibility Program
(HRSA #H54RH00014).
The Task Force members acknowledge the resources that were provided
by our own organizations. Our organizations have supported our time,
travel and related in-kind resources for the project.
(Cover photo: Foreground, Andrew Janssen, M.D., a 2005 graduate of
the Alaska Family Medicine Residency Program, examines 6-month-old
Cooper Baines at the Providence Family Medicine Center in Anchorage,
Alaska. Paul W. Davis, M.D., is shown in background. Photo by Greg
Martin, 2005, courtesy of Providence Family Medicine Center.)
Securing an Adequate Number of Physicians for Alaska's Needs
report of the alaska physician supply task force
(Prepared for Mark Hamilton, President, University of Alaska and
Karleen Jackson, Ph.D., Commissioner, Alaska Department of Health &
Social Services August 2006)
TABLE OF CONTENTS
Executive Summary..... 76
I.................................. Overview: The 80
Physician Supply Task
Force Approach.
II................................. Background: State and 81
National Trends in
Understanding
Physician Supply and
Demand.
III................................ The Alaska Story: 82
Historical and
Current Information
on Physician Supply.
A. Emerging Trends and
Issues Related to
Physician Supply.
B. Forecasting the
Need for Physicians
in the Next Two
Decades.
C. Reasons for Taking
Action to Assure an
Adequate Physician
Supply.
IV................................. Findings and Methods 88
for Forecasting
Supply and Demand to
2025 in Alaska.
A. Demographic Profile
of Alaska through
2025.
B. Projected Demand
and Supply of
Physicians through
2025.
V.................................. Overview of Alaska's 102
Current Health Care
Workforce Development
and Training
Activities.
A. Medical School
Opportunities for
Alaskans.
B. Graduate Medical
Education in Alaska--
the Alaska Family
Medicine Residency.
C. State, Federal and
Tribal Efforts to
Support Health Care
Workforce Development.
D. Lessons from Other
States and from
National Studies.
VI................................. Closing the Gap: 111
Strategies for
``Growing Our Own''--
Training, Recruiting,
and Retaining
Physicians for Alaska.
A. Context and Process
for Selection of
Strategy
Recommendations.
B. Goals and Strategy
Recommendations
Goal 1. Increase the
in-state production
of physicians by
increasing the number
and viability of
medical school and
residency positions
in Alaska and for
Alaskans.
Goal 2. Increase the
recruitment of
physicians to Alaska
by assessing needs
and coordinating
recruitment efforts.
Goal 3. Expand and
support programs that
prepare Alaskans for
medical careers.
Goal 4. Improve
retention of
physicians by
improving the
practice environment
in Alaska.
VII................................ Areas that Warrant 129
Further Consideration.
VIII............................... Appendices............ 129
A. Data Details.
1. Matriculants in
Medical Schools by
State.
2. Specialty
Distribution
Comparison (2004)
Alaska and US.
B. Strategies
Preferences
Scoresheet.
C. Physician Study
Annotated Reference
List.
D. Resource List......
E. Individual
Contributors, Persons
Consulted,
Commenters,
Reviewers, and
Persons who Attended
Task Force Meetings.
F. Acronym List.......
LIST OF FIGURES
Figure A. Gain in Alaskan 78
Physicians.
Figure 1. A First Look at 83
Physician Count in
Alaska.
Figure 2. Distribution of Alaska 84
Physicians by City
and Percent in
Primary Care.
Figure 3. Change from Prior Year 85
in Total Physicians,
by Practice Type.
Figure 4. New Licensees Annually 85
1996-2005 by Type.
Figure 5. A Linear Growth 86
Scenario for
Physician Supply.
Figure 6. Population Projection 89
for Alaskans over Age
65.
Figure 7. Alaska Population 90
Projection by Age and
Male/Female, 2024.
Figure 8. Active Physicians by 92
Degree Type.
Figure 9. Alaska's National 93
Ranking in MDs per
1000 Residents.
Figure 10. Physicians, 93
Podiatrists,
Physician Assistants,
and Paramedics.
Figure 11. Alaska Physicians' Age 94
Distribution.
Figure 12. U.S. Physicians' Age 94
Distribution.
Figure 13. Age Distribution of 95
Physicians (MDs and
DOs) in Alaska.
Figure 14. Age Distribution of 95
Physician's
Assistants in Alaska.
Figure 15. Age Distribution of 96
Advanced Nurse
Practitioners in
Alaska.
Figure 16. Age at Expiration of 96
License.
Figure 17. Age of 1998 Cohort 97
``Stayers'' and
``Leavers''.
Figure 18. Age at Expiration of 97
License of Non-
Current Physicians.
Figure 19. Age of Current Active 98
AK Physicians.
Figure 20. Count of Current, 98
Active AK Physicians
by Length of Service.
Figure 21. Alaska Mid-levels by 99
Type and Year
Licensed as of
January 1, 2006.
Figure 22. MDs and DOs by Year 99
Licensed.
Figure 23. Alaska 2004 Patient 100
Care Physicians (MDs)
by Specialty.
Figure 24. Physicians by Practice 100
Type in Alaska.
Figure 25. Physician Need 101
Forecasts for 2025.
Figure 26. Gain in Alaskan 102
Physicians (MDs):
Static Doctor to
Population Ratio vs.
Desired Growth.
Figure 27. WWAMI Outcomes Flow 103
Chart.
Executive Summary
The Alaska Physician Supply Task Force was commissioned in January
2006 by the President of the University of Alaska and the Commissioner
of the Department of Health and Social Services to address two
questions:
1. What is the current and future need for physicians in Alaska?
2. What strategies have been used and could be used in meeting the
need for physicians in Alaska? Strategies of interest are:
programs to attract and prepare students for health
careers;
medical school opportunities;
graduate medical education; and
recruitment and retention of physicians.
The Task Force has met regularly and drawn on a wide variety of
sources of information, including public participation. The consensus
of the Task Force is that this report represents the best answer
possible to these questions, within the constraints of time and budget,
and the inherent uncertainties of available data and predictions. The
major conclusions and reasoning of the group are summarized here, and
detailed in the body of the report.
Alaska has a shortage of physicians.\1\ Although not at crisis
levels, the shortage is affecting access to care throughout the State,
and increasing cost to hospitals and health care organizations. Up to
16 percent of rural physician positions in Alaska were vacant in 2004.
Patients with Medicare are having difficulty finding a primary care
physician. Several important specialties are in serious shortage in
Alaska.
---------------------------------------------------------------------------
\1\ Unless otherwise specified, ``physician'' in this report means
medical doctor as well as doctor of osteopathy.
---------------------------------------------------------------------------
The shortage is very likely to worsen over the next 20 years as the
State's population increases and ages. Physician supply nationwide is
entering a period of shortage, according to the best current
predictions. Physicians in Alaska are aging and one-third may be
retiring in the next 10-15 years. The new generation of physicians
wants a more balanced life, meaning fewer hours on duty and more
predictable schedules. These trends mean that more physicians will be
required to serve the same population. Technology and scientific
advances have increased the amount of medical care available, adding to
the need for physicians, as the patients expect more care than
previously.
As the national supply of physicians shrinks, recruitment will
become more competitive. Alaska's traditional system of recruiting
physicians from Federal assignment in the military and Indian Health
Service is much less effective with changes in these systems. Although
Alaska has two very successful programs to produce its own physicians,
the Alaska WWAMI medical school program and the Alaska Family Medicine
Residency, Alaska is far behind the other States in production
capacity. These two programs, even if expanded, cannot meet the need.
The current trend in physician growth in Alaska is inadequate to
keep up with basic population growth and to correct the current
deficit. Unless changes are made in the systems used to increase
physician numbers, the deficit will worsen, with significant
consequences for access and quality of care for Alaskans, as well as
increased cost for health care delivery systems.
The time frames to increase physician supply are long; it takes
from 7 to 13 years from entry into medical school to entry into
practice. The time it takes to develop new or expanded programs adds to
this delay. It is important to act quickly to begin the programs that
will yield more physicians in the next two decades. Delay will only add
to the cost and worsen the deficit to recoup.
Responses to this problem involve preparing and attracting Alaskan
youth so they can enter medical careers, improving recruitment of
physicians to practice in Alaska, and retaining the physicians who
currently practice here. The Task Force recommends specific strategies
and action steps to achieve four goals related to assuring an adequate
supply of physicians to meet Alaska's need.
Goals:
1. Increase the in-state production of physicians by increasing the
number and viability of medical school and residency positions in
Alaska and for Alaskans.
2. Increase the recruitment of physicians to Alaska by assessing
needs and coordinating recruitment efforts.
3. Expand and support programs that prepare Alaskans for medical
careers.
4. Increase retention of physicians by improving the practice
environment in Alaska.
The following sections summarize the findings of the Alaska
Physician Supply Task Force supporting these goals. The body of the
report contains the full discussion of the goals, strategy
recommendations, and the rationale behind the recommendations.
Assessment of need. The Task Force estimates that Alaska has a
shortage of 375 physicians, based on the conclusion that Alaska should
have 110 percent of the current national average physician-to-
population ratio. In order to correct the deficit and reach an adequate
supply of physicians by 2025, Alaska needs to add a net of 59
physicians per year, starting immediately. Alaska currently gains 78
physicians per year but loses 40 physicians yearly for various reasons.
In order to improve its doctor to population ratio, and assure having
an adequate supply in 20 years, the current net gain of 38 physicians
per year will need to increase to 59 per year, more than a 50 percent
increase. If the loss each year is greater than the recent average of
40 per year, Alaska will need more than 90 physicians to enter practice
in Alaska each year.
These conclusions are supported by the following findings.
Finding 1. The ratio of physicians to population in Alaska is below
the national average at 2.05 MDs per 1,000 population vs. 2.38 MDs per
1000 population in the United States.
Finding 2. Alaska should have 10 percent more physicians per
population than the national average because Alaska's rural nature,
great distances and severe weather result in structural inefficiencies
of the health care system. Alaskan physicians' administrative and
supervisory responsibilities in addition to patient care contribute to
the need for more physicians to provide patient care services.
Finding 3. Competition for physicians will intensify since the
entire Nation is expected to experience a shortage of physicians,
associated with the aging of the population and an inadequate
production of physicians.
Finding 4. Retirement and practice reductions of aging physicians
in Alaska and elsewhere, as well as changing preferences of physicians
for more limited work hours, add to the need for more physicians.
Finding 5. Alaska has and should maintain a higher ratio of mid-
level providers (advanced nurse practitioners and physician assistants)
to physicians than the national average, in order to make it feasible
to provide high quality and timely care to the population. Without
these providers the need for physicians would be even higher.
Finding 6. Shortages are most apparent in internal medicine,
medical subspecialties and psychiatry. It is important to evaluate the
need for specialty types and distribution throughout Alaska, in order
to plan for physician recruitment.
Over the next 20 years, nearly twice as many ``physicians in
practice'' will be needed--about 1,100 more than the current 1,347 MDs
in patient care--to meet expected demand as the State's elderly
population triples and as medical practice patterns change. This
projection assumes that doctors of osteopathy, advanced nurse
practitioners and physician assistants will continue to increase
proportionately over time.
Basis for strategies for meeting the need for physicians for
Alaska's health care system. After investigating the supply and need
for physicians and reaching Findings 1-6, the Task Force shifted its
focus to investigating strategies for meeting the need. The Task Force
drew on the knowledge of in-state professionals and educators, and of
national experts, to identify lessons and information that form the
basis for recommendations for action, as well as for further
investigation and monitoring. The Task Force's selection of strategies
is based on the following findings.
Finding 7. Alaska is one of six States without an independent in-
state medical school. Alaska funds 10 state-supported ``seats'' at the
regional WWAMI medical school, administratively centered at the
University of Washington School of Medicine. This number (10 seats)
represents fewer seats per capita than all but five of the 50 States.
Finding 8. Residency programs are one of the most effective ways to
produce physicians for a State or community. Alaska has only one in-
state residency, the AFMR, which places 70 percent of its graduates in
Alaska. Maintaining and expanding residency opportunities will be
critical in augmenting Alaska's physician numbers.
Finding 9. Over the last 10 years, an increasing number of Alaskan
students have applied to medical schools; the average number of
applicants has been 65. In 2005, 29 of 73 applicants were admitted into
medical school. Ten per year attend WWAMI and the remainder attends
medical schools without State support from Alaska. Since 1996, only
WWAMI has had Alaska-supported seats. Prior to 1996, Alaska supported
programs for medical and osteopathic students through the WICHE program
and student loans.
Finding 10. Recruitment for physicians is facilitated by the
availability of loan repayment programs such as the IHS and NHSC loan
repayment programs. Service obligations related to student loans have
historically accounted for some recruitment and should be explored.
Finding 11. There are several initiatives to increase interest in
medical careers among Alaskans, including efforts by the tribal health
care system, hospitals, the University of Alaska's newly funded Area
Health Education Center (AHEC) and the UA Scholars Awards, school
system initiatives for improvement of math and science programs, and
programs that encourage students to go into health careers.
Collectively, these initiatives generate qualified applicants to
medical schools, but too few applicants matriculate to replenish
Alaska's shortage, and there is inadequate diversity.
Finding 12. Medical practice environments in Alaska have positive
and negative aspects that affect the recruitment and retention of
physicians.
Finding 13. Surveys of providers (physicians and mid-levels) by the
AMA and many States have provided data on practice characteristics,
preferences, and retirement plans.
Finding 14. Workforce development activities exist in multiple
locations including the tribally managed system, private sector, and
various State and Federal agencies. However existing programs are not
monitoring or analyzing specialty distribution or needs, changing roles
of mid-level providers, or potential impact of electronic health
records on all providers. Coordination of the efforts, and research and
analysis of relevant trends, should inform policy.
In view of these findings, the relevant literature, and the
experience of other States, the Task Force developed the following
goals and strategies to respond to the physician shortage. The
strategies are chosen because of their likely effectiveness, cost-to-
benefit advantages, and achievability. Each strategy is discussed with
respect to the time frame in which it will be effective, and the
average expected cost to the State to produce each practicing
physician, where such information is reasonably accessible. The listing
below gives a brief identification of each goal and strategy. Full
discussion of the strategies is included in the body of the report.
Goals and Strategies for Securing an Adequate Physician Supply for Alaska's Needs
Major goal Strategy Timeline for impact Estimated cost
1. Increase the in-state production A. Increase the number Medium................. $250,000 per practicing
of physicians by increasing the of state-subsidized physician.
number and viability of medical medical school
school and residency positions in positions (WWAMI) from
Alaska and for Alaskans. 10 to 30 per year.
B. Ensure financial Short.................. $60,000 per practicing
viability of the AFMR physician.
through State support
including Medicaid
support.
C. Increase the number Short.................. $100,000 per year plus
of residency positions $30,000 for planning
in Alaska, both in in year 1 & 2.
family medicine and
appropriate additional
specialties.
D. Assist Alaskan Medium................. (i) $550,000 per
students to attend practicing physician
medical school by: (i) for WICHE;
reactivating and (ii) cost unknown at
funding the use of the time of PSTF report.
WICHE Professional
Student Exchange
Program with a service
obligation attached,
and (ii) evaluating
the possibility of
seats for Alaskans in
the planned
osteopathic school at
the Pacific Northwest
University of the
Health Science.
E. Investigate Medium................. Unknown at time of PSTF
mechanisms for Report.
increasing Alaska-
based experiences and
education for WWAMI
Students.
F. Maximize Medicare Short.................. Zero cost to the State.
payments to teaching
hospitals in Alaska.
G. Empanel a group to Long................... Undetermined at time of
assess medical PSTF Report.
education in Alaska,
including the
viability of
establishing an Alaska-
based medical school.
2. Increase the recruitment of A. Create a Medical Short.................. $250,000 per year.
physicians to Alaska by assessing Provider Workforce
needs and coordinating recruitment Assessment Office to
efforts. monitor physician
supply and facilitate
physician recruitment
efforts.
B. Research and test a Short.................. $65,000 per physician.
physician relocation
incentive payment
program.
C. Expand loan Short.................. Undetermined--need to
repayment assistance consult with other
programs and funding States.
for physicians
practicing in Alaska.
3. Expand and support programs that A. Expand and Medium................. Up to $1,000,000 per
prepare Alaskans for medical careers. coordinate programs year.
that prepare Alaskans
for careers in
medicine.
4. Increase retention of physicians A. Develop a physician Short.................. $100,000 to develop
by improving the practice practice environment index; $20,000
environment in Alaska. index for Alaska. annually to update.
B. Develop tools that Short.................. $50,000 per year.
promote community-
based approaches to
physician recruitment
and retention.
C. Support Federal tax Short.................. Zero cost to the State.
credit legislation
Initiative for
physicians that meet
frontier practice
requirements.
Adoption of these strategies will depend on further analysis of
resources and a balancing of effectiveness and achievability.
Strategies to recruit and retain physicians promise the earliest
positive results, but probably have a relatively low benefit ceiling,
in that the maximum number of physicians achievable by those strategies
will soon be reached. The strategies likely to produce significant
numbers of doctors over time are those designed to train physicians in
Alaska, i.e. medical school and residency programs, but the time to
realize the benefit in most cases is longer.
Implementation strategy--next steps for key policymakers. The
shortage of physicians and other health care providers creates one of
Alaska's most challenging public health and higher education issues. To
ensure the work of the Task Force is carried forward, it is recommended
that the President and Commissioner establish permanent structures to
implement these recommendations. One component of this action would be
creation of a Medical Provider Workforce Assessment Office (Strategy
2A).
SECTION I. OVERVIEW: THE PHYSICIAN SUPPLY TASK FORCE APPROACH
In December 2005, University of Alaska President Mark Hamilton and
Alaska Department of Health and Social Services Commissioner Karleen
Jackson appointed the Alaska Physician Supply Task Force to answer two
primary questions.
1. What is the current and future need for physicians in Alaska?
2. What strategies have been used and could be used in meeting the
need for physicians in Alaska? Strategies of interest are:
programs to attract and prepare students for health
careers;
medical school opportunities;
graduate medical education; and
recruitment and retention of physicians.
The Task Force as a group of experts, was charged by President
Hamilton and Commissioner Jackson to recommend the most appropriate and
effective response to a persistent physician supply shortage within
Alaska, spiraling costs of recruitment, effects on Alaska of projected
national shortfalls, and the need to develop a workable plan to meet
physician workforce needs throughout the State from now through 2025.
The Physician Supply Task Force worked through two phases:
Phase I (December 2005--March 2006); and
Phase II (February 2006--August 2006).
During Phase I the Task Force identified and analyzed the data
regarding medical provider counts for the State and compared it to data
from other States and nationwide. This phase assisted in evaluating the
scope of the problem. The Task Force also considered the expertise of
its members, and the knowledge of other advisors and consultants from
Alaska regarding State programs for encouraging students to enter
health careers, for subsidizing or contributing to training programs,
and for supporting students through scholarships and loans.
In Phase II the Task Force chose to focus on developing short,
medium and long term recommendations to meet physician supply
requirements in Alaska through 2025. They also considered the impact of
their recommendations on training, recruitment and retention of
physicians. The Task Force prioritized and grouped strategies based on
reports from other States, Alaska's experience, and expected
feasibility and effectiveness in the current environment.
Task Force members chose to operate under a consensus model related
to findings and strategies. During their work, the Task Force members
used scoring methodologies, expert testimony, and staff consultation to
reach their findings and recommendations.
Task Force members and invited guests shared their expertise
regarding training of physicians. Presentations included those from
WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) regional medical
school based within the University of Washington School of Medicine,
and the AFMR in Anchorage.
Staff contacted experts from the Center for Health Workforce
Studies at the University of Washington, the North Carolina Rural
Health Research Program and Program on Health Policy Analysis at the
University of North Carolina at Chapel Hill, the Utah Medical Education
Council, and other State and national programs. Reports of the several
Centers for Health Workforce Studies, U.S. Bureau of Labor Statistics,
Health Resources and Services Administration, and other States that
have addressed physician workforce issues were studied. A review of the
literature focused on assessing and forecasting physician supply and
demand at State and national levels, and on strategies being used to
increase physician supply. Current status of recruitment and retention
efforts and programs such as student loan programs and loan forgiveness
options that have been used in Alaska and elsewhere were reviewed.
The Task Force met monthly from December 2005 to August 2006.
Public comment was encouraged throughout the process. Meeting
announcements were publicly posted and time was set aside at each
meeting for public comment. In addition to monthly meetings, a longer
meeting was held March 27, 2006 to discuss, enhance and prioritize
recommendations. This meeting included a broad group including
stakeholders, members of the public, and Task Force and project staff.
The draft report was distributed for review and comment to over ninety
individuals who have expertise and interest in this issue.
The next three sections of the report describe current information
from diverse sources in Alaska about trends and issues related to
physician supply and recruitment, distribution, and factors in Alaska
that may need to be considered in forecasting need, followed by more
detailed information about the data that can be used to forecast
supply. This material provides the basis for the ``findings'' relating
to the first question asked of the Task Force: ``What is the current
and future need for physicians in Alaska?'' Section V provides the
information gathered to answer the second question: ``What strategies
have been used and could be used in meeting the need for physicians in
Alaska?'' Section VI contains detailed discussions of the goals and
strategies proposed by the Task Force. Section VII includes a listing
of areas that warrant further consideration, in that they were
discussed by the Task Force but not researched or thoroughly documented
in this report.
SECTION II. BACKGROUND: STATE AND NATIONAL TRENDS IN UNDERSTANDING
PHYSICIAN SUPPLY AND DEMAND
Alaska's health care organizations are facing major difficulties
and great expense in recruiting and retaining physicians. Both private
and public health care agencies have pointed out to State policymakers
and the University of Alaska that they are spending increasing time and
money seeking doctors to staff their services. A looming national
shortage is already affecting Alaska's service delivery. Indeed, a
review of the literature finds that the United States is experiencing a
shortage of physicians which is predicted to rise due to the needs of
an aging population, increases in physician retirement, restricted
production of new physicians nationally, insufficient GME training
capacity, and changes in practice patterns. By 2020, a deficit of
96,000 to 200,000 doctors is anticipated nationwide (Cooper, 2004).
History of national physician shortage. The current shortage can be
traced back to a response to a series of influential reports published
between 1981 and the mid 1990s, which inaccurately predicted that the
Nation would experience a large surplus of physicians by 2000. The
reports were written by national advisory groups, including the
Graduate Medical Education National Advisory Committee (GMENAC) and the
Council on Graduate Medical Education (COGME), that were tasked with
making policy recommendations regarding the adequacy of the supply and
distribution of physicians (Cooper, 2004).\2\ Their information was
driven by an opinion that health maintenance organizations (HMOs) would
decrease physician demand by promoting preventive care and reducing
tests and procedures.
---------------------------------------------------------------------------
\2\ Richard Cooper MD has written extensively on the evolution and
effect of these positions and reports. See Annals of Intern Med 141,
2004, p. 705.
---------------------------------------------------------------------------
Subsequent to these reports, allopathic medical schools around the
country voluntarily capped the production of new physicians. However,
residency programs and osteopathic medical schools did not heed the
reports' warnings and continued to increase the number of physicians in
the residency programs and osteopathic schools. Between 1980 and 1990,
the number of residents training in the U.S. increased by nearly 50
percent from 62,000 to 92,000 residents (Salsberg and Forte, 2002).
As concerns about physician oversupply escalated, COGME recommended
in 1996 that the number of physicians entering residency programs be
reduced from 140 percent to 110 percent of the baseline (the number of
medical school graduates in 1993) and that the percentage of
specialists to generalists be evenly split, 50/50. Finally, in 1997,
Congress placed a cap on the number of available residency slots that
would be supported by the Medicare program. This significant economic
disincentive effectively capped GME in the United States.
It was not long, however, before the wisdom of these
recommendations and subsequent restrictive policies was questioned.
Physician oversupply did not occur. Instead, reports of shortages for
both general practitioners and specialists surfaced (Schubert et al.,
2003; Miller et al., 2001). It appeared that a significant shortage
rather than oversupply was looming on the horizon. As a result, COGME
reviewed physician workforce projections again, predicted that
physician demand would significantly outpace supply, and recommended
that medical schools expand the number of graduates by 3,000 per year
by 2015. In 2005, the executive council of the Association of American
Medical Colleges (AAMC) called for a 15 percent increase in medical
school enrollment, and in June, 2006, the AAMC called for a 30 percent
increase in medical school slots by 2020 in order to meet future
physician needs (AAMC, 2006).
Economic impact of physician supply. The supply of physicians
impacts State economies in many ways. It is an economic driver and
affects a State's ability to draw businesses as well as skilled,
competitive employees. Businesses and potential staff are more likely
to locate in communities that assure the availability of quality
medical care services. Dollars spent on health care are recycled in the
economy to the extent that labor, supplies and services are acquired
locally. In 2004, personal health care expenditures represented 13.4
percent of the gross national product. It represented 12.3 percent (1.6
billion dollars) of Alaska's gross State product.
(www.cms.hhs.gov/NationalHealthExpendData/downloads/
nhestatesummary2004.pdf)
In Alaska, business concern about adequacy of health services in
the State has been expressed by the Commonwealth North study of primary
care and the subsequent initiatives in 2005-2006 of the Alaska Health
Care Roundtable to examine costs of health care and health insurance,
and availability of options for employers and employees (Commonwealth
North, 2005). The University of Alaska, Institute for Social and
Economic Research recently produced an analysis of costs of health care
in Alaska (UA ISER, 2006). The Alaska State Medical Association (ASMA),
the Alaska State Hospital and Nursing Home Association (ASHNA), the
University of Alaska, and the State's largest health care organizations
(Providence Health Systems and the Alaska Native Tribal Health
Consortium (ANTHC)) have all focused on the looming shortage and have
begun to take steps to improve practice environments.
SECTION III. THE ALASKA STORY: HISTORICAL AND CURRENT INFORMATION ON
PHYSICIAN SUPPLY
A. Emerging Trends and Issues Related to Physician Supply
In 2004, Alaska's physician-to-population ratio ranked 17th lowest
in the Nation--i.e., in the lower third of all States.\3\ \4\ About
1,350 allopathic physicians (MDs) work in patient care and about 100
osteopathic physicians (DOs) are in practice in Alaska. Alaska has 205
physicians (MDs and DOs) providing patient care per 100,000 population,
compared with 238 for the United States (AMA, 2006).
---------------------------------------------------------------------------
\3\Allopathic medicine is conventional medicine. The term was
coined in 1842 by C.F.S. Hahnemann to designate the usual practice of
medicine as opposed to homeopathy. Doctors of osteopathy have completed
a course of study equivalent to that of an MD and are licensed to
practice medicine. They may prescribe medication and perform surgery,
and they often use manipulation techniques similar to chiropractics or
physical therapy.
\4\ Chen et al., 2005 show Alaska in the middle of the range of
States using the 2005 AMA master file, selecting ``clinically active''
physicians, but using a slightly lower population estimate than that
used in this report. Kaiser Family Foundation ``statehealthfacts.org''
and the U.S. Statistical Abstract show rankings using counts of ``non-
Federal physicians'' only. Since these use population estimates that
include the military and Alaska Native and American Indian populations
who are served by the excluded physicians, the resulting rankings
placing Alaska lower than 17th. These differences show the importance
of understanding the definitions of the inputs and assumptions made in
any presentation of similar data.
---------------------------------------------------------------------------
A recent survey of ``vacant'' slots for Alaska physicians indicated
a 16 percent vacancy rate outside of Anchorage. Although doctors of
osteopathy, advanced nurse practitioners and physician assistants are
available in Alaska to provide medical care, the current deficit in
allopathic physicians is being felt by the profession and by health
care organizations as they seek to staff their services. The current
``shortage'' using the national physician to population ratio as the
norm can be defined as equal to 218 fewer physicians currently in
patient care in Alaska than if the U.S. ratio applied.
Figure 1. A First Look at Physician Count in Alaska
------------------------------------------------------------------------
MDs Per
Measure MD Count 1000
(Alaska) Population
------------------------------------------------------------------------
2004 actual physicians in patient care (per 1,347 2.05
AMA Master File).............................
2004 ``expected'' at national average......... 1,565 2.38
``Deficit'' from national norm................ 218 ---
Percent ``deficit''........................... 14 percent ---
Outside Anchorage Vacancy Rate (AFMR survey 16 percent ---
2004)........................................
------------------------------------------------------------------------
Alaska's specialists are located mainly in the largest urban
centers. Anchorage, which serves as the specialty center for the State
as a whole, has approximately 464 specialists and 323 ``primary care''
physicians (family practitioners, internists, pediatricians and
obstetrician-gynecologists).\5\ Anecdotal information suggests that
Anchorage lacks sufficient primary care physicians, especially
internists, to meet the population's needs. The Task Force identified
this as one area needing further study.
---------------------------------------------------------------------------
\5\ DHSS Health Planning and Systems Development analysis of
occupational licensing and ASMA data (merged).
---------------------------------------------------------------------------
Rural areas are served by primary care physicians who are
headquartered mostly in regional centers. In rural census areas and
boroughs there are fewer physicians per population than in the urban
areas. Telehealth development in Alaska has improved the ability of
physicians in regional centers to supervise and consult with mid-level
providers in sub-regional and village clinics, and with community
health aides and practitioners in the Alaska tribal health care system.
Similarly, the telehealth options have enabled primary care physicians
in rural areas to consult with specialists in Anchorage and in some
cases out-of-state experts. Within both the tribal system and the
private sector, there are still itinerant specialists (both in-state
and out-of-state residents) who visit rural communities or regional
centers to hold specialty clinics or see selected patients. The
regionalized structure provides for a level of access to care that
could not be supported economically by individual communities.
Small communities typically have a difficult time supporting
physician services, in Alaska as well as elsewhere. Communities may be
``too small, too poor, or too disadvantaged in geographic competition
to support sufficient viable physician practices,'' and may not have
the ``economic wherewithal to support more physician practices even
though physician to population ratios may indicate they are needed''
(Wright et al., 2001). Seasonal fluctuations related to tourism,
fishing season, and weather-dependent construction are often an
additional challenge to small Alaskan communities. Staffing levels
which may be appropriate on average through a year may be inadequate
for peak periods, which can also ``burn out'' an isolated, solo
provider. National trends are away from solo practices. Alaska is also
experiencing trends toward hospital hires of physicians, reliance on
emergency medicine specialists to staff emergency rooms, and clinics
having a combination of physician and mid-level (advanced nurse
practitioner and physician assistants) staffing.
Distribution of Alaska physicians. The Task Force has recognized
that there are inherent inefficiencies related to the vast distances
that must be covered by patients and providers, uncertainties of
weather and transportation options, and the inherent challenges of
living and working in remote and geographically isolated conditions.
These factors were considered in Task Force deliberations about targets
for physician supply. Figure 2 shows the distribution of physicians and
population for areas with five or more physicians.
Figure 2. Distribution of Alaska Physicians by City and Percent in Primary Care
----------------------------------------------------------------------------------------------------------------
Physicians
State's in the City Alaska
Total Physicians who are in Population
City/Area of Physicians in Alaska Physicians in the City Primary in the City/
(percent) Care Area
(percent) (percent)
----------------------------------------------------------------------------------------------------------------
Anchorage Total.............................................. 787 60 41 42
Fairbanks Total.............................................. 151 11 51 13
Wasilla, Palmer, Willow...................................... 83 6 49 11
Juneau/Auke Bay.............................................. 70 5 46 5
Soldotna & Kenai............................................. 46 3 52 7
Sitka........................................................ 31 2 68 1
Ketchikan.................................................... 27 2 56 2
Kodiak....................................................... 23 2 74 2
Homer........................................................ 18 1 44 1
Bethel....................................................... 15 1 100 4
Dillingham................................................... 8 1 100 1
Nome......................................................... 8 1 88 1
Kotzebue..................................................... 6 0 100 1
Seward....................................................... 6 0 83 1
Barrow....................................................... 5 0 80 1
Balance of State............................................. 32 2 7
Total with known spec'ty..................................... 1,316 100
----------------------------------------------------------------------------------------------------------------
Note: Primary Care physicians include family practitioners, internists, pediatricians and obstetrician-
gynecologists.
Source: Merged ASMA Directory listing and Alaska Occupational Licensing
database (AKDHSS HPSD 2006).
It should be noted that Anchorage has a higher percent of the
State's physicians for their population because it is Alaska's largest
city and is a specialty referral center. Many patients come to
Anchorage from other parts of the State for medical care. Fairbanks,
Juneau, Sitka, Kenai/Soldotna and Ketchikan each have several
specialties represented among the physicians.
Fluctuations in physician supply. The Task Force has examined the
data on licensing of new physicians in the State and loss of resident
physicians, measured by expiration of licenses or moves out of state.
Losses are attributable to retirement, migration, and mortality.
Detailed findings are described below in analysis of trends.
The ASMA Directory showed a drop in listed physicians in 2004,
prompting discussion and concern. (See Figure 3.) The decline was
explained by a sudden drop in the listed members of the military
services, related to the base closings and deployments to Iraq.
A critical finding of the Task Force has been that since 1998 new
MD licenses have averaged 78 per year, and on average 40 licenses have
expired each year.\6\
---------------------------------------------------------------------------
\6\ The number of both new and expired licenses has varied from
year to year (see Figure 4), with new licensees ranging from a high of
108 in 2002 to 61 in 2004. The timing of losses to the State's
physician supply is more difficult to pinpoint than entry since out-
movers or retirees may not report changes in address or activity to the
Alaska State Medical Board immediately. When they do report, the
information is entered as ``comments'' with the status change noted,
but the details about the date and specific reasons for change would
need to be analyzed through a study of the Board's detailed file
``comment'' entries. These are not part of the publicly available
electronic files.
---------------------------------------------------------------------------
Physician recruitment in Alaska appears to have declined since a
high point in 2002 (there were 108 new MD licenses for physicians with
Alaskan addresses in 2002 and only 73 in 2005). Licenses of new DOs
have been increasing (from six in 1998 to nine in 2005), and numbers of
advanced nurse practitioners and physician assistants being licensed
annually have increased as well (see Figure 4).
Figure 4. New Licensees Annually 1996-2005 by Type
(Active Licenses, Alaska Addresses, in practice in January 2006)
------------------------------------------------------------------------
MD DO NP PA
------------------------------------------------------------------------
1996........................ 68 1 18 15
1997........................ 65 7 26 14
1998........................ 86 6 28 19
1999........................ 92 8 18 9
2000........................ 67 5 32 13
2001........................ 71 4 25 11
2002........................ 108 8 25 22
2003........................ 90 7 30 12
2004........................ 61 11 32 39
2005........................ 73 9 30 29
------------------------------------------------------------------------
Note: From comparative data for 1998 it is evident that some of the
earlier licensees have left Alaska or left practice. To do a precise
and complete analysis would require analysis of the ``comments'' files
kept by Occupational Licensing, which was not feasible during this
project.
Source: Alaska Division of Occupational Licensure
If the number of Alaska physicians retiring increases, or out-
migration or ``lapsing'' of licenses increases, Alaska could lose more
physicians than it gains, adding to the burden of boosting the current
supply. The Status of Recruitment Resources and Strategies report
indicated rapidly escalating costs of recruitment for rural physicians,
and increased dependence on locum tenens physicians to handle patient
care (DHSS/ACRH, 2006).
Two trends could intensify the need for new physician recruits in
Alaska. One trend is that the physician workforce is aging, so the rate
of retirement is likely to increase, thus increasing the loss of
physicians. The second trend is the growing national shortage, which is
already making recruitment to Alaska more difficult.
B. Forecasting the Need for Physicians in the next Two Decades
According to the Task Force projections of need (elaborated in
Section IV below), at this time Alaska needs a net gain of about 59 new
physicians each year to offset the number of physicians who leave or
retire. Annual losses are currently 40 per year, but are expected to
increase as a higher proportion of physicians age and retire. One
``linear'' scenario for replacing physicians as they leave practice,
and building the total supply, is illustrated in Figure 5. A net gain
of 59 physicians per year would be a 50 percent increase over the
recent average net gain of 38 per year. This increment could be
accomplished by increasing the number of new licensees to average
between 100 and 105 per year.
Figure 5. A Linear Growth Scenario for Physician Supply
----------------------------------------------------------------------------------------------------------------
Year Projected Physicians in Needed Estimated Recruitment
----------------------------------------- Practice Annual Loss due to Needed to
--------------------------------- Increment Migration/ Achieve
------------- Retirement Needed
MDs in ------------- Increment
Practice DOsActive Total ------------
----------------------------------------------------------------------------------------------------------------
2004.................................... 1,347 109 1,456 59 40 99
2005.................................... 1,399 115 1,515 59 40 99
2006.................................... 1,451 122 1,573 59 41 100
2007.................................... 1,504 128 1,632 59 41 100
2008.................................... 1,556 135 1,690 59 42 101
2009.................................... 1,608 141 1,749 59 42 101
2010.................................... 1,660 147 1,808 59 43 102
2011.................................... 1,712 154 1,866 59 43 102
2012.................................... 1,765 160 1,925 59 44 103
2013.................................... 1,817 167 1,983 59 44 103
2014.................................... 1,869 173 2,042 59 45 104
2015.................................... 1,921 179 2,101 59 45 104
2016.................................... 1,973 186 2,159 59 46 105
2017.................................... 2,026 192 2,218 59 46 105
2018.................................... 2,078 199 2,276 59 47 106
2019.................................... 2,130 205 2,335 59 47 106
2020.................................... 2,182 211 2,394 59 48 107
2021.................................... 2,234 218 2,452 59 48 107
2022.................................... 2,287 224 2,511 59 49 108
2023.................................... 2,339 231 2,569 59 49 108
2024.................................... 2,391 237 2,628 59 50 109
2025.................................... 2,444 244 2,688 59 50 109
----------------------------------------------------------------------------------------------------------------
More physicians are needed for the following reasons: to correct
the current deficit, to keep up with population growth, to address
increased demand and need associated with aging of the population, and
to compensate for changing practice patterns that are resulting in less
time available for patient care on the part of the physicians in
practice. Nationally the practice pattern changes are adding to the
need for higher numbers of physicians in practice per 1,000 population,
even where the number of ``full time equivalents'' might be relatively
stable (HRSA, 2005; Bureau of Labor Statistics, 2006). Such practice
patterns include:
physician preferences for salaried positions with fewer
hours in patient care and ``on call'';
reduced hours for older physicians (nationally it has been
noted that older physicians reduce their average hours, whether by
shortening office hours, reducing patient rosters, bringing on
partners, or taking more vacations);
more ``job sharing'' by physicians;
longer office visits and/or more time devoted to group
sessions with patients as part of efforts to improve clinical
prevention counseling;
more time devoted to consults and supervision and training
of other health workers; and
other changes that may improve productivity of the system
as a whole but not increase patient care productivity of the physician
workforce, itself.
Alaska's rural physicians face additional challenges. Approximately
75 percent of Alaskan communities are not connected by road to another
community with a hospital. Geography and climate together limit
transportation options for providers and patients. Health care services
for the rural population have evolved with a regional model where
physicians and hospitals are located mostly in regional centers. A
number of mid-level providers work in sub-regional centers, generally
the largest ``villages'' in their areas, or serve villages on an
itinerant basis from the regional or sub-regional clinics. In most
villages populated by Alaska Natives, a community health aide or
practitioner serves immediate behavioral and physical health needs,
referring patients to higher level providers or using telehealth
consults as needed.
These arrangements result in physicians serving more of their time
in a consultative and oversight role than in typical settings in the
Nation. In addition to such differences in practice responsibilities,
rural physicians (almost all family practitioners rather than
specialists) have to handle the entire spectrum of needs. They must
often decide on and arrange for referrals to specialists located in
distant cities. The poverty and hazardous occupations of Alaska's
remote areas also contribute to high levels of need. These
circumstances must be considered in determining a reasonable
expectation for physician to population ratios.
C. Reasons for Taking Action to Assure an Adequate Physician Supply
In Alaska as well as throughout the Nation, there are mounting
concerns about patients facing dangerously long wait times even for
primary care physicians. Wait times for specialty care doctors are even
longer and reflect the emerging strain. A system unable to provide
timely medical care is certain to have a deleterious impact on health
outcomes and further erode long-term population health goals.
Many patients, especially elderly patients on Medicare, are
having difficulty finding a primary care physician. Most
Internal Medicine physicians cannot afford to take on new
Medicare patients because Medicare payment rates are so low. In
addition, salaries of sub-specialists are much higher and
discourage physicians from going into Internal Medicine.
Generalists are being starved out.
--Richard Neubauer, MD, Internal Medicine, Anchorage,
American College of Physicians, Board of Regents.
Increasing access to comprehensive high quality health care
services is a key goal of the Healthy Alaskans 2010 plan. Reaching that
goal depends upon having an adequate supply of doctors practicing in
Alaska, having an appropriate distribution of physicians geographically
to support the systems in place including mid-level providers and
community health aides and practitioners in remote communities, and
having an appropriate distribution of specialists to provide the
continuum of services needed. Specific shortages of internists,
psychiatrists (for adults and children), and certain medical sub-
specialties have been reported to the Task Force. Comparisons of
specialists per 1,000 population confirmed the large differences in
availability of these providers in Alaska compared with the United
States as a whole.
Key factors that will exacerbate the Alaska deficit include:
aging of the population. Alaska's population over age 65
is expected to nearly triple by 2025 (Williams, 2005);
aging physician workforce;
increased competition among States to recruit from a
limited supply of physicians;
practice changes (such as preferences for fixed hours and
limited number of hours) that further increase the number of physicians
needed to meet adequately the health care needs of the State's
population; and
patients' increasing expectations for diagnosis and
treatment.
Availability of health services in an area affects demographics of
communities and of Alaska as a whole. Historically, the percentage of
Alaskan residents over age 65 has been lower than in most States (6
percent in Alaska in 2005 compared with 12 percent nationwide).
Although much of this difference has been related to high mortality
rates of Alaska Natives and the in-migration of adults in the 1980-1985
oil boom who are just now reaching retirement age, another explanation
has been that many older Alaskans have moved either to the cities or
out-of-state because they were unable to have their health care needs
met in their home communities. Improved availability of physicians
including internists and specialists in the diseases that affect older
people is likely to affect the rate of out-migration of senior
citizens.
National workforce projections indicate that the shortage of
physicians is escalating, although the gap could be held close to
constant if medical schools and residencies expand.\7\ Since the lead-
time for preparing a college graduate to practice medicine is 7 years,
policymakers need to consider promptly any indication of an emerging
shortage of physicians.
---------------------------------------------------------------------------
\7\ The shortage hypothesis is not universally accepted. Starfield,
Salsberg, Blumenthal, Elison and others have pointed out that health
status is not directly correlated with physician to population ratios
(many countries with lower ratios have better health status than the
United States, for example) but in some instances a higher ratio of
primary care to specialists is associated with better health status;
they point to systems changes including broader roles for ANPs and PAs,
electronic health records, more effective health promotion and clinical
prevention approaches, holding down the need for higher physician to
population ratios even if physicians practice shorter hours and retire
earlier and at higher rates.
---------------------------------------------------------------------------
SECTION IV. FINDINGS AND METHODS FOR FORECASTING SUPPLY AND DEMAND
TO 2025 IN ALASKA
A. Demographic Profile of Alaska Through 2025
Alaska's 664,000 population in 2005 included about 37,000 new
residents since 2000, or a 6 percent increase in 5 years. The most
recent population projections for Alaska indicate an increase to about
788,000 by 2025--another 124,000 people--about 1 percent (7,000)
increase per year. Population projections are based on patterns of
birth, death and migration that are evident or expected based on recent
trends and on anticipated economic developments known at the time the
projections are made. (To account for some of the uncertainty, Alaska's
demographer provides a ``low'' and ``high'' projection series as well.
For 2020 the ``low'' projection is 712,000, the ``high'' is 823,000.)
In addition to its resident population, Alaska hosts over a million
tourist visitors a year, and hundreds of thousands of people who come
to the State or its waters to work in fishing and fish processing,
tourism, extractive industries, and other activities. Alaska also has
seasonal residents who are not included in census counts of the
resident population.
One quarter of the resident population lives in approximately 321
places that have fewer than 2,500 people. Most of these communities are
geographically isolated from not only each other but also from the
``urban'' hub communities that have health care facilities including
staff at the mid-level or physician level. The geography and
demographic distributions of small populations of these communities as
well as some communities on the ``road system,'' are challenges that
underlie the effort to provide access to health care in an extreme
frontier State with 1.1 persons per square mile in 353 communities.
Assuming that age-specific migration and mortality patterns will
remain similar to the current (2000-2005) patterns, it is projected
that the population aged 65 and older will nearly triple by 2025, from
about 43,000 people in 2005 to about 124,000 in 2025. The State
Demographer has noted: ``Given the lag time necessary to train
occupations such as nurses, already in short supply, and to expand home
care and assisted living, major efforts to meet what is already
becoming a crisis in the State cannot begin too soon. The impact of the
rapidly increasing numbers of older residents may be greater than
elsewhere, because Alaska, with its historically younger population and
relatively small number of elders, has fewer existing resources to
serve the elderly'' (Williams, 2005). Aged dependency (currently 10
elders per 100 Alaskans of working age) is expected to nearly triple by
2025, while child dependency will increase from the current level of 46
to about 49 children per 100 working age adults.
While the age distribution of the population changes in the next
two decades, the health risks associated with both age and occupation
may change. Alaska's economy relies considerably on oil extraction,
fisheries, fish processing, tourism and mining, which include
seasonally variable work and many occupations with high risk of injury.
A trend to more service sector jobs may reduce the rate of
occupational injuries and death, but may also be associated with
limited health insurance benefits. A continuing trend toward the
service sector jobs may contribute to a drop in average median
household income, and increases in the percentage uninsured. There may
be a higher demand for health care if better health insurance coverage
is available in the future, for all age groups. Risks for chronic
disease have been increasing generally, so the needs for clinical
preventive work as well as diagnosis, treatment and therapeutic
services are likely to grow considerably.
B. Projected Demand and Supply of Physicians Through 2025
Current physician mid-level counts. This report describes,
references and summarizes three independent sources of data about
physicians in Alaska, including the State of Alaska Occupational
Licensing database, ASMA directory listing (includes association
members and non-members), and the American Medical Association (AMA)
Master File. Strengths and limitations of each source are noted.
According to the State of Alaska Division of Occupational
Licensing, 1,392 allopathic physicians (MDs), and 109 doctors of
osteopathy (DOs) have Alaska addresses and ``AA'' (active) status, for
a total of 1,501 physicians, or 2.26 physicians per thousand residents.
However, the true supply of Alaskan physicians is actually smaller, as
these figures include those not actively providing patient care, as
well as those who moved out-of-state without notifying the Medical
Licensing Board since the last license renewal date (December 31,
2004).\8\
---------------------------------------------------------------------------
\8\ Nearly 1,000 additional physicians (MD and DO) have active
licenses to practice in Alaska but do not have Alaska addresses. These
include physicians who work periodically as locum tenens practitioners,
some who visit the State to provide specialty services on an itinerant
basis, physicians licensed in Alaska in order to provide telemedicine
consults for Alaska patients, others who may not visit on any regular
basis, some who have left the State but maintain their license, and
some who have obtained a license but decided not to practice in the
State.
---------------------------------------------------------------------------
A second source of data is the ASMA directory, which lists a total
of 1,414 MDs and DOs (as of January 2006), of whom 1,221 are
``active.'' This database appears to slightly underestimate the actual
supply of Alaskan physicians, despite the fact that it includes both
members and non-members of the Association. A comparison of the ASMA
database and the State of Alaska Occupational Licensing database
indicates that the ASMA list excludes some military physicians as well
as a number of physicians working in the Alaska tribal health care
system who are licensed in the State.
Both of the ASMA and State of Alaska Occupational Licensing
databases specify whether a physician is ``active'' (ASMA) or ``AA''
(Occupational Licensing). However, there is no standard definition for
active status in either database. Therefore, the databases may include
physicians practicing less than 20 hours a week, or active in non-
patient care work such as administration, teaching or research.
A third independent source is the AMA Master File of Allopathic
Physicians (MDs), which counted 1,580 physicians in Alaska in 2004, of
whom 1,347 are reported to be actively engaged in patient care (20
hours a week or more). This database is the only known source with
standardized definitions uniformly applied to physicians throughout the
United States. As such, the Physician Supply Task Force uses the
physician supply data from this database for purposes of working toward
an ``Alaska Standard'' physician-to-population ratio. The AMA Master
File tracks physicians from medical school onward. It counts primary
location and primary specialty. Since the AMA also obtains information
about practice activity that permits distinguishing providers ``active
in patient care'' for 20 hours a week or more, it provides a more
accurate estimate of physicians providing care to the population than
the other available sources. The Task Force uses the data based on the
2004 AMA survey for comparisons of ``active allopathic physicians in
patient care'' with other States and with the Nation as a whole.
Separate data from Occupational Licensing and from the professional
associations is provided about doctors of osteopathy and mid-level
providers.
Retirement status is reported in all three databases. In Alaska, a
physician may let a license ``lapse'' by not renewing, for example when
starting retirement, but may within 2 years of the license expiration
date request reinstatement without penalty. After a 2-year lapse, re-
licensure must begin as if the individual had never been licensed in
Alaska before.
The Task Force recognizes that of the 109 DOs with Alaska
addresses, 77 percent (84) work in primary care (Occupational Licensing
database). This is a substantially higher percentage than the 60
percent reported nationally.\9\ Ninety-two (92) active DOs are listed
by ASMA. Among the DOs active in Alaska as of early 2006, about five
had come into the State each year during the 1990s. That number
increased to seven per year for licenses awarded in 2000-2005, or one
new DO license for every 11 MD licenses.
---------------------------------------------------------------------------
\9\ Memo to Alaska Task Force, March 27, 2006 from Byron Perkins,
DO, President, AKOMA.
---------------------------------------------------------------------------
Each of the available databases thus provides useful information.
Since detailed analysis of the AMA Master File would require a costly
purchase, it has not been feasible to use that source for regional or
other detailed analysis. It is possible to compare the specialty
distributions between the AMA and ASMA databases, and to check for
consistency between the age distributions for physicians included in
the licensing database as ``active'' and those in the AMA Master File.
The Task Force has been able to analyze the occupational licensing
database merged with the ASMA listing of members and non-members known
to be practicing in Alaska, as of January 2006. The occupational
licensing database has birth date of provider, while the ASMA database
has activity type and declared primary specialty. It should be noted
that the ``counts'' might differ slightly (see Figure 8).
Figure 8. Active Physicians by Degree Type
----------------------------------------------------------------------------------------------------------------
Private Practice,
Military, Public Health
(Excludes retirees, Number of MDs in
Physician Degree Type residents, and those Patient Care 20+ hours/ Active Licensee, No
who report State and wk Restrictions
Federal Number rather
than PH)
----------------------------------------------------------------------------------------------------------------
Data Source: ASMA (2005) AMA (2004) Occ Lic-``AA'' with
AK address (2005)
MD................................... 1,221 1,347 1,392
DO................................... 92 N/A 109
TOTAL................................ 1,313 1,347 1,501
``Per 1,000''population for the year. 1,000 * 1,313/664,000 1,000 * 1,347/658,000 1,000 * 1501/664,000
=1.98 =2.05 =2.26
----------------------------------------------------------------------------------------------------------------
The Occupational Licensing and ASMA data indicate that 59 percent
of Alaska's resident active physicians are based in Anchorage
Municipality (including Elmendorf), which accounts for about 42 percent
of the State's population. Fifty-one percent of the State's primary
care physicians are located in Anchorage. Sixty-eight percent of the
State's specialists are in Anchorage.
Physician assistants and advanced nurse practitioners are critical
providers of care in Alaska, complementing and extending physician
coverage for primary care, for supervision and training of community
health aides and practitioners, and in some settings for serving as
specialists in surgery, emergency medicine, and other areas. As of the
end of 2005, there were 284 active physician assistants with Alaska
addresses and ``AA'' status; 29 percent were in Anchorage. Of 486
advanced nurse practitioners with active licenses and Alaska addresses,
51 percent were in Municipality of Anchorage.
The Task Force used the AMA listing for ``physicians in practice''
(excluding academics, retirees and others) by specialty, although this
is for MDs only. One can be reasonably sure of the validity of
comparing Alaska to the U.S. physician to population ratio using this
standardized approach. This is the most reliable basis for selecting an
``Alaska Standard'' for target ratio of physicians (MDs) to
population.\10\ The physician to population ratio using the AMA count
of MDs in patient care 20 hours or more per week is 2.05 physicians per
1,000 population for Alaska for 2004, compared with 2.38 for the United
States as a whole. If Alaska had the same number per 1,000 as the
United States, there would be 1,569, or 16 percent (218) more
physicians in Alaska providing patient care 20 hours per week or more.
The current level of 2.05 physicians per 1,000 population puts Alaska
17th lowest among the States.
---------------------------------------------------------------------------
\10\ UW Center for Health Workforce Studies Working Paper #98 used
the Master File of the AMA to examine age and county distribution of
physicians so purchase of the Master File or request to the CHWS could
provide for another analysis but this will still be limited to MD
degree holders. The licensure and ASMA data sets provide a more
complete accounting of Alaska based physicians including Doctors of
Osteopathy and physicians not licensed in Alaska but serving in the
Public Health Service Commissioned Corps or the Military.
---------------------------------------------------------------------------
Keeping in mind the differences among the data sets, and the
strengths and limitations of each, summary information is presented
from each of the data set as appropriate, to show relevant information
about Alaska's physician and mid-level providers. Each data set is
useful for specific analyses and comparisons. The data permit
examination and consideration of the factors that are likely to
influence future demand and supply to 2025.
In State rankings of physicians per 1000 population, Alaska's
ranking in recent years has varied from sixth lowest to thirty second
lowest, depending on whether or not the count includes only non-federal
physicians, or whether the ranking focuses on physicians in patient
care at least 20 hours per week. Figure 9 shows one method of
``ranking'' States based on ratios for 2004 counting physicians in
patient care.
Alaska has proportionally more ``Federal'' physicians than most
States because of the presence of military physicians, IHS physicians,
and Public Health Service Commissioned Corps who serve in several
agencies in Alaska. Methods that exclude ``Federal'' physicians rank
Alaska lower in comparisons of ``physician to population ratios''
because they exclude Federal providers from the numerator, but retain
the populations served (military and Alaska Native) in the denominator.
(For example, the Kaiser Family Foundation ``State health fact'' Web
site uses the non-federal physician count only.)
Figure 10 shows the numbers of physicians, physician assistants,
podiatrists and paramedics licensed by the Alaska State Medical Board.
Other data provided below allow for analysis of physicians and mid-
level provider counts (including advanced nurse practitioners) in more
detail.
Figure 10. Physicians, Podiatrists, Physician Assistants, and Paramedics by Fiscal Year
(licensed regardless of State of residence or practice)
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 95 FY 96 FY 97 FY 98 FY 99 FY 00 FY 01 FY 02 FY 03 FY 04 FY 05
--------------------------------------------------------------------------------------------------------------------------------------------------------
MD/DO Active.................................................... 1,419 1,593 1,603 1,826 1,810 2,034 1,850 2,080 2,099 2,321 2,309
MD/DO Inactive.................................................. 262 262 277 266 300 289 285 268 249 242 240
Podiatrists Active & Inactive................................... 13 14 14 15 15 16 16 17 18 17 20
Physician Assistants Active & Inactive.......................... 200 231 221 255 244 266 245 284 266 297 307
Paramedics-Active............................................... 134 158 151 191 195 230 233 255 245 283 280
TOTAL........................................................... 2,028 2,258 2,266 2,553 2,564 2,835 2,629 2,904 2,877 3,160 3,156
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: Alaska State Medical Board.
Characteristics of the physician workforce in Alaska. The annual
directories from the Alaska State Medical Association and the biennial
versions of the Occupational Licensing database both provide trend
information on the following characteristics of physicians \11\:
---------------------------------------------------------------------------
\11\ State files: are more current (by a year) than the AMA report
(especially useful for military); contain geographic location listed in
license application and ASMA membership application; include DOs as
well as MDs; provide specialty (ASMA) linked to other characteristics
(licensing); allow examination of length of licensure, timing of
license applications and license lapses; and allow comparison of
licensed providers at different points in time (about every 2 years) to
determine approximate age at time of move from Alaska, by specialty;
likewise changes in status (locums to regular license, for instance).
demographic characteristics;
practice characteristics;
specialty distribution; and
geographic distribution.
Alaska physicians are younger than the national physician supply,
and younger than those in other WWAMI States (average age 48.4 vs.
49.2) according to Chen et al., (Chen, 2005); however as in other
States, the physician population is aging.
Since 1998, the percentages of all physicians who were under age
35, and between 35 and 44 have decreased while the percentages 55 to 64
and 65 and over have increased. However by comparing the ages of those
who left Alaska during the 1998-2006 period with those who stayed, one
can see that departure rates are similar across age rather than being
higher for older physicians.
Age distribution of physicians (MD and DO), physician assistants
and advanced nurse practitioners. As shown in Figures 13 to 15, very
few (2 or 3 percent) of advanced nurse practitioners and physician
assistants (mid-level providers) are in the age group 65 and older.
This compares with 11 percent of physicians being 65 years or older. A
proportionally larger number of mid-level practitioners are aged 45-
54--about 42 percent compared with 32 percent of physicians.
Figure 16 shows age distribution of both the active physicians in
Alaska and the age distribution of those who have let their licenses
expire, whose last known address was in Alaska. Some of these
individuals may be working in positions that do not require maintenance
of an active license, or they may have left the State without informing
the State Medical Board. They have 2 years to re-activate their
licenses--after that time they need to re-apply for a license.
Cohort analysis of the active licensed MDs in 1998 and those who
were still active in Alaska as of January 2006 shows a similar age
distribution for those who stayed and those who left practice over 8
years (see Figure 17). This suggests that departures from Alaska
practice are not predominantly associated with aging and retirement,
but occur about equally at any age.
Figure 18 compares the age of all physicians who have ever been
licensed in Alaska with the number of those who have left the State and
no longer hold Alaska licenses. This data again indicates that
departures are distributed across all ages, rather than occurring
mostly at ``retirement'' age.
A comparison of active physicians located in Alaska in 2006 and
1998 shows similar age distributions in both groups although the total
number of physicians in 2006 is larger (Figure 19, below). It is
notable that the number of physicians under age 33 was smaller in 2006
than in 1998, which might suggest failure to recruit recent graduates
to the State. With students tending to enter medical school at older
ages and taking more years of graduate training, it is likely that this
may be true in other States as well, although it appears that only
about 9 percent of Alaska's physicians are under age 35, while about 16
percent are under age 35 nationwide. (Figures 11 and 12 above).
Figure 20 shows length of service for current active physicians
living in Alaska, indicating that a very large number and proportion
have been in the State for 10 years or less. Retaining current
physicians for additional years is a priority for assuring adequate
physician supply into the next two decades.
New mid-level and physician licensees in Alaska. Graphs of year of
entry (year licensed) for current mid-levels and physicians shows that
physician assistants are now exceeding advanced nurse practitioners as
new licensees, although this is a recent development. Mid-level
providers were first licensed in Alaska in 1980. The total of 60 to 70
mid-levels each of the last 2 years approaches the number of new
physicians in each of those years (68 and 80), as shown in Figures 21
and 22.
Figure 23 shows the distribution by specialty for allopathic
physicians active in patient care (20 hours or more per week),
according to the AMA's master file, based on an annual survey. The
counts by specialty show that nearly 53 percent of Alaska's allopathic
physicians are in primary care, compared with about 50 percent of U.S.
physicians being in primary care. Half of Alaska's primary care
physicians are family practitioners (366 of 709 primary care
physicians), compared with only a third of the Nation's primary care
physicians being in family medicine. Nationally, doctors in internal
medicine outnumber family practitioners two to one (see Appendix A),
while in Alaska the ratio is reversed--there are twice as many family
practitioners as internists. For additional data comparing specialty
distributions in Alaska and the United States, see Appendix A.
``Internal Medicine private practice is part of a dying breed
unless something is done. There are many more specialists and
sub-specialists than general Internal Medicine physicians in
Anchorage now. If our trend continues, there will be few or no
general Internal Medicine private physicians in Anchorage due
to high student debts and low Medicare payment rates.''
--Richard Neubauer, MD, Internal Medicine, Anchorage,
American College of Physicians, Board of Regents.
Figure 23. Alaska 2004 Patient Care Physicians (MDs) by Specialty
----------------------------------------------------------------------------------------------------------------
Total Patient
Care Patient Care Percent of
Specialty Physicians Physicians per Total by
2004 (MDs, per 1000 Specialty or
AMA) population Group (2004)
----------------------------------------------------------------------------------------------------------------
Total Physicians................................................ 1,347 2.05 100
Primary Care.................................................... 709 1.08 52.6
Family Medicine (& GP)...................................... 366 0.56 27.2
Internal Medicine........................................... 157 0.24 11.7
Pediatrics.................................................. 108 0.16 8.0
Ob/Gyn...................................................... 78 0.12 5.8
Medical Specialties............................................. 55 0.08 4.1
Surgical Specialties............................................ 237 0.36 17.6
Psychiatry...................................................... 69 0.10 4.9
Emergency Medicine.............................................. 72 0.11 5.3
Other Specialties............................................... 205 0.31 15.2
----------------------------------------------------------------------------------------------------------------
Source: AMA Master File
Besides focusing on differing specialties, physicians work in
differing practice settings, such as private practice, State or
municipal or Federal public health activities, and military service.
The Alaska State Medical Association surveys its members regarding
their practice settings. Private practice accounts for the vast
majority of practice settings (nearly 1,200 physicians). The number of
military physicians who have let ASMA know about their presence has
shrunk in recent years, accounting even for a shrinkage in the absolute
number of physicians listed in 2004, but the licensing list indicates
there was in fact not a decline in active licensed physicians. A review
of the ASMA listing and occupational licensure found that some
physicians working in the Alaska tribal health care systems do not list
their names with ASMA. Certain physicians in Federal service may work
in the State without an Alaska license. See Figure 24 for the
distribution by practice type of physicians in the ASMA databases for
1997 through 2005.
Typically some portion of the military physicians have worked part-
time in the private sector. Both military and public health service
staff detailed to Alaska have served as a rich resource for recruitment
into the private and public sector resident physician workforce,
according to anecdotal reports.
Forecasting Assumptions. The Physician Supply Task Force agreed on
general principles for forecasting need for physicians.
1. Assume that the proportion of physicians whose area of practice
is primary care will remain close to the 2004-05 level (53 percent).
This proportion is expected to drop up to three points, to 50 percent,
as the number of physicians practicing in medical subspecialties such
as cardiology and pulmonology, and in psychiatric specialties, which
are far below national norms, are brought more into alignment with
population needs.
2. Assume that the ratio of DOs to MDs, and the ratios of physician
assistants and advanced nurse practitioners licensed to practice in
Alaska, will remain the same as the 2004-05 levels. In practice the
ratio of DOs to MDs has increased gradually over time to 1:11, while
the number of mid-level providers has increased more rapidly than the
number of physicians of both types since 1980. The increase may level
off unless training programs for mid-levels expand faster than
expected.
3. The rationale for estimating ``need'' for physicians at 110
percent of the national norm is based on several considerations.
a. Rural Alaska communities require a regionalized system. This
is operationalized by the Alaska tribal health corporations,
which generally staff the smallest village clinics with
community health aides and practitioners who will continue to
be the primary day-to-day health workforce in those clinics. In
the tribal health care system, mid-levels provide care and
train and supervise community health aides and practitioners,
but physician back up is required for complex and severe cases
and for oversight of other providers' services and training.
The system requires physician travel and office time for
handling phone and telehealth consults, supervision, training,
and direct patient care.
b. To attain Continuing Education Units (CEUs) and continuing
education for professional development and maintaining
licensure, physicians in Alaska require more time for the
travel involved than physicians in the ``Lower 48.'' Even if
additional full time equivalents (FTE) in patient care are not
needed, more individuals may be needed to provide the FTE
equivalents.
c. In rural and frontier areas, part-time staff cannot be
available on short notice as easily as in urban areas. There is
thus a structural ``inefficiency'' in that a community that may
need 1.2 physicians according to national norms will require
two physicians, and communities that would be expected to need
a fraction of a physician FTE will need to be served either by
a mid-level provider, a community health aide or practitioner,
or by transporting patients or providers.
d. Although Alaskans are younger than the population of the
United States as a whole, Alaskans engage in more high-risk
occupational and subsistence activities. Thus Alaska's typical
case mix results in higher than average needs of the
population.
e. High poverty segments of the population tend to have
additional risks associated with both environmental hazards and
lifestyle behaviors. Since much of the low-income population is
in the most remote parts of the State, this adds to the burden
of illness and injury to be addressed in the areas hardest to
reach with physician services.
Figure 25. Physician Need Forecasts for 2025
------------------------------------------------------------------------
------------------------------------------------------------------------
Physicians (MDs) in patient 1,347 2.05 per 1,000 population
care, 2004:
2004 MD count if at U.S. norm 1,565 2.38 per 1,000 population
(2.38).........................
Current shortage using U.S. (218)
Norm:......................
Current shortage using 110 (375)
percent U.S. Norm:.........
2025 MD Need Forecasts:
U.S. Forecast need for 2025
2.82/1,000 * 1.1 = 3.1 per
1,000......................
2,444 3.1 per 1,000 population
Additional Physicains Needed: 1,097
Average Annual ``gain'' needed, 52
21 years:
------------------------------------------------------------------------
Figure 26 compares several possible patterns of increase in
physician (MD) supply and the ``desired gain'' linear increase that is
based on Alaska reaching the target of 110 percent of the U.S. norm of
physicians per 1,000 people by 2025. The ``potential access gap''
suggests the widening gap between the anticipated need forecast by the
Task Force and supply if supply fails to increase. Strategies
recommended below aim to ensure that the gap does not widen, and the
need for adequate physician supply is met over the next two decades.
SECTION V. OVERVIEW OF ALASKA'S CURRENT HEALTH CARE WORKFORCE
DEVELOPMENT AND TRAINING ACTIVITIES
A. Medical School Opportunities for Alaskans
``I was first on the waiting list for University of Washington.
They only had space for 10 Alaskans and I was 11th, so I went
to OHSU in Portland, Oregon. OHSU is not part of the WWAMI
program. I paid out-of-state tuition, roughly four times more
expensive than the WWAMI program. My intention from the time of
my medical school application was to become a family practice
physician in Alaska. OHSU was an excellent school, but I had to
arrange my own training experiences in Alaska with my elective
rotations, one of which was in Dillingham where I now work.''
--Leif Thompson, MD. Bristol Bay Area Health Corporation.
Wyoming, Washington, Alaska, Montana and Idaho (WWAMI). For the
past 35 years Alaska has participated in a unique collaborative medical
education program known as the WWAMI Program. In 1971 Alaska was the
first State to join with the University of Washington School of
Medicine in an initiative designed to provide medical school
opportunities in northwest rural States that did not have their own 4-
year medical schools. WWAMI decentralizes medical education, allowing
medical students to receive training in their home States and in rural
settings. This approach encourages students to return to their home
States or WWAMI States to practice medicine. WWAMI remains the only in-
state medical education opportunity available to Alaskans.
Each year since 1971 there have been 10 medical student slots
available for Alaskans in WWAMI. Admission to Alaska WWAMI has become
extremely competitive. In 2005-06 there were about eight Alaskan
applicants for each slot.
The applicants selected for admission to WWAMI pay in-state tuition
rates, about $20,000 less than out-of-state tuition. This $20,000
difference is subject to a payback provision, but is forgiven if the
recipient practices in Alaska after medical school. Twenty percent of
the total amount is forgiven for each year of practice. The payback
provision was enacted in 1999. Its impact cannot yet be assessed, but
it is likely to increase the rate of return.
Alaskans who are admitted to WWAMI now complete their first year of
medical school at the University of Alaska Anchorage, their second year
at the University of Washington, and their third and fourth years in
clerkships and rotations in Alaska or other WWAMI locations. Signing up
for clerkships and rotations in Alaska is the mechanism that allows for
completion of nearly 3 years of the 4-year curriculum in Alaska.
Such clerkships and rotations are partially supported by the Alaska
Department of Health and Social Services, the University of Alaska
Anchorage, and the University of Washington, most often using federally
funded grant programs, so that the students' costs are minimized.
An average of seven to eight WWAMI medical students begins practice
in Alaska each year. Five of those students are from the cadre of 10
per year in Alaska WWAMI. The other two or three come from one of the
other WWAMI States and are students who usually completed a 3rd or 4th
year medical school clerkship experience in Alaska as part of their
WWAMI medical education. Figure 27 depicts the effectiveness of the
WWAMI affiliations in producing doctors for Alaska. The 50 percent rate
of return on Alaska's investments in 10 Alaska medical students ranks
it as #5 among all U.S. States (AAMC, 2006).
The WWAMI program as part of the University of Washington School of
Medicine is consistently ranked among the very best medical school
programs in the United States. The University of Washington is ranked
as the #1 primary care medical school in the Nation, for the 14th
consecutive year (The U.S. News and World Report, 2006). It was also
ranked first in family medicine and rural medicine, and in the top 10
in every category that was ranked. Thus, WWAMI offers a superior
medical education to Alaskans while providing that education largely
in-state, encouraging students to return to practice and helping to
build in-state capacity.
``We have such an exceptional applicant pool for our 10 Alaska
WWAMI slots. Last year, all applicants had very strong grade
point averages and MCAT scores. The number of slots that we
have in WWAMI has not increased to reflect the needs of our
growing and aging population.''
--Peter Marshall, MD. Private Practice, North Pole.
Western Interstate Commission on Higher Education (WICHE). In the
past, the WICHE program has provided access to medical education
(including osteopathy) and other fields of graduate or professional
study for the residents of member states. The WICHE PSEP provided
preferential admissions consideration (above other nonresident
applicants) in participating institutions in the participating States,
and in doing so agreed to charge admitted PSEP students either the
resident tuition rate, or, for those private institutions
participating, a reduced rate of tuition. In return, the State
``sending'' the participant agreed to pay a support fee associated with
each of its residents in the program. However, the program for students
of medicine and osteopathy ended in 1997, after supporting 528 student
years of study for medical students, 82 of whom were in osteopathic
medicine between 1982 and 1997, at a cost of $5,700,000. The
unduplicated student count was 176 (Barrans Memo, 2006). The ``return
rate'' for WICHE-supported students is reported to be 18 percent, which
means the program supported about 35 physicians who have served in
Alaska.
B. Graduate Medical Education in Alaska--the Alaska Family Medicine
Residency
Alaska's only in-state GME program is the AFMR. Alaska was the last
State in the United States to have a residency program. The AFMR was
developed in the 1990s by a consortium of State health leaders with the
intent to train family physicians for the unique aspects of practice in
the most remote parts of the State. AFMR residents receive extra
training in emergency medicine, orthopedics, obstetrics, pediatrics,
neonatal intensive care, and trans-cultural medicine to prepare them
for the exigencies of bush practice.
The AFMR program started in 1997 with eight residents per class,
and expanded to ten residents per year in 2004 and twelve in 2006.
Since AFMR's first graduating class in 2000, the program has graduated
a total of 55 physicians. Of these graduates 70 percent remain in
Alaska to practice after graduation. This gives Alaska the highest rate
of return for GME in the United States (AAMC, 2006). Fifty-five percent
of them practice in rural communities and one-third practice in tribal
health corporation facilities.\12\
---------------------------------------------------------------------------
\12\ This is an exceptional result compared to residencies in other
States. Even the best rural training programs consider themselves very
successful if they can place 40 percent of their graduates in rural
communities.
---------------------------------------------------------------------------
The AFMR residents are drawn from the Alaska WWAMI program and
other medical schools throughout the United States and other countries.
They all arrive with the expressed interest in practicing in rural
settings and most of them have a commitment to Alaska from the start of
their training.
AFMR program faculty members are family physicians with rural
experience in Alaska and other parts of the United States. The
program's affiliation with the University of Washington WWAMI program
provides for faculty development and access to academic resources which
otherwise would not be available in Alaska.
The Providence Family Medicine Center is the outpatient clinic
where residents in the program receive much of their training. The
faculty and residents there provide comprehensive primary care
including outpatient visits, disease management, health maintenance,
hospital care, obstetrical care and delivery, and surgical procedures
for all corners in the Anchorage community. The program has provided
30,000 patient visits per year with over 15 percent of its population
from low-income uninsured.
The AFMR has operated at a deficit since its inception because of
several factors unique to Alaska.
1. Most funding for resident training is provided by Medicare
through the GME funding authority, and this revenue is 25 percent to 50
percent lower than in other States due to a smaller proportion of
Medicare business at AFMR's sponsoring hospital, Providence Alaska
Medical Center.
2. The average reimbursement per visit is below what many other
residencies experience.
3. Unlike most States, the State of Alaska does not appropriate
State general funds for direct support of the residency program. The
State of Alaska does support the Residency through Medicaid, as do most
States, by reimbursing the hospital for Medicaid's share of the costs
of the program, (about $875,000 per year) and by paying full-Medicaid-
rate professional fees for the medical care rendered by the program to
Medicaid patients in the Providence Family Medicine Center and the
hospital (about $668,000 per year).
C. State, Federal and Tribal Efforts to Support Health Care Workforce
Development
State, Federal and tribal funds support an array of health care
workforce development and training activities that are critical to
improved access and quality of care in Alaska. There are programs for
health career development, pre-med programs, loan repayment programs,
placement programs for medical student rotations, and recruitment and
retention programs that encourage health workforce growth. Alaska
placements and sites are not, however, always available to interested
applicants.
Health career development. Although not focused strictly on
preparing and guiding qualified students into the practice of medicine,
new curriculum offerings not available a decade ago provide more
educational choices to Alaskan students, and these can lead to
heightened interest in medical careers. The University of Alaska has
expanded its nursing program and added courses in basic sciences,
nutrition, public health, behavioral health, biology, and other health-
related subjects, as well as a health sciences major for undergraduates
and Masters in Public Health program for graduate students, all of
which provide opportunities for preparation for health careers.
In 2005, the University of Alaska Anchorage's School of Nursing
received funds from HRSA to establish a basic AHEC program. Nationwide,
the AHEC program creates formal relationships between universities and
community partners to strengthen the health workforce in underserved
communities. For Alaska, community partners developed in the first 3
years of funding are the Yukon Kuskokwim Health Corporation AHEC Center
(serving YK Delta region) and Fairbanks Memorial Hospital AHEC Center
(serving Fairbanks and the Interior) and the Alaska Family Practice
Residency AHEC Center (serving the Anchorage and the Mat-Su Borough).
The Alaska AHEC network achieves its collective purpose by encouraging
Alaska's youth to pursue careers in health care, facilitating clinical
rotation opportunities in underserved sites, and improving access to
continuing education for health professionals in underserved areas.
The University of Alaska WWAMI Program offers a high school summer
enrichment program called the Della Keats/U-DOC Summer Enrichment
Program. The goal of this program is to foster, affirm, and encourage
high school students' interest in the medical professions by allowing
them to explore health careers and to obtain a valuable introduction to
college life. Applicants must be Alaska residents with a strong
interest in the health professions. Underrepresented minority, rural-
area, first-generation, and/or economically disadvantaged students are
encouraged to apply. Stipends may be available to help with the costs
of participating in this program.
As well as the University of Alaska, the ANTHC administers several
programs that focus on health career development. The ANTHC Education
and Development Department awards five scholarships of $5,000 per
academic year in health care-related fields to full-time undergraduate
students and five scholarships of $5,000 per academic year in health
care-related fields to full-time graduate students who are Alaska
Native or American Indian permanent Alaska residents. ANTHC grants
these scholarships as an integral part of its long-term strategy of
providing the highest quality health care services to all Alaska
Natives and American Indians. ANTHC graduate scholarships provide
supplemental funds for graduate education for students with the
greatest demonstrated need.
ANTHC works with the IHS to administer a scholarship program. The
IHS Scholarship provides selected scholarship recipients who are Alaska
Native or American Indian permanent Alaska residents with paid tuition,
related fees, a small amount for travel and books, and a monthly
stipend for living expenses. IHS currently funds several health career
and allied health career scholarship programs.
The ANTHC runs a summer internship program that awards 9-week paid
internships to approximately 25 high school and undergraduate students
and five graduate students who are Alaska Native or American Indian
permanent Alaska residents. ANTHC grants these internships as part of
its long-term strategy of providing the highest quality health services
to all Alaska Natives and American Indians and providing work
experience in a range of medical professions and support services.
``I completed my undergraduate studies at Cornell and came out
of college with no debt. I went to medical school at Yale and
fell in love with Internal Medicine. I took an IHS scholarship
for medical school, which led to my 2-year position in Wyoming.
I completed my residency in Michigan. I worked in Juneau for 6
months and am now in private practice in Anchorage. The amount
of debt that medical students now accrue is problematic. Since
I had not incurred significant student debts, it never occurred
to me to consider going into a high pay specialty.''
--Richard Neubauer, MD. Internal Medicine, Anchorage,
American College of Physicians, Board of Regents.
Medical student clinical experiences. Medical students have the
opportunity to have clinical experience in Alaska's clinical sites at
the end of the first year of medical school. Most of the programs
discussed here focus on rural sites. All of these programs give
priority to students that are either residents of Alaska or have some
ties to the State. This approach is based on evidence that students who
are trained in rural areas tend to work in rural areas and that that
they tend to work near their training sites. Thus, it is anticipated
that they are more likely to return to the State to attend the AFMR or
to serve as physicians after graduation.
Alaska has at least three programs that provide clinical
experiences or medical student clinical rotations in the State. The
Department of Health and Social Services (Alaska Primary Care Office)
administers the NHSC Student/Resident Experiences and Rotations in
Community Health (NHSC SEARCH) program, also called the Alaskan
Exposure program. The ANTHC places students and residents in rotations
in tribal sites. The Alaska Center for Rural Health (ACRH) manages the
Rural/Underserved Opportunities Program (R/UOP) summer clinical
experience for WWAMI students in Alaska.
The NHSC SEARCH: Alaskan Exposure program supports rotations for an
average of 40 health professions students each year in underserved
sites. Of these 40 health professions students, about 20 per year are
medical students and residents. This program gives priority to Alaska
residents and NHSC scholarship recipients, and also places interested
medical students and residents from throughout the United States. It
also partners with the AFMR, the R/UOP program, and the ANTHC to
support rotations for medical students and residents.
The ANTHC supports several rotations in IHS sites each year for
fourth-year medical students and medical residents who apply and are
accepted from schools throughout the United States. The Rural/
Underserved Opportunities Program, administered by the ACRH, supports
rotations each year for students who have just completed their first
year at the University of Washington School of Medicine (WWAMI
program).
Scholarship and loan repayment programs. Some physicians take
positions in Alaska through a Federal scholarship or loan repayment
program with a service obligation. Such programs in Alaska include the
NHSC and the IHS. NHSC scholars can meet their scholarship obligation
by working at underserved sites with high federally designated Health
Professional Shortage Area (HPSA) scores. Since most Alaskan sites with
high enough HPSA scores are too small to support physicians, the
placement opportunities are very limited, resulting in only a few
physician recruits for Alaska through this program.
The Alaska Primary Care Office (APCO) works with Alaska sites and
the Federal Government to conduct research for federally designated
HPSAs and, with other State PCOs, seeks to make the HPSA process more
effective in identifying areas experiencing difficulty in filling
positions, where the need for additional health professionals may be
acute but not reflected in physician to population ratios. The APCO
also serves as HRSA's designated lead contact to link interested NHSC
physicians with Alaska sites, thereby supporting the recruitment of
these physicians.
Placement at Alaska sites through the NHSC loan repayment program
is more extensive than through NHSC scholarship obligations because
NHSC has not required such high HPSA scores for loan repayment. Under
the loan repayment program a physician works for 2 years at a qualified
HPSA site in exchange for up to $25,000 of loan repayment, tax-free,
with the option to renew year by year for up to $35,000 per year.
Currently there are eight NHSC physician loan repayers working in
Alaska. Physician specialties eligible for NHSC support are family
medicine, general pediatrics, general internal medicine, general
psychiatry, and obstetrics/gynecology.
Alaska is one of 13 States that does not participate in the HRSA
Bureau of Health Professions State Loan Repayment Program. Funding for
this program is matched 50/50 by NHSC. The APCO and others have
researched and coordinated efforts to organize one of these programs
for Alaska and gain the required 50 percent State match, but funds have
not been identified. In this program NHSC grants matching funds
directly to States to operate their own loan repayment programs.
Primary care health professionals who are providing full-time clinical
services in a public or non-profit facility located in a federally
designated Health Professional Shortage Area are eligible for this
program. Eligibility requirements and benefits vary from State to
State.
The IHS has several scholarship programs to support health
education. Some require a service obligation at a qualified IHS site.
Under the IHS loan repayment program, applicants sign contractual
agreements for 2 years and fulfill their agreements through full-time
clinical practice at an IHS facility or approved Alaska Native tribal
health program. In return, the loan repayment program will repay all or
a portion of the applicant's eligible health professionals educational
loans (undergraduate and graduate) for tuition expenses. Applicants are
eligible to have their educational loans repaid in amounts up to
$20,000 per year for each year of service, tax-free. Eligible
specialties are family medicine, internal medicine, pediatrics,
geriatric medicine, obstetrics and primarily gynecology, and podiatric
medicine. Currently there are 18 IHS physician loan repayers working in
Alaska.
``As far as scholarships, there is very little available. I
couldn't find any scholarships while in medical school. I was
able to find enough funding in loans to cover my tuition and
living expenses, roughly $50,000/year, but most of these were
unsubsidized loans. In general the more you have to borrow, the
less attractive the loans, and the greater the loan fees. I
considered National Health Service Corps, however there were
very few sites for service in Alaska. I didn't want to risk
having to work outside of Alaska to fulfill a commitment.''
--Leif Thompson, MD. Bristol Bay Area Health Corporation.
Recruitment and retention. Several organizations provide some
support for the recruitment of physicians in Alaska. These
organizations focus primarily on their own mandates and specific grant
requirements. The ANTHC provides recruitment and referral service and
support to tribally managed hospitals and clinics throughout Alaska.
The Alaska Primary Care Association (APCA) maintains an updated list of
locum tenens providers and a clearinghouse of candidates looking for
permanent opportunities in Alaska's Community Health Centers. The
Northwest Regional Primary Care Association has instituted a fee-for-
service recruitment service to Alaska sites. The Alaska Department of
Labor has a job bank for vacancies in health care settings.
The APCO coordinates some placement efforts, provides recruitment
and retention training, researches Health Professional Shortage Areas,
and analyzes workforce need. The APCO also serves as a focal point for
NHSC activities, providing technical assistance to monitor and increase
the number of sites and individuals qualified for NHSC.
The Alaska Office of Rural Health in DHSS supports recruitment and
retention by strengthening Alaska's rural health system, facilitating
network development and administering Alaska's State Web page on the
Rural Recruitment and Retention Network (3RNET) Web site, where
clinical sites can advertise positions and health care workers can seek
jobs. There is no charge to sites or job seekers for this service. The
posting of positions on 3RNet does not include in-depth candidate
screening, this function is the responsibility of the site recruiting
the provider.
Many of Alaska's medicine-related professional associations and
membership organizations provide workforce and/or recruitment
assistance to their members. As examples, the Alaska State Medical
Association, the ASHNA, and the APCA provide guidance and recruitment
assistance to their members.
The APCA is a non-profit membership organization founded in 1995 to
promote, expand, and optimize access to primary care in Alaska,
particularly for the underserved. The APCA works with the private and
public sectors to support and connect the organizations and people who
provide that care. The APCA promotes workforce development by enhancing
internship and rotation opportunities in Alaskan health centers;
marketing health center opportunities to students, faculty and alumni;
and focusing on retention efforts. With State and Federal partners, the
APCA maintains an updated list of locum tenens providers and a
clearinghouse of candidates looking for permanent opportunities in
Alaska.
Alaska recruits some international medical graduates through the J-
1 Visa program, which provides incentives to those from other countries
to receive their medical education and work as physicians with
underserved populations in the United States. The Alaska Primary Care
Office coordinates communication for those seeking J-1 visa placements
through the United States. Department of State Conrad 30 program.
Currently five J-1 physicians serve in Alaska under this program; all
are specialists. There were concerns among Task Force members that the
J-1 program disadvantages health care delivery in developing countries.
More stringent J-1 Visa policies are likely to be enacted which will
decrease the physician supply from this source.
According to Task Force members' observations, many physicians have
been recruited through the Public Health Service Commissioned Corps and
the military. Both entities have undergone system-wide reorganizations
and enacted changes to their physician placement policies resulting in
reductions to the number of doctors now available to practice medicine
in Alaska, and smaller cohorts from which to recruit former military
physicians.
The Alaska Department of Health and Social Services contracted with
the University of Alaska, ACRH, for a report called the Status of
Recruitment Resources and Strategies. This report documents that Alaska
relies heavily on recruitment to meet its physician workforce needs.
Competition for the supply of physicians is dramatically increasing
recruitment costs and decreasing return on investment. Between 2004 and
2006, physician recruitment costs in rural Alaska increased nearly 30
percent, from $2,400,000 to $3,400,000. In spite of the scope and cost
of these efforts, positions are difficult to fill and physician
turnover is high. Physician locum spending nearly tripled between 2004
($871,000) and 2006 (over $2,300,000) (DHSS/ACRH, 2006).
Workforce development research and infrastructure. The Alaska
Primary Care Office (APCO) in the Department of Health and Social
Services (DHSS) addresses health care access and workforce disparities
that exist in Alaska through the expansion of new access points and the
support of existing health centers. The APCO's goals include:
assessment of needs; sharing data; workforce development; safety net/
health center growth initiative; designation applications for HPSA and
Medically Underserved Areas (MUA); and community development. The APCO
is the major point of contact in Alaska for the NHSC, HPSA
designations, site development, and students' community-based rotations
through the NHSC SEARCH: Alaskan Exposure program.
Between 2000 and 2005, $148,000,000 in Federal funding has been
made available through the Denali Commission to support rural health
care infrastructure development. As a result, a combined total of 55
clinics have been either built or remodeled and outfitted with quality
medical equipment to date. These efforts have improved the physician
practice environment, which has aided recruitment efforts. Federal
Section 330 funds for community health centers' operations have also
supported the rural health care delivery system, resulting in
opportunities to staff the clinics. Thus more health centers now offer
physician-level staffing to complement mid-levels and community health
aides and practitioners.
Alaska has a history that demonstrates its commitment to reducing
workforce deficits by establishing innovative programs and leveraging
resources. For over 35 years, community health aides and community
health practitioners have been providing primary health care in rural
Alaska Native villages as the first link in the Alaska tribal health
care system. In addition, Alaska has a well-established effective
patient care model using mid-levels throughout the State. Utilization
of advanced nurse practitioners, physician assistants and community
health aides has been a critical component of delivering primary care
health care service in Alaska, especially in the most rural regions of
the State.
D. Lessons From Other States and From National Studies
Information from other States and national studies point to three
types of interventions as being effective in improving physician
supply: medical education strategies to address the training
experiences of physicians; applicant pool strategies to target the
types of students who enter medical school; and practice-environment
strategies to make practice more attractive (Grumbach, et al., 1999).
Examples of each of these three types of intervention are discussed in
several State and national reports as described below. These reports
mostly focus on shortages in rural areas. It should be noted that
physician shortages also adversely affect access to primary care in
urban settings.
Medical education strategies. Kentucky's short-term strategies for
addressing physician shortages include increasing State support of
Kentucky's residency programs, maintaining or increasing Federal
support of rural GME through Medicare and Title VII of the Public
Health Service Act. Long-term strategies include expanding rural
residency programs to graduate more residents, opening new schools,
creating a new residency program in a rural area that needs it most,
increasing class size in existing medical schools, and taking steps to
increase the ``rural pipeline'' (Casey, et al., 2004).
Policies that alter the composition of the classes entering medical
school have the most delayed effects on service in shortage areas, but
are critical elements of a comprehensive plan for addressing the
physician shortage because they increase the number of physicians who
could practice in medically underserved communities. In California it
was recommended to increase resources for science enrichment programs
targeted toward K-12 student and college-level educational enrichment
programs that focus on promoting interest in the health professions
among disadvantaged students. Characteristics that students bring to
medical school, such as rural upbringing, racial and ethnic identity,
or values of public service, are probably the greatest influences on
their decision to practice in an underserved community. Minority
physicians are much more likely to practice in underserved communities,
and physicians who grew up in rural areas are much more likely to
practice in rural communities (Grumbach, et al., 1999).
A Utah study discussed the steps to alleviate physician shortage
that included continuing to expand residency training programs as the
population grows, to increase rural training, rotations and tracks
during residency training, and to increase GME funding this study
recommended targeting students most likely to remain in practice and
recruiting to increase retention (Taylor, p. 2).
Utah's GME planning initiative may be a model for other States,
especially those with only one or two medical schools and a small
number of teaching hospitals. Nevada and Hawaii have begun to emulate
the model. The goal of the demonstration is to use a portion of the GME
monies to increase the number of physicians who choose to practice in
rural areas. This funding arrangement has helped increase the number of
generalist physicians, particularly in rural and inner city communities
(Taylor, p. 2-3).
Increasing medical school capacity, graduate medical training
capacity, and medical education and training in shortage areas are key
strategies to address California's projected physician shortage (Center
for Health Workforce Studies, December, 2004). The supply of rural
physicians is largely dependent on the production of family physicians,
both allopathic and osteopathic physicians. Although many factors such
as rural upbringing, medical school attended and special educational
service experiences are important, the final common pathway for the
largest number of rural physicians is a family medicine residency
(Council on Graduate Medical Education, 1998. p. 23).
The Physician Shortage Area Program (PSAP) at Jefferson Medical
College in Philadelphia selectively admits students from rural areas.
According to the Director of the PSAP since 1976, graduates of PSAP
were eight times more likely to choose rural practice (Wisconsin
Hospital Association and the Wisconsin Medical Society, 2004).
Hands-on experiences in underserved communities stimulate and
reinforce interest in caring for underserved populations (Grumbach, et
al., 1999). The following are examples of clinical rotation programs at
State universities. These programs aim to support recruitment and
retention of rural physicians. Eight Michigan State University medical
students are selected each year for the Rural Physician Program that
provides rich clinical experiences and community service opportunities
in small towns in order to boost recruitment of rural physicians.
University of Illinois College of Medicine Rural Medical Education
Program is designed to prepare students for unique challenges that face
rural physicians, with a 30-month ambulatory primary care experience at
rural primary care centers. Fourth year students participate in a 16-
week rural preceptorship in small, rural communities (Wisconsin
Hospital Association and the Wisconsin Medical Society, 2004).
Many other States fund GME in part with Medicaid dollars. Federal
law allows Medicaid to fund GME through a number of different models,
including paying hospitals for direct and indirect GME costs and by
increasing the Medicaid payment rate for patient services rendered by
teaching physicians and teaching centers, such as the Family Medicine
Center. The amount allowed is limited by the Federal Medicare payment
amounts. The advantage of maximizing funding through Medicaid is that
State appropriations for GME are matched by Federal funds at the
Medicaid match rate of at least 1:1.
In addition to supporting Medicaid GME for residencies, many States
also appropriate funds directly for their support. An excellent example
is the State of Washington program, which supports each of its family
medicine programs with about $250,000 per residency per year.
Recruitment strategies. A national study assessed all State
programs that provided financial support to medical students, residents
and practicing physicians in exchange for a period of service in
underserved areas. Compared to younger nonobligated physicians,
physicians serving obligations to State programs were more satisfied
and remained in their practices longer, half of them staying over 8
years. Retention rates were highest for loan repayment, direct
incentive, and loan programs. An advantage of these programs is that
they target physicians at the end of their training, when they know
more about their career interests, job options, and family needs
(Pathman, et al., 2004).
A report on Kentucky's physician shortage identified a number of
barriers to physician recruitment and retention, including medical
education costs, workload and demands, and decreased opportunity for
professional contacts in medically underserved areas. Economic concerns
that affected recruitment and retention included publicly supported
insurance programs Medicaid and Medicare that reimburse rural providers
at a lower rate than urban providers for the same medical procedures;
rise in insurance payments; relief coverage and assurance of a
reasonable amount of time off from work is the most important factor in
decisions to stay or leave. Other issues include quality of public
schools and ability to become a part of the local community, which was
scored as more important than income. Having an unhealthy population
with high rates of disease including heart disease, hypertension,
asthma, diabetes and cancer can adversely affect the ability to recruit
and retain physicians. Kentucky's short-term strategies for addressing
physician workforce shortages include creating waivers for physician
placement in rural areas, allowing alternative loan repayment matching
funds, using coal severance tax returns for State match for the SLRP,
using physician placement services, and continuing support of J-1 visa
waivers (Casey, et al., 2004).
A study about California's physician shortage recommended
increasing the diversity of the physician workforce, and providing
incentives to encourage physicians to migrate to the State as well as
incentives to retain physicians currently practicing in the State
(Center for Health Workforce Studies, December, 2004).
Physicians whose spouses are from urban areas stay in practice as
long as those whose spouses are from rural areas. Length of stay in
rural practice is not associated with attending a public vs. private
medical school or with training in a community-based vs. medical
school-based residency. Physicians involved in teaching remain in rural
practice longer than those who are not involved. For obligated NHSC
scholars, students from private schools are more likely to stay in a
rural payback site after they have fulfilled their obligation period
than are those from public medical schools. Although many urban
physicians assume otherwise, rural physicians do not necessarily view
professional isolation and an inability to access medical information
as drawbacks to rural practice. Lack of quality of rural school
systems, perceived or real, is related to length of stay for physicians
in a rural practice (American Academy of Family Physicians, 2006.)
The location of a physician's training influences his or her future
choices of practice location. Students with rural origins are more
likely to train in primary care and return to rural areas; however,
they are no more likely to stay in rural practice than are those who
were raised in urban areas. Residents who have their training in rural
areas are more likely to choose to practice in rural areas. Family
medicine is the key discipline of rural health care. Residents practice
close to where they train (Council on Graduate Medical Education,
1998).
Community and health care leaders must acknowledge that their
communities may not have the economic capacity to support physicians or
maintain state-of-the-art equipment and facilities. This situation can
be caused by low population of the community, high poverty status of
the community, or because the community is too geographically isolated
or disadvantaged to financially support physicians. Continuous
subsidies would be required to sustain a physician in such areas
(Wright, et al., 2001).
Practice environment strategies. Strategies offered to meet
California's physician shortage included the following: increase the
productivity and capacity of the existing physician workforce through
expansion of the supply and use of non-physician clinicians, investment
in new technologies, increasing the use of treatment protocols and
utilization review. Promoting physician loan repayment and placement
programs are key strategies noted in a study addressing California's
shortages (Center for Health Workforce Studies, December, 2004).
Regarding practice environment, it was recommended that California:
(1) resurrect its Shortage Area Medical Matching Program which matched
graduating residents with practice opportunities in underserved areas;
(2) match Federal funding for the NHSC SLRP; (3) support pilot programs
that encourage innovative public health-oriented prevention activities
for physicians participating in the above programs; and (4) support the
Rural/Underserved Provider Opportunity Program's locum tenens network
in rural California (Grumbach, et al., 1999).
In addition to examples from California that address the physician
practice environment, a Kentucky study recommended reforming medical
liability as a means of improving the practice environment (Casey, et
al., 2004).
Workforce planning. A workforce report focused on California
recommended promoting a more effective environment for physician
workforce planning and policies through increasing data collection and
monitoring around physician requirements, developing systems to track
physician supply and requirements, comprehensive re-assessment of
physician supply and requirements every 5 years, and establishing an
overall statewide process for physician workforce planning (Center for
Health Workforce Studies, December, 2004).
Strategies included in a Utah report were developing a
Comprehensive State Health Care Workforce Plan to coordinate the
training of various health professions and maximize limited State
resources, i.e., funding, faculty and infrastructure, prioritizing
statewide needs by specialty, and improving data collection methods for
ongoing collection of physician data (Taylor, p. 2-3). A national
shortage affects the supply of physicians in Utah; they can no longer
rely on the national pool to cover local deficits (Taylor, p. 2-3).
``Steps should be taken to build stronger rural health communities
that mobilize all types of human resources (e.g., patients and family
care givers) and institutions (e.g., educational, social, and faith-
based) to both augment and support the contributions of health
professionals.'' (Committee on the Future of Rural Health Care, 2005,
Chapter 4).
Key strategies to address California's projected physician
shortages include promoting programs and policies to address physician
mal-distribution by region and specialty, offering targeted site
development grants, and increasing reimbursement rates in shortage
areas (Center for Health Workforce Studies, December, 2004).
The NHSC Site Development Manual includes a chapter on ``Involving
the Community'' (U.S. DHHS, 2006). This manual recommends the formation
of Community Primary Health Care Councils that will be involved in
making decisions related to the community's health care system,
including developing sites that can tap into NHSC resources and
providers who are NHSC Scholars or are eligible for NHSC Loan
Repayment.
section vi. closing the gap: strategies for ``growing our own''--
training, recruiting, and retaining physicians for alaska
A. Context and Process for Selection of Strategy Recommendations
One of the two primary charges to the Alaska Physician Task Force
was to identify strategies that could address the need for physicians
in Alaska over the next 25 years. In order to formulate its response to
this charge, the Task Force collected its findings regarding the need
for physicians and the nature of physician supply, along with previous
strategies in both Alaska and other States.
From March 2006 through July 2006, the Task Force and staff
undertook a detailed investigation of various strategies that have been
in place in Alaska and other States. The Task Force engaged experts in
Alaska, the University of Washington, and others outside the State, and
reviewed literature from national and professional organizations. Also
considered were physician supply data and trends, Alaska population
demographic predictions, physician recruitment and retention experience
in Alaska and other States, current physician practice environment, and
the professional experience of those consulted during the
deliberations.
Beginning with about forty potential strategies gleaned from their
research, the Task Force reviewed and rated each strategy according to
feasibility, cost, desirability, effectiveness, and length of time that
the strategy would take to affect Alaska's physician supply, and then
concluded with a shorter list of recommended strategies and action
steps for this report. The list of the original strategies and their
ratings is in Appendix B.
The Task Force's selections of strategies are based on the
following findings:
Finding 7. Alaska is one of six States without an independent in-
state medical school. Alaska funds 10 state-supported ``seats'' at the
regional WWAMI medical school, administratively centered at the
University of Washington School of Medicine. This number (10 seats)
represents fewer seats per capita than all but 5 of the 50 States.
Finding 8. Residency programs are one of the most effective ways to
produce physicians for a State or community. Alaska has only one in-
state residency, the AFMR, which places 70 percent of its graduates in
Alaska. Maintaining and expanding residency opportunities will be
critical in augmenting Alaska's physician numbers.
Finding 9. Over the last 10 years, an increasing number of Alaskan
students have applied to medical schools; the average number of
applicants has been 65. In 2005, 29 of 73 applicants were admitted into
medical school. Ten per year attend WWAMI and the remainder attends
medical schools without State support from Alaska. Since 1996, only
WWAMI has had Alaska-supported seats. Prior to 1996, Alaska supported
programs for medical and osteopathic students through the WICHE program
and student loans.
Finding 10. Recruitment for physicians is facilitated by the
availability of loan repayment programs such as the IHS and NHSC loan
repayment programs. Service obligations related to student loans have
historically accounted for some recruitment and should be explored.
Finding 11. There are several initiatives to increase interest in
medical careers among Alaskans, including efforts by the tribal health
care system, hospitals, the University of Alaska's newly funded AHEC
and the UA Scholars Awards, school system initiatives for improvement
of math and science programs, and programs that encourage students to
go into health careers. Collectively, these initiatives generate
qualified applicants to medical schools, but too few applicants
matriculate to replenish Alaska's shortage, and there is inadequate
diversity.
Finding 12. Medical practice environments in Alaska have positive
and negative aspects that affect the recruitment and retention of
physicians.
Finding 13. Surveys of providers (physicians and mid-levels) by the
AMA and many States have provided data on practice characteristics,
preferences, and retirement plans.
Finding 14. Workforce development activities exist in multiple
locations including the tribally managed system, private sector, and
various State and Federal agencies. However existing programs are not
monitoring or analyzing specialty distribution or needs, changing roles
of mid-level providers, or potential impact of electronic health
records on all providers. Coordination of the efforts, and research and
analysis of relevant trends, should inform policy.
The Task Force recognized that forecasting physician supply and
need is a daunting task. Some factors that will significantly impact
needs have not yet emerged. Conversely, some factors that have been
forecast may turn out differently than predicted. These unknown
dynamics will influence the number and type of physicians needed in
Alaska. Given the limitations of all predictions, the Task Force
advises that the strategies recommended for achieving an adequate
physician supply in Alaska be reviewed and updated regularly to insure
that they are guided by current information.
B. Goals and Strategy Recommendations
Four goals encompass the strategies needed to address the physician
supply in Alaska over the next 25 years.
Goals:
1. Increase the in-state production of physicians by increasing the
number and viability of medical school and residency positions in
Alaska and for Alaskans.
2. Increase the recruitment of physicians to Alaska by assessing
needs and coordinating recruitment efforts.
3. Expand and support programs that prepare Alaskans for medical
careers.
4. Increase retention of physicians by improving the practice
environment in Alaska.
These goals and the related strategies are summarized below. Short-
term strategies are those that require less than 5 years to impact the
physician supply, medium-term strategies require 5-20 years and long-
term strategies are expected to have an effect in more than 20 years.
In the subsequent sections, each strategy is discussed in depth,
including an explanation of the problem, related action steps,
timeframe, benefit, cost, responsible party(ies), impact, and
rationale. Further discussion including a review of the literature is
included for each strategy.
Goals and Strategies for Securing an Adequate Physician Supply for Alaska's Needs
Major goal Strategy Timeline for impact Estimated cost
1. Increase the in-state production A. Increase the number Medium................. $250,000 per practicing
of physicians by increasing the of state-subsidized physician.
number and viability of medical medical school
school and residency positions in positions (WWAMI) from
Alaska and for Alaskans. 10 to 30 per year.
B. Ensure financial Short.................. $60,000 per practicing
viability of the AFMR physician.
through State support
including Medicaid
support.
C. Increase the number Short.................. $100,000 per year plus
of residency positions $30,000 for planning
in Alaska, both in in year 1 & 2.
family medicine and
appropriate additional
specialties.
D. Assist Alaskan Medium................. (i) $550,000 per
students to attend practicing physician
medical school by: (i) for WICHE;
reactivating and (ii) cost unknown at
funding the use of the time of PSTF report.
WICHE with a service
obligation attached,
and (ii) evaluating
the possibility of
seats for Alaskans in
the planned
osteopathic school at
the Pacific Northwest
University of the
Health Science.
E. Investigate Medium................. Unknown at time of PSTF
mechanisms for Report.
increasing Alaska-
based experiences and
education for WWAMI
Students.
F. Maximize Medicare Short.................. Zero cost to the State.
payments to teaching
hospitals in Alaska.
G. Empanel a group to Long................... Undetermined at time of
assess medical PSTF Report.
education in Alaska,
including the
viability of
establishing an Alaska-
based medical school.
2. Increase the recruitment of A. Create a Medical Short.................. $250,000 per year.
physicians to Alaska by assessing Provider Workforce
needs and coordinating recruitment Assessment Office to
efforts. monitor physician
supply and facilitate
physician recruitment
efforts.
B. Research and test a Short.................. $65,000 per physician.
physician relocation
incentive payment
program.
C. Expand loan Short.................. Undetermined--need to
repayment assistance consult with other
programs and funding States.
for physicians
practicing in Alaska.
3. Expand and support programs that A. Expand and Medium................. Up to $1,000,000 per
prepare Alaskans for medical careers. coordinate programs year.
that prepare Alaskans
for careers in
medicine.
4. Increase retention of physicians A. Develop a physician Short.................. $100,000 to develop
by improving the practice practice environment index; $20,000
environment in Alaska. index for Alaska. annually to update.
B. Develop tools that Short.................. $50,000 per year.
promote community-
based approaches to
physician recruitment
and retention.
C. Support Federal tax Short.................. Zero cost to the State.
credit legislation
Initiative for
physicians that meet
frontier practice
requirements.
Goal 1. Increase the in-state production of physicians by increasing
the number and viability of medical school and residency positions in
Alaska and for Alaskans.
Strategy 1A. Increase the number of state-subsidized medical school
positions (WWAMI) from 10 to 30 per year.
Problem. Alaska currently ranks 46th among U.S. States in terms of
the number of state-supported medical school positions. Alaska ranks
49th among U.S. States in terms of the success of its applicants to
U.S. medical schools, despite applicant qualifications equal to or
better than the national average. Long-range planning, even if it
includes a 4-year medical school in Alaska, will not address current
physician needs in a timely fashion, so interim measures are needed.
Action Steps
1. WWAMI--Increase WWAMI positions to 20 per year and then
potentially to 30 per year over a period of several years.
2. WICHE--Fund 10 additional seats per year via WICHE. Such funding
should include a payback provision.
3. Monitor the rate of return and cost to benefit ratio.
4. Adjust the number of program seats available to reflect program
objectives and outcomes, and to maximize accrual of physicians to
Alaska from these programs.
Timeframe. Medium Term
Benefit. An increase of WWAMI positions by 10 per year will result
in five additional physicians for Alaska each year. Providing 10 WICHE
positions per year will result in two additional physicians for Alaska
each year. Building in-state capacity for medical education supports
long-term actions that will help to make Alaska more self-sufficient
and less susceptible to outside factors that could negatively impact
the health of Alaskans.
Cost. $400,000 per physician practicing in Alaska trained through
WWAMI ($200,000/0.50); $600,000 per physician practicing in Alaska
trained through WICHE ($110,000/0.18).
Responsibility. University of Washington, University of Alaska,
Alaska State Legislature.
Impact. Training; Recruitment.
Rationale. A major determinant of the eventual practice location of
physicians is where they went to medical school; so educating Alaskans
in Alaska is likely to produce physicians for the State (COGME, 1998).
Fifty percent of Alaskans who enter WWAMI practice in Alaska. Rate of
return data for the Alaska WICHE physician programs suggest that 18
percent return to practice in the State.
Further Discussion. Increasing the number of WWAMI seats to 30
students would require a significant increase in resources at UAA to
add capacity to serve the additional students. UAA would need to design
and build additional facilities and to significantly increase the
number of faculty in the program. It is difficult to accurately predict
the amount of funding needed for the expansion. It has been suggested
that enrollment be doubled to 20 in the medium term with the allocation
of adequate funding, then re-examine the possibility of increasing to
30.
The cost to the State of a medical school position through WWAMI
would be about $50,000 per student per year, or about $200,000 for the
4-year education of one student. With a 50 percent rate of return, each
practicing Alaska physician costs $400,000. Increasing the class size
from 10 to 20 students increases the total cost from about $2,000,000
to $4,000,000 per year. An additional increase to 30 students will add
another $2,000,000 per year to the total.
Alaska can increase the number of state-subsidized medical school
positions to 30 per year by either immediately increasing WWAMI
positions to 20 per year and then building to 30 over a period of
several years, and/or funding 10 additional seats per year via WICHE
(with a payback provision). Over a period of several years these
additional seats may be converted to WWAMI seats, depending on rate-of-
return data.
WWAMI educates Alaskans in the State for as many as 3 of the 4
years of medical school. The program is recognized as one of the best
medical school education programs in the country, especially for rural
and primary care. Alaska's membership in the WICHE PSEP could be
utilized to revise and re-establish the student loan program with a
service obligation. Providing 10 WICHE positions per year will result
in two additional physicians for Alaska each year. A payback provision
may increase the number, but so many States now offer to pay off
physician debt as a recruiting tool, the effect may not be large.
Since its inception in 1971, 50 percent of WWAMI graduates have
returned to practice in Alaska. That percentage increases to 75 percent
when WWAMI graduates from other WWAMI States are counted as
``returned'' WWAMI physicians. None of the graduates to date have been
subject to the payback clause instituted in 1999, because it takes a
minimum of 7 years before medical students are qualified for
independent practice. Thus, the percentage returning to practice in
Alaska may increase as those affected by the clause begin to enter
practice, starting this year.
The Alaska Legislature has taken the first step in implementing
this recommendation by appropriating $475,000 toward the one-time costs
of doubling the WWAMI class size. This perceptive appropriation,
anticipating an important State need, represents half of the required
one-time costs and is an important first step to increase physician
supply.
Under the WICHE program Alaskans can select from a variety of
medical schools in western States. They apply independently and must be
accepted in order to be eligible for their tuition to be subsidized by
the State. The cost to the State of a medical school position through
WICHE is about $26,000 per student per year ($25,600 for 2006-07,
$26,500 projected for 2007-08 and $27,400 projected for 2008-09). Thus,
the annual cost for 10 WICHE students in each of the 4-year medical
school curriculum would be about $1,100,000. With an 18 percent rate of
return, each practicing Alaska physician costs $610,000.
Increasing state-subsidized medical positions is a medium-term
action that will provide a long-range payoff. Thus, it is part of an
overall strategy to increase the number of physicians practicing in
Alaska. However, it is an interim measure that is required until Alaska
develops an in-state 4-year medical school.
``We need to `grow our own.' Physicians tend to practice in the
geographic area where they have completed their training or go
back to where they have family. These factors mean that we need
to expand both the Family Medicine Residency in Anchorage and
the number of positions we have in WWAMI. ''
--Peter Marshall, MD. Private practice, North Pole,
Chairman, Alaska WWAMI Admissions Committee.
Strategy 1B. Ensure financial viability of Alaska Family Medicine
Residency through State support, including Medicaid support.
Problem. The AFMR operates at an annual loss of over $2,000,000.
The sponsoring institution, Providence Alaska Medical Center, has been
funding the deficit since the program's inception in 1997. The
program's quality and viability are jeopardized by this dependence on
private support, which could be withdrawn. Without such ongoing support
the program would be forced to close, ending the only in-state GME
program in Alaska.
Action Steps.
1. Work with State legislature to maximize Medicaid support of the
AFMR.
2. Work with multiple State partners to revise Medicare policies
that currently disfavor States with younger populations, such as
Alaska.
3. Investigate ways to maximize Medicaid support for developing
other GME programs in Alaska.
Timeframe. Short
Benefit. Directly places eight to nine family physicians per year
in Alaska, a rate of placement that needs to be maintained.
Cost. $60,000 State cost per practicing physician. There would also
be a cost for staff time to investigate additional Medicaid support of
GME.
Responsible Entity. Alaska State Legislature with support of Alaska
State Hospital and Nursing Association, Alaska State Medical
Association, Department of Health and Social Services.
Impact. Training; Recruitment; Retention
Rationale. Seventy percent of AFMR's graduates remain in Alaska to
practice. With 70 percent placed in Alaska, this gives Alaska the
highest rate of return for GME in the United States (AAMC, 2006).
Residency programs are one of the best ways to increase the number of
physicians in a State (COGME, 1998). The AFMR is Alaska's only GME
program, training 12 physicians per year. All States support their
residency programs through a variety of funding mechanisms, including
direct appropriation of funds. Currently Alaska has not maximized the
amount of support for GME allowed under Federal law. By increasing the
funding through Medicaid, Alaska would take advantage of the Federal
Medicaid match, reducing the total State funds necessary. It is
estimated that the AFMR is eligible for approximately $800,000 in
additional Medicaid funds, under Federal law, which would require only
an additional $400,000 of State appropriations.
Working with the State's Federal congressional delegation, changes
in Medicare regulations can result in an additional payment of
approximately $900,000 for the costs of rural training of residents in
the program. Combined with increased Medicaid payments, this total of
$1,700,000 brings the required program subsidy within $400,000. Other
strategies to eliminate this deficit could include direct State
appropriations, or further increases in the Medicaid payment rates for
physician services (both are strategies used by other States). The
final effect of achieving full funding will be to eliminate the
program's financial vulnerability to cessation of private support.
Further Discussion. The AFMR is Alaska's only GME program. The
program recruits and trains 12 doctors each year from Alaska and the
United States. These doctors undergo a rigorous internship and
residency program for 3 years, to become family physicians. The
training emphasizes practice in rural and bush communities in Alaska
and is very successful, placing over 70 percent of graduates in Alaska,
over 50 percent in rural areas, and over 30 percent in tribal health
practices, a performance achieved by very few, if any, other programs.
The total budget for the AFMR program is about $7,000,000 per year.
The program operates at a deficit of over $2,000,000 per year. This is
because the Medicare program, which funds most of GME nationwide,
disfavors a young population like Alaska's. Consequently the sponsoring
institution, Providence, receives only about half the reimbursement
from Medicare that a similar hospital in the lower 48 would receive.
Other States support their family medicine residency programs with
a combination of direct State appropriations, Medicaid payments for GME
to hospitals, and increased Medicaid payment rates for the physician
services provided by the residents and faculty. Alaska's Medicaid
program provides $875,000 per year in support of the residency costs to
Providence, and pays the regular physician rate for professional
services to Medicaid patients. This rate is above the minimum rate
Medicaid is required to pay for resident services, but not above the
rate paid to non-academic physicians in private practice. There is no
direct State appropriation.
Action by Alaska's congressional delegation may result in
additional Federal support for the program totaling $800,000 per year,
reducing the deficit to $1,200,000 annually. State support will be
required to make up this deficit, to ensure the ongoing presence of the
residency program.
Following trends in other States, Alaska has three obvious
opportunities to secure the funding of the AFMR:
increasing Medicaid GME funds to the sponsoring hospital
to the maximum allowable will provide the program with $800,000, at a
cost to the State of only $400,000;
further increasing the payment rates for residency
services to patients to the comparable private insurance payment rate
is also allowable, and would provide the program an additional
estimated $150,000 per year. (This would cost the State $75,000, due to
the Federal matching benefits); and
a direct State appropriation to support GME of $250,000
per year (very similar to support provided by other States).
Assuming the congressional efforts are successful, the State can
ensure the viability of the AFMR by adopting these three measures.
These measures will also create the environment where additional growth
of residency programs and positions is possible in Alaska.
Funding needs breakdown:
------------------------------------------------------------------------
Funding source Amount Deficit
------------------------------------------------------------------------
Current funding............................... $7,000,000 $2,000,000
Medicare rule changes......................... 800,000 1,200,000
Maximize Medicaid for GME..................... 800,000 400,000
Maximize Medicaid fees........................ 150,000 250,000
Direct State support.......................... 250,000 0
------------------------------------------------------------------------
The supply of rural physicians depends largely on the production of
family physicians. Although many factors contribute to the choice to
practice in rural areas--rural upbringing, medical school attended, and
special educational service experiences--the final common pathway for
the largest number of rural physicians is a family medicine residency
(Council on Graduate Medical Education, 1998). Some of the residents
are recruited from the State's population, after they graduate from
medical school. Typically, however, a majority of the residents are
recruited from other medical schools, bringing new doctors into the
State. Doctors, especially in family medicine, tend to stay and
practice in the State where they finish their residencies, the last
stage of training. All States in the United States have residency
programs. Alaska was the last State to start a residency, and since
Alaska has far fewer physicians per population than any other State in
the Western United States, it is very important to keep a residency
viable.
``I am from Fairbanks, Alaska. I chose the Alaska Family
Practice residency primarily because it was in Alaska, where I
wanted to be. It also helped that it was gaining a reputation
for being an excellent residency.''
--Leif Thompson, MD. Bristol Bay Area Health Corporation.
One of the major obstacles to expanding GME in Alaska is the lack
of funding. All the GME expansion strategies are unlikely to succeed if
they cannot be operated at a ``break even'' level for the sponsoring
institutions. The existing AFMR operates at a deficit, which
jeopardizes its long-term viability. All States support their GME
programs. By maximizing the use of Medicaid, the State leverages its
investment through the Federal matching funds, thereby minimizing the
cost to the State and maximizing support for the programs.
Alaska has not yet investigated thoroughly the ways to maximize
Medicaid support for GME. Doing so would require staff time to research
the issue and discuss with colleagues in other States. Most of the
necessary changes can be done administratively within Alaska's Medicaid
program. Within a year, new GME funds could be made available, provided
the analysis reveals opportunity. Once funds are available, hospitals
statewide will be in a position to explore starting GME programs.
Strategy 1C. Increase number of residency positions in Alaska, both in
family medicine and appropriate additional specialties.
Problem. Currently Alaska ranks last among west coast States in the
number of medical residents in training per capita. Limited number of
residency training opportunities contributes to the statewide physician
shortage.
Action Steps. Increase the number of residency positions in Alaska
by the following mechanisms.
1. Increase the number of short-term resident rotations in Alaska
by coordination and marketing.
2. Develop ``Alaska Tracks'' in collaboration with established
residencies in other States to provide significant parts of training in
Alaska.
3. Develop additional full-fledged residencies in Alaska, as
conditions permit.
4. Establish a central agency to coordinate, track and develop
additional residency experiences.
Timeframe. Short term. Two to six years.
Benefit. Residencies in Alaska or sponsored for Alaskans in other
States impact the number of physicians who choose to practice in
Alaska. Increasing the number of residency options and implementing an
``Alaska Tracks'' program would result in net gains to Alaska's
physician supply each year.
Cost. $100,000 per year. ``Alaska Tracks'' could gain funding from
Medicare, if located in rural areas under certain conditions that need
to be explored to determine feasibility. This funding could cover half
or more of the cost of the programs. The State portion would depend on
the number and length of the programs.
Planning for additional residencies would cost approximately
$30,000 per year for 1 to 2 years. Operational costs for new
residencies would depend greatly on the size, location and specialty.
The current budget for the AFMR is over $7,000,000 per year.
Responsibility. For appropriations, Alaska State Legislature. For
operations, AFMR.
Impact. Training; Recruitment.
Rationale. Local resident training is a very effective way of
increasing doctors in a State. Up to 70 percent of residents ultimately
enter practice in the State where they train (Council on Graduate
Medical Education, 1998). Since residencies are major determinants of
practice location of physicians, it is important that Alaska maximize
its opportunities to offer residency positions in State. Alaska could
offer residency tracks as an adjunct to programs in other States, and/
or Alaska could be more efficient in supporting residencies for
Alaskans completing residencies in other States.
Further Discussion. Currently, Alaska can maximize the number of
short-term, 1- to 2-month rural experiences associated with residencies
in other States. A number of these are coordinated by DHSS (NHSC
SEARCH: Alaskan Exposure program) and ANTHC's tribal sites. Many of
these experiences are currently arranged based on the interest of the
resident and availability of sites. There is some coordination across
these programs but no mechanism exists for centralized coordination. A
central coordinating agency should be established to coordinate, track
and develop these experiences.
Opportunities for increasing the number of resident rotations in
Alaska may exist in psychiatry in Juneau, in surgery in Fairbanks, in a
variety of specialties in Anchorage and the Mat-Su Valley, and in many
Alaska Native tribal health care system hospitals in rural areas.
Residents frequently seek opportunities in Alaska, and a better system
of marketing and coordination could increase the number of residents
coming to the State.
Development of additional full residencies in Alaska may be
difficult, but adding ``Alaska Tracks'' as part of existing residencies
in other States may be more feasible. Currently, the Alaska Native
Medical Center (ANMC) has a 3-to-6-month track for surgical residents
from a program in Arizona; all the practicing surgeons at ANMC came
from this program. Fairbanks Memorial Hospital is working to develop a
similar program with the University of Washington. In Boise, the VA
hospital has a 1-year (of three total) track for internists from the
UW. Such tracks are much more effective in recruiting doctors than
short 1 or 2 month rotations, but less effective than a full residency
program. ``Alaska Tracks'' could be available in many specialties in
many parts of the State. There are many barriers to this approach, most
importantly the ability and willingness of residencies in other States
to send their trainees to Alaska. There may be significant loss of
funding to the home programs when residents leave.
The feasibility of establishing residencies in Alaska in addition
to the AFMR should be carefully and critically evaluated. Current
Medicare law does not allow new residencies to be funded, except in
rural areas. However, rural parts of the State lack the physician
specialists and patient types and volumes to support residencies in
most specialties. Even in Anchorage the same issues limit the possible
programs to pediatrics, internal medicine, psychiatry, and perhaps a
few others. But, again, Medicare funding would not be available. The
AHEC and the AFMR should study this option and work with existing
institutions to develop plans for implementation.
Additional 1-to-2-month rural rotations would have a net
recruitment rate of 10-15 percent. Assuming as many as 30 additional
rotations would become available; this would net Alaska an additional
three to five doctors per year. These recruits would begin practicing
as soon as 2 years after the program started.
The recruitment rate from ``Alaska Tracks'' would be higher,
probably in the 20-30 percent range, depending on the specialty and the
length of the track. A longer track would have a higher recruitment
rate, but could accommodate fewer doctors per year. If three different
tracks were developed, exposing 10 residents per year, the net would be
two to three doctors, starting 2 years after inception.
The AHEC could prepare a report on the feasibility of new
residencies in 1 to 2 years. If a new program were planned, a minimum
of 2 years would be required to develop it, achieve accreditation and
start training. The production of the program would begin 3 to 4 years
later. The output would be four to six doctors per year, of whom three
to five would remain in State, beginning in 2012.
``Alaska Tracks'' could gain funding from Medicare, if located in
rural areas and not in Alaska Native tribal health care system
hospitals. This funding could cover half or more of the cost of the
programs. The State portion would depend on the number and length of
the programs.
A professional estimate is that planning for additional residencies
would cost approximately $30,000 per year for 1 to 2 years. Actually
operating a residency would depend greatly on the size and location and
specialty. The current budget for the AFMR is over $7,000,000 per year.
The supply of rural physicians is largely dependent on the
production of family physicians. Although many factors contribute to
the choice to practice in rural areas, including rural upbringing,
medical school attended, and special educational service experiences.
The final common pathway for the largest number of rural physicians is
a family medicine residency (Council on Graduate Medical Education,
1998. p. 23).
Strategy 1D. Assist Alaskan students to attend medical school by: (i)
reactivating and funding the use of WICHE PSEP with a service
obligation attached, and (ii) evaluating the possibility of seats for
Alaskans in the planned osteopathic school at the Pacific Northwest
University of the Health Sciences.
Problem. Alaska lacks adequate state-funded financial supports for
Alaskan students in medical school, and the State lacks state-
subsidized positions at an osteopathic school.
Action Steps.
1. Utilize Alaska's membership in the WICHE Professional Student
Exchange Program to revise and re-establish the student loan program
with a service obligation.
2. Explore the possibility with the Pacific Northwest University of
Health Sciences, in Yakima, Washington of seats for Alaskans in the new
osteopathic school upon its completion, which is scheduled for Fall,
2008.
Timeframe. Mid term. Five to ten years.
Benefit. This strategy helps State residents afford medical
education while simultaneously providing the state/community with a
quantifiable pool of future medical professionals. Loan repayment and
other direct financial incentives have the benefit of insuring that any
funds expended are associated with an individual practitioner providing
a service. Alaskan student slots in the osteopathic school would boost
the number of Alaskans attending medical school and impact the number
of physicians who choose to practice in the State.
Cost. The cost of the WICHE PSEP action step is projected to be
$550,000 per practicing physician. The cost of guaranteed slots in the
osteopathic school in Yakima is unknown at time of this report.
Responsible Entities. For Federal appropriations, Alaska
Congressional Delegation. For appropriation of operational funds,
Alaska State Legislature.
An operational entity, such as a board or task force, needs to be
established that can set policy regarding the level of subsidies, the
manner in which the subsidies are to be deployed, and other financial
strategies to best meet health care workforce needs. The proposed
Medical Provider Workforce Assessment Office would investigate these
strategies and provide information to the entity making the policy
decisions. The Alaska Commission on Postsecondary Education would be
the most likely organization to administer the financial support
programs. For the medical school seats, discussions would be needed
with Pacific Northwest University of the Health Sciences.
Impact. Training; Recruitment; Retention.
Rationale. Loan repayment, direct incentive, and loan programs have
been found to be effective for recruitment and retention (Pathman, et
al., 2004). Past WICHE students with service requirements account for a
number of physicians who have stayed in Alaska after the service pay-
back that was required previously. However, State funds were cut to the
WICHE program in 1995. The Task Force determined that the State student
aid program with a service obligation should be funded again by the
State. Additionally, educating Alaskans with seats at the DO school is
likely to build the pipeline and produce physicians for the State.
Further Discussion. The WICHE PSEP provided loans to medical
students in participating schools, with an obligation to return to the
State to practice, but Alaska has not participated in the medical
school component for 10 years.
Increases in financial supports for medical education are needed to
build the number of Alaskans in the physician supply pipeline, and to
strengthen recruitment and retention strategies. Through their
deliberations, the members of the Physician Supply Task Force
considered the five recognized types of incentives to encourage
physicians to practice in underserved areas: scholarships, service-
option loans, loan repayment, direct financial incentives, and resident
support.
Loan repayment and other direct financial incentives have the
benefit of insuring that any funds expended are associated with an
individual practitioner providing a service (in contrast to the
contingent loans, which must be administered for either the life of the
service commitment or for the entire repayment period). Additionally,
the benefit can be made available to draw residents of other States to
Alaska. These options would also have relatively low administrative
costs.
A national study assessed all State programs that provided
financial support to medical students, residents and practicing
physicians in exchange for a period of service in underserved areas.
Compared to young non-obligated physicians, physicians serving
obligations to State programs were more satisfied and remained in their
practices longer, half of them staying over 8 years. Retention rates
were highest for loan repayment, direct incentive, and loan programs.
These State programs target physicians at the end of their training,
when they know more about their career interests, job options, and
family needs (Pathman, et al., 2004).
The current PSEP support fees for each medical student beginning
their GME in 2007 would be a total of $111,400 over 4 years. The cost
of loan repayment/direct financial incentives currently is
undetermined. Alaska would need to identify what other States are doing
and figure out what a reasonable ``tipping point'' is to insure the
repayment cap is high enough and/or financial incentive substantial
enough to be effective.
Strategy 1E. Investigate mechanisms for increasing Alaska-based
experiences and education for WWAMI students.
Problem. Currently, medical students in Alaska's sole medical
education program, WWAMI, complete their first year in Anchorage. They
have the option to complete nearly all of the third year and large
parts of the fourth year in Alaska. Second year classes for all WWAMI
students are held in Seattle.
Action Step. Work with University of Washington WWAMI, the
University of Alaska and the Alaska medical profession to investigate
the feasibility and cost of providing all WWAMI first and second year
classes and third and fourth year clerkships in Alaska.
Timeframe. Medium term.
Benefit. Providing rotations in all 4 years of medical school in
Alaska will make the State more independent, able to negotiate
economies of scale and more independent in setting class size according
to State needs.
Cost. Undetermined at time of Task Force Report. Responsibility.
University of Alaska, University of Washington Impact. Training;
Recruitment.
Rationale. Medical students who experience increased exposure to
Alaska through in-state training, rotations, clerkships and other
experiences in Alaska are more likely to practice in the State (COGME,
2004).
``We need to offer more support for the Alaska students who
attend medical school in other States. They should be
considered part of our `family'. They should be offered some
type of financial deal and/or electives in Alaska that may
encourage them to return to the State to practice. The
physicians in Fairbanks and Fairbanks Memorial Hospital have
purchased diagnostic kits to give to the students who are
accepted into the WWAMI Program. We also have a few kits that
we will be awarding to some of the students who are going to
medical school elsewhere.''
--Peter Marshall, MD. Private practice, North Pole,
Chairman, Alaska WWAMI Admissions Committee.
Strategy IF. Maximize Medicare payments to teaching hospitals in
Alaska.
Problem. Current levels of Medicare support for GME in Alaska are
inadequate to cover teaching hospital expenses. The current payment
formulas are biased against States with young populations such as
Alaska, because the formulas are driven by the number of Medicare
patients in the teaching hospital. Alaska-based GME is jeopardized by
this funding deficit.
Action Steps.
1. Continue to maximize existing opportunities for Medicare
coverage for GME.
2. Identify and advocate for specific areas where additional
Medicare coverage would be beneficial to GME in Alaska.
Timeframe. Short term. Within 5 years.
Benefits. Changes to Medicare payment formulas to reflect GME
expenses would stabilize GME programs in States with younger
populations by providing a long-term funding stream. These changes will
need to be led by the Federal delegation.
Cost. Zero cost to the State, as this is a Federal funding stream.
The total Federal cost would depend on the formula changes and the
number of programs that subsequently develop.
Responsibility. Alaska Federal Congressional Delegation supported
by Alaska State Medical Association, Alaska State Hospital and Nursing
Association, statewide health care partners.
Impact. Training; Recruitment.
Rationale. Medicare is the primary funder of GME nationwide.
Establishing new formulas specific to rural or frontier States would
allow a more even distribution of Medicare funds. Changes in Medicare
statutes/regulations are needed to help stabilize GME in Alaska.
Further Discussion. Current levels of Federal support for GME in
Alaska are inadequate. The Federal laws establishing and regulating GME
payments through the Medicare program are designed to provide
marginally adequate funding for large teaching hospitals on the east
coast. The number of Medicare patients in the teaching hospital drives
the formulas. Alaska, having a young population, has a much smaller
proportion of Medicare patients than other States. The funding that is
marginal in New York is completely inadequate in Alaska. Improving the
payment rates for Alaska will require new formulas specific to rural or
frontier States, and/or alteration in Medicare regulations. These
changes will need to be led by the Federal delegation.
If it becomes possible to alter Federal law, programs would develop
in the State alone or in concert with GME programs from other States.
Alteration of the formulas to more evenly distribute the funds would
give Alaska a long-term recurring stream of funds.
Strategy 1G. Empanel a group to assess medical education in Alaska,
including the viability of establishing an Alaska-based medical school.
Problem. Alaska does not have an independent 4-year medical school
nor does it have a sufficient number of slots in other State programs
for qualified Alaskans to pursue medical education. This deficit in
training capacity contributes to the shortage of physicians in Alaska.
Currently, no entity exists to explore options and strategically plan
for medical education in Alaska. There is no strategic plan for medical
education in Alaska that allows for rational reassessment and planning
to accommodate continually changing State needs.
Action Step. Empanel a group or charge an existing group to develop
a strategic plan for medical education in Alaska that will define the
requirements (including cost estimates) and the potential benefits
(including economic impact) of a 4-year medical school in Alaska and
ensure continued adherence to this recommendation as needs change.
Timeframe. Long term.
Benefit. This recommendation develops options for the State of
Alaska. A rational strategic planning process will ensure that medical
education in Alaska will develop in a way that will maximize the
State's return on its investment, producing the largest number of
physicians, as needed. A 4-year medical school in the State would
provide significant economic benefit and an enhanced practice
environment to encourage physician recruitment, and would provide
increased opportunity to develop one of Alaska's most precious
resources, young Alaskans seeking professional medical education.
If continuing collaborative medical education with other WWAMI
participants is in the State's best interest, that partnership can be
maintained. If a more independent medical school is more appropriate,
then the program is positioned to take that next sequential step.
Based on the current number of medical school applications by
Alaskans, their qualifications and reasonable projections, implementing
this strategy could provide 30 physicians per year by 2020, about 23
more than the current WWAMI program.
Cost. Undetermined at time of Task Force Report.
Responsibility. New empanelled group to investigate State medical
education.
Impact. Training; Recruitment.
Rationale. Alaska lacks the benefits enjoyed by States with 4-year
medical schools. These benefits include: a significant boost to
regional economy, stimulation of associated businesses, a more
attractive recruiting environment for physicians, an improved medical
practice environment, and better health status in the State. A rational
strategic plan is needed to insure that Alaska has an adequate
physician supply through 2025. The creation of an Alaska medical school
would allow more of the State's resources to remain in the State,
developing capacity and infrastructure in Alaska.
Further Discussion. Rational planning for medical education
requires that there be regular, critical evaluation of the potential
for future development. This task should be charged to an appropriate
planning group. The alternative is a crisis management approach that
often leads to sudden, wholesale changes that challenge the maintenance
of a quality educational program.
While medical education in Alaska has the greatest potential to
supply future Alaskan physicians, the current class size in WWAMI
relegates it to a miniscule role in physician supply. Currently, class
size cannot be changed easily. Agreement is needed by the University of
Alaska Anchorage, the University of Washington School of Medicine,
statewide offices of the University of Alaska and the Alaska
Legislature to change the class size. Alaska currently participates in
a very successful medical education program, WWAMI, but there are
minimal economies of scale as class size increases.
There is little doubt that Alaska will have a medical school in the
future. There are many examples of small States with their own medical
schools, including States with far less resources. Until that time,
Alaska should work to nurture and develop its current medical education
program (WWAMI) in ways that support the development of a more complete
in-state program, or a freestanding medical school. Sequential
development within the existing medical education program will maintain
the high quality of the program currently in place.
Implementing these provisions could provide 30 physicians per year
by 2020, about 23 more than the current program. This number assumes a
medical school class of about 50, selected from an anticipated
applicant pool of more than 100 applicants. There are between 70 and 80
Alaska applicants per year. About half of all applicants are qualified
for admission. Other applicants could be drawn from outside Alaska.
The medical education program in Alaska can be responsive to
changing State needs by readily accommodating changes in the number of
students admitted and allowing economies of scale to be realized when
class size increases.
Goal 2. Increase the recruitment of physicians to Alaska by assessing
needs and coordinating recruitment efforts.
Strategy 2A. Create a medical provider workforce assessment office to
monitor physician supply and facilitate physician recruitment efforts
Problem. Currently there is no statewide entity with sufficient
resources to adequately coordinate and address medical provider
workforce issues. Effective planning for future physician supply is
hindered because there is no office with an ongoing responsibility to
regularly assess physician supply and need, and research and report on
medical provider data. Alaska's medical provider recruitment efforts
are disjointed, resulting in higher recruitment costs and duplicate
efforts by various organizations.
Action Steps.
1. Establish a centralized, statewide Medical Provider Workforce
Assessment Office.
2. Develop performance standards and measures for the Medical
Provider Workforce Assessment Office.
3. Implement scope of work and tasks of the Medical Provider
Workforce Assessment Office.
Timeframe. Short term. 12-18 months.
Benefit. A Medical Provider Workforce Assessment Office would
result in ongoing assessment of the status of medical provider supply,
support long-term planning efforts, directly contribute to net gains in
physician supply, and improve the cost efficiency of Alaska's medical
provider workforce recruitment.
Cost estimate. $250,000 per year. Costs should be shared between
the organizations concerned with physician and other medical provider
workforce and the State of Alaska. The office could establish fees for
its services in addition to this core appropriation.
Responsibility. The Medical Provider Workforce Assessment Office
should be located in the State of Alaska, Department of Health and
Social Services.
Impact. Recruitment; Retention
Rationale. Assuring access to health care is a State public health
function. A key component of access to health care is an adequate
medical workforce. Assessment of the status of the health care
workforce, including physicians, and the impact on health status is a
critical activity and warrants a focused and coordinated response by a
Medical Provider Workforce Assessment Office.
As well as assessing and reporting the adequacy of the medical
provider workforce, the Medical Provider Workforce Assessment Office
would play a critical role in responding to provider shortages by
facilitating and marketing recruiting activities statewide among all
potential employers and practices in the State.
Further Discussion. The two primary areas of focus for the proposed
Medical Provider Workforce Assessment Office include the study and
analysis of the medical provider workforce, including physicians; and
the facilitation and support of recruitment activities.
Alaska needs a centralized office in order to identify and track
physician supply, trends, and practice. The Alaska Physician Supply
Task Force report is the first report to determine the supply and need
for physicians and to identify action steps to affect the supply.
Ongoing assessment is needed of the multiple data sets from national,
State, regional and local sources that were used by the Task Force.
Other States have created an office similar to the proposed Medical
Provider Workforce Assessment Office, with good results. The envisioned
program would be run from a State office, most likely from the
Department of Health and Social Services. A precedent for such an
office is the Alaska Seafood Marketing Institute. The Medical Provider
Workforce Assessment Office would document the status of the medical
provider workforce, assess the market, and work with multiple
stakeholders to plan a recruitment strategy that would assist where
needed and avoid interference where appropriate.
The Medical Provider Workforce Assessment Office would share
information about physician supply and recruitment ``best practices''
across sites to help minimize costs and reduce duplication in
recruitment efforts and to promote ongoing policy discussions regarding
physician availability. The Task Force recognized that hospitals and
other entities will want to continue their own specific recruitment
activities.
Workforce development activities exist in multiple locations
including the tribally managed system, private sector, and various
State and Federal agencies. However existing programs are not
monitoring or analyzing specialty distribution or needs, changing roles
of mid-level providers, or potential impact of electronic health
records on all providers. Coordination of the efforts, and research and
analysis of relevant trends, should inform policy.
Strategy 2B. Research and test a physician re-location incentive pay
program.
Problem. The ability to attract and retain physicians to care for
medically underserved populations is compromised due to the high
expense of establishing a practice in Alaska as compared to other
States.
Action Steps.
1. Research relocation incentive pay programs in other States.
2. Research Federal laws related to provision of relocation
incentive pay.
3. Design and implement a relocation incentive pay pilot program.
Timeframe. Short term. Six to twelve months.
Benefit. If successful, this strategy would give Alaska another
method to attract physicians to medically underserved areas. It would
contribute to a more favorable practice climate resulting in a net gain
of physicians willing to provide care for medically underserved
populations.
Cost. Estimated cost of $65,000 one-time funds to secure one
physician. This includes approximately $15,000 for travel related
expenses plus up to $50,000 for a financial incentive payment depending
on specialty of physician selected. Research and design efforts would
be funded through the proposed Medical Provider Workforce Assessment
Office (Strategy 2A).
Responsibility. ASMA, Alaska State Hospital and Nursing
Association, proposed Medical Provider Workforce Assessment Office.
Impact. Recruitment; Retention.
Rationale. Many States have established programs that offer a
signing bonus to compete effectively for the limited number of
physicians, especially in medically underserved areas. This pilot
program would provide an opportunity to determine the efficacy of a
relocation bonus in securing physicians for medically underserved
populations in Alaska. This strategy and related action steps will need
to address requirements of Stark regulations that prohibit hospitals
from providing direct financial incentives to physicians.
Further Discussion. There are challenges in attracting physicians
to Alaska to establish a practice, or to remain in practice if already
in the State. One of those is the expense of establishing a practice in
Alaska compared to other States due to higher salaries, office
expenses, and uncompensated care burden. Other factors include
affordable housing, malpractice expense, cost to periodically visit
family out of State, and generally higher family expenses at a time
when many new physicians are burdened with medical school debt that
must be repaid. Newly established physicians do not have the financial
flexibility to cover all of these higher costs of living in Alaska,
which may cause them to consider more economically advantageous
locations around the United States.
Alaska must identify creative ways to reduce the financial gap
between establishing a practice in Alaska versus other States. A number
of States have created programs that offer a signing bonus to attract
physicians in return for a set commitment in years to stay in that
State.
Alaska should test the feasibility of a physician relocation
incentive pilot program. The pilot program should be based on:
a review of design and effectiveness of other States'
programs, looking at overall return on investment for the bonuses
awarded;
the estimated amount of signing bonus needed to
effectively impact a physician's decision to establish a practice in
Alaska;
the estimated cost to administer the program and most
appropriate agency to house the responsibility;
the scope of specialties that would be eligible for this
program;
areas of the State that would be given priority for award
of these bonuses;
initial discussions included rural and underserved
communities that do not have the resources to offer these bonuses on
their own;
an analysis of Federal laws impact on this strategy,
specifically the Federal Stark provisions;
the estimated cost for administering a full scale program
and number of placements that could be supported; and
the amount of signing bonus needed to effectively impact a
physician's decision.
Many States have a program that offers a signing bonus simply to
compete effectively for the limited number of physicians looking to
start or relocate their practice. These signing bonuses generally come
with a 3- to 5-year practice commitment to avoid repayment of the bonus
if the physician leaves the State early. This strategy would target
already established physicians who wish to leave their current location
as well as physicians completing a residency program and planning to
establish their first practice. Members of the Alaska Legislative
leadership did not support a request for funding a financial incentive
program during the 2006 Session in part because they wanted evidence
that this strategy would produce results. This pilot program would
provide an opportunity to demonstrate whether Alaska could be
successful competing with other States/organizations. If successful,
this strategy could be presented as part of a comprehensive set of
recommendations to the Alaska Legislature to create statutory authority
and financing to fund a full-scale program to recruit physicians.
Alaskans for Access to Health Care (AAHC) has been actively
involved in this Legislative session to bring attention to the need to
invest funding to attract physicians to Alaska. AAHC is made up of
ASHNHA, ASMA, Alaska Physicians and Surgeons, and Providence Alaska
Health Systems. AAHC is informally referred to as ``ACCESS.'' It would
be helpful for ACCESS members and Alaska DHSS to continue exploring
financing a pilot effort to travel to physician conferences, medical
school campuses, large residency settings and other opportune locations
to promote the benefits of an Alaska practice and to offer financial
incentives to choose Alaska for their practice.
If successful, this strategy would give Alaska another effective
selling point along with the other strategies in this document to
attract physicians. Clearly this would not be the primary ingredient in
each physician's decision when choosing a practice location, but it
would perhaps tip the scale in enough cases to warrant funding a
program of this type on a permanent basis.
Strategy 2C. Expand loan repayment assistance programs and funding for
physicians practicing in Alaska.
Problem. The main loan repayment programs available to physicians
in Alaska are provided through IHS and NSHC. Limitations of these
programs are that funding is restricted and subject to annual cutbacks
that threaten their stability, and that only certain practice locations
and specialties are eligible for loan repayment through these programs.
In order to gain more physicians Alaska could participate in the
HRSA Bureau of Health Professions (BHPr) State Loan Repayment Program
which has a 50/50 State and Federal match, but Alaska is one of 13
States that do not participate. In addition, Alaska does not have its
own SLRP for physicians committing to practice in Alaska in specialties
or areas not allowed in the Federal programs (including the SLRP).
Action Steps.
1. Identify opportunities to apply for the HRSA Bureau of Health
Professions SLRP and a supplemental State loan repayment program.
2. Work with DHSS, Governor, State Legislature, and/or local
communities to secure the 50 percent State match required for the HRSA
BHPr SLRP.
3. Research the structure of physician loan repayment programs in
other States.
4. Fund a State loan repayment program to supplement the Federal
loan repayment programs, for physicians serving in shortage areas
designated by the State.
5. Identify and work with an agency to administer the HRSA BHPr
SLRP and/or the supplemental State loan repayment program.
6. Continue informing Alaska's national delegates of the need to
maintain or increase annual Federal allocations for NHSC loan repayment
program and IHS loan repayment program.
Timeframe. Short term. One to two years.
Benefit. Improved Federal funding will enable the IHS and NHSC loan
repayment programs to be stabilized and will allow more clinical sites
to recruit physicians. This will support rural placements including
tribal facilities and community health centers. Alaska's participation
in the HRSA SLRP would allow more physicians in the general specialties
to work in underserved areas. With an Alaska State loan repayment
program not tied to HRSA BHPr, the State could more easily recruit not
only general specialists but also other physician specialists that are
needed and could use state-designated shortage areas so that many
additional sites would be eligible.
Cost. Undetermined at time of Task Force Report.
With an Alaska State loan repayment program not tied to HRSA BHPr,
the State could more easily recruit not only general specialists but
other physician specialists that are needed, and many additional sites
could be eligible for loan repayment.
Under the IHS loan repayment program, applicants sign contractual
agreements for 2 years and fulfill their agreements through full-time
clinical practice at an IHS facility or Alaskan Native tribal health
program. In return, the LRP will repay all or a portion of the
applicant's eligible health professional educational loans
(undergraduate and graduate) for tuition expenses. Applicants are
eligible to have their educational loans repaid in amounts up to
$20,000 per year for each year of service, tax-free. Eligible
specialties are family medicine, internal medicine, pediatrics,
geriatric medicine, obstetrics and gynecology, and podiatric medicine.
Currently there are 18 physicians working in Alaska with IHS loan
repayment.
``Physicians carry a heavy burden of debt coming out of
training and are attracted to areas where a healthy share of
that burden can be taken away.''
--John Bringhurst, CEO, Petersburg Medical Center.
Goal 3. Expand and support programs that prepare Alaskans for medical
careers.
Strategy 3A. Expand and coordinate programs that prepare Alaskans for
careers in medicine.
Problem. Too few Alaskan high school students choose to pursue a
career in medicine. Opportunities that would motivate a greater number
of middle and high school students to pursue medicine as a career path
are lost due to lack of medical career counseling, insufficient
academic preparedness in math and science, and insufficient exposure to
careers in medicine made available through school programs. Alaska
ranks 49th among U.S. States in terms of the success of its applicants
to United States medical schools, despite applicant qualifications at,
or better than, the national average.
Action Steps.
1. Expand and coordinate programs which prepare students for
careers in medicine.
2. Provide financial support to effective programs that provide in
school and summer experiences, internships and job shadowing.
3. Provide support to programs that make math and science available
to K-12 students.
4. Facilitate clinical rotations to rural and underserved areas.
5. Provide State support for an industry/university partnership
geared to encourage youth into health careers.
6. Support current programs to attract students to health careers.
7. Create a Web site and clearinghouse for opportunities and
experiences in health careers.
8. Strengthen the Alaska AHEC by providing State support and by
increasing number of regional AHEC centers required to accomplish above
stated goals.
Timeframe. Medium term of 10-15 years for impact.
Benefits. The benefits of implementing this strategy and action
steps are that students will be more academically prepared for medical
school. The long-term benefit of this strategy will be an increased
number of Alaskan students who select medicine as their career.
Cost. Provide up to $1,000,000 in State matching funds for Federal
pipeline programs.
Responsibility. University of Alaska, Alaska AHEC, State of Alaska,
Alaska State Legislature.
Impact. Training
Rationale. Alaska must grow its own pool of academic talent to
prepare for careers in medical education. To support this growth and
adequately prepare Alaskan students for a career in medicine, more
attention needs to be directed to preparing and exposing students to
related careers in a meaningful way within their community. Today there
are too few opportunities to expose students to the realities and the
excitement of these careers. The opportunities that do exist are not
well known.
Further Discussion. Alaska has a variety of programs that address
specific components of the health workforce and the training
curriculum. Coordination between programs is sporadic at best,
resulting in gaps and redundancies. A communication venue and tracking
database, which facilitates coordination between and among the various
Alaskan agencies supporting the development of Alaska's health
workforce is needed.
Most programs supporting the health workforce curriculum do not
receive sufficient funding to support long-term tracking, let alone the
development of intermediate impact measures. This compromises their
ability to advocate for future funding. An on-line database with a
self-administering format and protected access reduces barriers to both
tracking students and coordinating student participation across
programs.
Based on interviews conducted across Alaska in 2004, and
corroborated by national data, a primary reason for youth not to select
careers in medicine is lack of exposure to those opportunities (Elder,
1997; Alexander, 2003; Bumgarner, 2003; Gill, 1996; Ramsey, 2001;
Magzoub, 2000 and Weiler, 1997).
In Alaska, attrition and recruitment costs are the highest in
remote, underserved regions (DHSS/ACRH, 2006). Research shows that
tangible, positive clinical experience in a setting prior to graduation
is a factor in encouraging graduates to select that setting for
employment (Boulger, 2000; Jones, 2000; Neill, 2002; Ramsey, 2001;
Bacon, 2000; and Rabinowitz, 1999).
It is important to provide regionally tailored activities with
measurable outcomes to expose youth to information about careers in
medicine and a tangible connection to those opportunities. These would
include speaker's bureaus to high schools, summer immersion programs
and job shadowing in local health facilities. Additionally, efforts
must be made to reach out to all those who are currently applying to
medical school to give them coaching for applications and interviews.
Goal 4. Increase retention of physicians by improving the practice
environment in Alaska.
Strategy 4A. Develop a physician practice environment index for Alaska.
Problem. Alaska lacks an objective and reliable method to compare
its physician practice environment to that in other States.
Action Step. Develop a practice environment assessment and
comparison tool. Similar tools currently exist for other States and can
be modified for Alaska.
Timeframe. Short term. Within 2 to 3 years.
Benefit. This strategy would provide an objective basis to measure
Alaska's physician practice environment relative to other States and
the national average. The index would identify elements that cause
Alaska's practice environment to be relatively better or worse than
other States. This would provide indications for strategies that could
better the environment. Also, it would identify those elements that are
strong, relative to other States, and therefore should be stressed in
the recruiting process.
Cost. $100,000 to develop the physician practice environment index.
$20,000 annually to update.
Responsibility. Medical Provider Workforce Assessment Office and
health care partners.
Impact. Recruitment; Retention.
Rationale. The various elements that together constitute the
practice environment need to be identified and quantified in a manner
that allows comparison to the entire United States as well as to other
States. It can serve as a mechanism that would suggest the specific
element or elements that cause Alaska to rank either higher or lower.
Such objective measures can provide the basis for strategies to
strengthen or improve a particular element as well as an objective way
to market the elements in which it has relatively higher strengths.
Further Discussion. An important part of the index would be the
relative weightings among the various elements in the practice
environment. For example, one expected element could be the medical-
legal climate. One measure that could be used for this element would be
physician professional liability premium rates. This element, for
example, could receive a higher relative weighting. In a 2003 survey,
62 percent of medical residents stated that the most important aspect
in practice environment was the medical liability environment (Merit,
2003).
At least one other State has developed such an index. The
Massachusetts Medical Society (MMS) developed an index 5 years ago
based on nine elements that are weighted based on their importance to
the overall practice environment. The base year is 1992, and MMS has
developed the index for each year from 1992 through 2005 for the United
States and Massachusetts. It hires an economic consulting firm to do
the statistical analysis. The MMS index could provide a starting point
for developing an Alaskan Physician Practice Index.
Cost would probably depend on who will conduct the analysis given
that template exists in Massachusetts and that the medical community
could be tapped for volunteer, expert input, $100,000 would probably be
sufficient funding for the initial development. Annual index
development and re-calculation would probably not exceed $20,000 per
year.
The Task Force identified the University of Alaska, Institute for
Social and Economic Research as an organization that potentially could
coordinate development and implementation of the index.
Strategy 4B. Develop tools that promote community-based approaches to
physician recruitment and retention.
Problem. Practice sites and communities engaged in physician
recruitment efforts are often less successful because they are unaware
of factors that influence physician practice location and effective
strategies to improve recruitment outcomes.
Action Steps.
1. Provide tools for technical assistance and training on physician
shortage and the impact of site development efforts.
2. Provide tools to form community-based organizations, such as
community health councils, to address local site development (U.S.
DHHS, 2006).
3. Develop promotional materials that highlight community resources
and economy as a component of the physician recruitment efforts
(Commonwealth, 2005. p. 30).
4. Increase the partnerships among health care sites and
organizations, such as Chambers of Commerce and Economic Development
Councils that can help promote the community as a desirable practice
location.
Timeframe. Short term. Twelve to eighteen months.
Benefits. This strategy would result in more appropriate matches
between communities and physicians. As a result, physicians seeking
employment would find Alaska practice sites and communities to be more
desirable. The anticipated benefits are shorter length of vacancies,
increased number of hires, and increased length of retention.
Cost. $50,000 per year.
Responsibility. Proposed Medical Provider Workforce Assessment
Office and health care partners.
Impact. Recruitment; Retention.
Rationale. Numerous factors influence where a physician chooses to
practice. Some of the factors are characteristics of the practice site
or the community, such as schools or employment opportunities for a
spouse (American Academy of Family Practice, 2006; Rosenblatt, et al.,
2006; Casey, et al., 2005; DHSS/ACRH, 2006). Other critical factors
include the population and economic base of the community that can
support a physician's practice (Wright, et al., 2001). Communities that
do not address such factors in their site and in their recruitment and
retention efforts are less effective in securing and retaining
physicians for their community. Providing tools and technical
assistance to communities that tap into their unique strengths,
identify weaknesses and help them strategize ways to make their
community more attractive to physicians will contribute to successful
outcomes.
Further Discussion. The physician shortage affects not only the
quality of life of a community's citizens, but also a community's
economic health. Often, the health care sector is one of the largest
employers in the community. The adequacy of the health care system
influences communities' ability to attract and retain business.
Physician supply is correlated with economic development, expressed as
real per capita gross domestic product (GDP) (Cooper, et al., 2003).
Community leaders may be unfamiliar with the nature of the
physician shortage, how it could affect them locally, and the
mechanisms that can increase the ability to attract and retain
providers. Such mechanisms include local internships and residency
training, teaching opportunities for the physicians, loan repayment and
scholarships, marketing strategies, and community friendliness toward
the physician and their family. Community leaders need to address
elements that impede physician searches, such as the perception
(whether accurate or not) that rural schools, housing or spousal
employment opportunities are inadequate (American Academy of Family
Practice Physicians, 2006). Major perceived barriers to recruitment
include low salaries and, in rural community health centers (CHCs),
cultural isolation, poor-quality schools and housing, and lack of
spousal job opportunities (Rosenblatt, et al., 2006). Successful
recruitment is often attributed to effectively communicating the high
quality of life available in a rural community and addressing the needs
of the physician's family (DHSS/ACRH, 2006).
Communities need to play an active role in assuring that there are
an adequate number of providers in their communities. Since small
communities often lack recruitment staff, they may benefit from
training on effective recruitment strategies. Also a clear, concise
description of the shortage facing Alaska can stimulate local problem
solving.
Community characteristics, economic expansion and physician supply
are interrelated. Major factors cited by graduating family practice
residents as important ones in choosing their first medical practice
site, include: significant other's wishes; medical community friendly
to family physicians; recreation/culture; proximity to family/friends;
significant other's employment; schools for children; size of
community; initial income guarantee; benefits plan; proximity to
spouse's family/friends (American Academy of Family Physicians, 2006).
Marketing strategies that highlight community resources as a
component of the physician recruitment efforts need to be developed.
Such marketing strategies should address factors cited by physicians
such as their perceptions of community inadequacies related to schools,
housing or spousal employment. Marketing the Alaska lifestyle to
outside doctors is another effective strategy. (Commonwealth, 2005. p.
30).
``Just as we have marketed Alaskan king crab and Copper River
salmon, we can market the variety of exciting opportunities
available for physicians in this area.''
--John Bringhurst, CEO, Petersburg Medical Center.
It is important for community leaders to be aware of the challenges
to recruitment and to tailor strategies to address these concerns.
Community leaders can influence provider housing; hiring packages
(leave, work schedules and continuing education); teaching
responsibilities; and service opportunities (i.e. serving on local,
regional, State, national committees).
Community and health care leaders must acknowledge that their
communities may not have the economic capacity to support physicians or
maintain state-of-the-art equipment and facilities. This situation can
be caused by low population of the community, high poverty status of
the community, or because the community is too geographically isolated
or disadvantaged to financially support physicians. Continuous
subsidies would be required to sustain a physician in such areas
(Wright, et al., 2001).
A report on Kentucky's physician shortage identified a number of
barriers to physician recruitment and retention. Such barriers
included: medical education costs, workload and demands; and decreased
opportunity for professional contacts in medically underserved areas.
Economic concerns that affected recruitment and retention included:
publicly supported insurance programs (Medicaid and Medicare) that
reimburse rural providers at a lower rate than urban providers for the
same medical procedures; rise in insurance payments; relief coverage
and assurance of a reasonable amount of time off from work is the most
important factor in decisions to stay or leave. Other issues include
quality of public schools and ability to become a part of the local
community, which was scored as more important than income. Having an
unhealthy population with high rates of disease including heart
disease, hypertension, asthma, diabetes and cancer can affect the
ability to recruit and retain physicians (Casey, et al., 2005).
Physicians involved in teaching remain in rural practice longer
than those who are not involved. Although many urban physicians assume
otherwise, rural physicians do not necessarily view professional
isolation and an inability to access medical information as drawbacks
to rural practice. Lack of quality of rural school systems, perceived
or real, is related to length of stay for physicians in a rural
practice. (American Academy of Family Physicians, 2006.)
The Medical Provider Workforce Assessment Office would coordinate
this strategy's activities and support existing organizations that work
on physician supply and recruitment, e.g., State Office of Rural Health
and Primary Care Office in DHSS; Primary Care Association, Alaska AHEC,
ACRH, ANTHC, University of Alaska, ASHNA and professional associations
such as ASMA. Linkages among health care sites that recruit and employ
physicians, mayors, city/borough managers, tribal health corporation
leadership, economic development organizations, Chambers of Commerce,
the AFMR, and other training institutions need to be strengthened.
Contracts with statewide organizations that address health care issues
would be needed to support training events and technical assistance.
The NHSC Site Development Manual recommends the formation of a
Community Primary Health Care Council that would be involved in making
decisions related to the community's health care system, including
developing sites that can tap into NHSC resources and providers who are
NHSC Scholars or are eligible for NHSC Loan Repayment (U.S. DHHS,
2006).
Strategy 4C. Support Federal tax credit legislation initiative for
physicians that meet frontier practice requirements.
Problem. There are insufficient financial incentives to attract and
retain physicians in rural/frontier practices. Financial-related
recruitment strategies often create non-cash income that is subject to
Federal income tax.
Action Step. Engage statewide health care partners in efforts to
pass physician tax credit legislation at the Federal level.
Timeframe. Short term. 12 months.
Benefit. A tax credit will help offset the taxes on the non-cash
taxable income created by a loan forgiveness program and thus maintain
the recruitment benefit of such programs. Additionally, when a tax
liability is not a factor, a tax credit, in effect, increases the
income of a physician practicing in a frontier area which influences
practice location decisions.
Cost. Zero cost to the State.
Responsibility. The Alaska Congressional Delegation with support of
the Alaska State Hospital and Nursing Association, ASMA, and health
care partners.
Impact. Recruitment; Retention.
Rationale. Financial-related recruitment strategies that are
commonly used, such as loan repayment programs, create non-cash income
that is often subject to Federal income tax. A tax credit approach made
available to physicians who practice in frontier areas or who treat
patients from frontier areas would help maintain the recruiting benefit
of a loan forgiveness program.
Further Discussion. A tax credit will help offset the taxes on the
non-cash taxable income created by a loan forgiveness program and thus
maintain the recruitment benefit of such programs. Additionally, when a
tax liability is not a factor, a tax credit, in effect, increases the
income of a physician practicing in a frontier area.
The loan forgiveness program that is currently in place for WWAMI
students forgives the loan at a rate of 20 percent per year of Alaskan
practice. For example, a WWAMI graduate, with $150,000 in loan
repayment obligation who practices in Alaska for 5 years, has $30,000
per year in taxable income created.
S.2789 introduced on May 11, 2006 by Senator Conrad Burns (Montana)
and Senator Lisa Murkowski is an example of legislation that provides
for tax credits for physicians who practice in frontier areas or treat
patients from frontier areas. The tax credit is $1,000 a month for a
maximum 60 months. (This bill amends the Internal Revenue Code of
1986).
A short-term timeframe for adoption of such legislation is
important. The WWAMI loan forgiveness element (for practice in Alaska)
is impacting the first WWAMI students completing their GME this year.
This is a strategy that would not have impact on the Alaska State
budget. The cost will depend on the extent of financial incentive
strategies that create non-cash taxable income and the extent to which
they are used. The cost is in ``soft dollars'' of Federal income tax
not collected.
section vii. areas that warrant further consideration
Some areas related to Alaska's physician supply warrant further
consideration but could not be discussed in depth in this report, due
to limits of the Task Force's directive and time constraints. Such
areas include:
patterns and effect of physician turnover on the physician
supply;
the need for specialists and sub-specialists;
the impact of physician assistants and advanced nurse
practitioners on the need for physicians;
the impact of community health aides on medical care in
Alaska;
the opportunities offered by the developing Doctor of
Osteopathy program in Yakima, Washington;
the factors within the Alaska practice environment that
influence decisions to practice in the State;
the relationship of the needs of subpopulations such as
the elderly and those in urban as well as rural locations, on physician
supply;
the role of emerging technologies including electronic
health records and telehealth in physician supply and practice; and
the relationship between physician supply and health care
access.
The Task Force determined that while many of these topics would be
appropriate duties of the proposed Medical Provider Workforce
Assessment Office, some of the areas would fall under the
responsibilities of other organizations.
section viii. appendices
A. Data Details
1. Matriculants in Medical Schools by State
2. Specialty Distribution Comparison (2004) Alaska and United
States
B. Strategies Preferences Scoresheet
C. Physician Study Annotated Reference List
D. Resource List
E. Individual Contributors, Persons Consulted, Commentors,
Reviewers, and Persons who attended Task Force Meetings
F. Acronym List
APPENDIX A. DATA DETAILS
1. Matriculants in Medical Schools by State
----------------------------------------------------------------------------------------------------------------
Applicants Applicants' Matriculation Status
----------------------------------------------------------------------------------------------------------------
Matriculated In Matriculated Out of NOT Matriculated
State State ---------------------
--------------------------------------------
N Percent N Percent N Percent
----------------------------------------------------------------------------------------------------------------
Region..........................................................................................................
----------------------------------------------------------------------------------------------------------------
Northeast........................ 7,867 2,072 26.3 1,773 22.5 4,022 51.1
Central.......................... 8,580 2,884 33.6 1,125 13.1 4,571 53.3
South............................ 12,089 4,287 35.5 1,284 10.6 6,518 53.9
West............................. 8,069 1,439 17.8 2,041 25.3 4,589 56.9
U.S. Total....................... 37,364 10,682 28.6 6,322 16.9 20,360 54.5
----------------------------------------------------------------------------------------------------------------
State of Legal Residence, Western States:.......................................................................
----------------------------------------------------------------------------------------------------------------
Alaska........................... 73 29 39.7 44 60.3
Arizona.......................... 602 109 18.1 98 16.3 395 65.6
California....................... 4,288 812 18.9 1,167 27.2 2,309 53.8
Colorado......................... 609 108 17.7 125 20.5 376 61.7
Hawaii........................... 208 51 24.5 39 18.8 118 56.7
Idaho............................ 161 61 37.9 100 62.1
Montana.......................... 108 53 49.1 55 50.9
Nevada........................... 167 42 25.1 25 15 100 59.9
New Mexico....................... 245 71 29 24 9.8 150 61.2
Oregon........................... 387 68 17.6 87 22.5 232 59.9
Utah............................. 478 75 15.7 150 31.4 253 52.9
Washington....................... 670 103 15.4 155 23.1 412 61.5
Wyoming.......................... 73 28 38.4 45 61.6
----------------------------------------------------------------------------------------------------------------
Alaska Applicants to Medical School by Year, 1994-2005
----------------------------------------------------------------------------------------------------------------
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
----------------------------------------------------------------------------------------------------------------
72 51 62 59 60 48 59 76 75 69 71 73
----------------------------------------------------------------------------------------------------------------
Source: AAMC: Data Warehouse: Applicant Matriculant File as of 10/20/
2005.
2. Specialty Distribution Comparison (2004), Alaska and U.S.
----------------------------------------------------------------------------------------------------------------
2004
----------------------------------------------------------------------------------------------------------------
Alaska Population: 657,755 Alaska Alaska Alaska U.S. Alaska Alaska
----------------------------------------------------------------------------------------------------------------
``Actual''
Total Patient Patient ``Expected minus
Specialty Total Patient Care Phys/ Care Phys/ # at U.S. ``Expected
Physicians Care 1,000 1,000 rate'' at U.S.
Physicians Rate''*
----------------------------------------------------------------------------------------------------------------
Total Physicians.................. 1,580 1347 2.05 2.38 1,569 -222
----------------------------------------------------------------------------------------------------------------
2.28/1,000
----------------------------------------------------------------------------------------------------------------
Primary Care...................... 732 709 1.08 1.14 753 -44
Family Medicine................... 342 333 0.51 0.26 173 160
GP/FM............................. 34 33 0.05 0.04 25 8
Internal Medicine................. 161 157 0.24 0.48 315 -158
Pediatrics........................ 116 108 0.16 0.23 148 -40
Ob/Gyn............................ 79 78 0.12 0.14 91 -13
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Med Spec.......................... 57 55 0.08 0.19 126 -71
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
SurgSpec.......................... 243 237 0.36 0.39 259 -22
General Surgery................... 73 71 0.11 0.12 81 -10
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Child & Adol Psych................ 4 3 0.00 0.02 14 -11
Psychiatry........................ 74 66 0.10 0.13 83 -17
Emergency Medicine................ 75 72 0.11 0.09 60 12
OthSpec........................... 231 205 0.31 0.40 263 -58
Neurology......................... 12 12 0.02 0.04 28 -16
Anesthesiology.................... 75 74 0.11 0.13 84 -10
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Non Pt Care Activities............ 69
Inactive.......................... 117
Not classified.................... 47
----------------------------------------------------------------------------------------------------------------
Adapted by HPSD/AKDHSS..........................................................................................
*Negative implies potential ``need''............................................................................
----------------------------------------------------------------------------------------------------------------
Source: AMA 2006 (Master File database)
APPENDIX B. STRATEGIES PREFERENCES SCORESHEET: STRATEGIES FOR
INCREASING PHYSICIAN SUPPLY IN ALASKA
completed by members of the physician supply task force (6 respondents)
----------------------------------------------------------------------------------------------------------------
Strategy- Short Title Strategy Description Preference Scale (circle number reflecting your
---------------------------------------------------------- preferences, keeping in mind cost, feasibility,
desirability, effectiveness)
Short Term (1-5 ------------------------------------------------------
year impact on Resp 1 Average
supply) Resp 2 Resp 3 Resp 4 Resp 5 Resp 6 Response
----------------------------------------------------------------------------------------------------------------
Recruitment................... Overall 3 4 4 3.7
Recruitment
Effort.
----------------------------------------------------------------------------------------------------------------
Targeting ad 3 3 3 3 2 3 2.8
campaigns
(prof.
journals, TV).
Recruitment at 3 5 3 3 5 4 3.8
national
meetings of the
specialty
societies.
Match candidates 3 3 3 2 4 3 3.0
with local
cultural and
recreational
needs.
Include spouse/ 4 5 3 5 5 3 4.2
SO and family
in recruitment.
Use recruiters 3 4 2 4 5 3 3.5
from the local
area.
Explain 2 4 3 3 3 3 3.0
advantages of
work in
underserved
areas, rural
communities.
Signing bonuses. 2 5 4 4 5 5 4.2
Loan repayment 4 3 4 5 5 5 4.3
options
available.
Higher salary 4 4 5 5 3 4.2
and benefit
offerings
(including
leave options).
Tax credits..... 2 5 5 5 5 4.4
----------------------------------------------------------------------------------------------------------------
Retention..................... Overall 4 4 4 4.0
Retention
Effort.
----------------------------------------------------------------------------------------------------------------
Provide extra 3 4 4 4 3 3 3.5
support to
integrate
provider and
family into
local community.
Loan repayment 4 5 4 5 5 5 4.7
options
available.
Improved salary 4 4 4 4 5 4 4.2
and benefit
scales.
Offer/improve 3 4 5 2 3 3.4
housing.
Improved 4 3 3 3 2 3.0
clinical
facilities.
Good schools/ 5 4 4 5 4 4 4.3
community
resources.
----------------------------------------------------------------------------------------------------------------
Practice environment.......... Overall Practice 1 3 4 2.7
Environment
Effort.
----------------------------------------------------------------------------------------------------------------
Continuing 2 4 2 3 2.8
education
opportunities.
Good management 3 4 2 3 3.0
in work
environment.
More opportunity 1 4 3 3 2.8
for
professional
interaction
thru
videoconferenci
ng & other
means.
Welcome provider 2 4 2 2.7
to community.
Flexible 2 3 3 3 2.8
schedule and
call.
Malpractice 3 4 4 1 3.0
insurance
relief/support.
Adequate 3 5 2 2 3.0
staffing.
----------------------------------------------------------------------------------------------------------------
Education/Training............ Overall 5 5 4 4.7
Education/
Training Effort.
----------------------------------------------------------------------------------------------------------------
Expand residency 5 5 5 5 4 5 4.8
programs.
Increase medical 5 5 5 5 5 5 5.0
school slots.
Early college 4 5 4 4 3 5 4.2
conditioning
for health
careers.
Pre-college..... 3 5 3 4 3 3 3.5
AHEC program 3 5 2 3 3 5 3.5
expansion.
Mentor Alaskan 3 5 2 3 3 3 3.2
high school
students to be
health
providers--talk
at local
schools.
Scholarships.... 4 5 3 5 4 4 4.2
----------------------------------------------------------------------------------------------------------------
Medium Term (6-20 year planning horizon)
----------------------------------------------------------------------------------------------------------------
Education/Training
----------------------------------------------------------------------------------------------------------------
Medical school 5 2 4 2 4 2 3.2
in Alaska.
Additional 5 5 5 4 5 5 4.8
medical school
slots.
Practice environment.......... Additional 5 5 4 5 4 5 4.7
residency
programs.
Retention..................... New and improved 4 4 3 4 3 3 3.5
healthcare
facilities.
Financial Incentives.......... Improved housing 3 4 3 4 2 2 3.0
and facilities.
Improved health 2 4 3 3 1 2 2.5
insurance
coverage.
----------------------------------------------------------------------------------------------------------------
Long Term (>20 years)
----------------------------------------------------------------------------------------------------------------
Education/Training............
----------------------------------------------------------------------------------------------------------------
Medical school 5 5 5 2 4 5 4.3
in Alaska.
----------------------------------------------------------------------------------------------------------------
APPENDIX C. PHYSICIAN STUDY ANNOTATED REFERENCE LIST
Casey, B.R, Jones, J., Gross, D.A., Dixon, L. (2004). Rural Kentucky's
physician shortage: strategies for producing, recruiting and retaining
primary care providers within a medically underserved region. Revised
for publication in the Journal of the Kentucky Medical Association,
September 2005. University of Kentucky, Center for Rural Health.
http://www.mc.uky.edu/RuralHealth/Research/WhitePaperJKMArvsd.pdf.
Kentucky has 400 family physicians that are age 60 or above. The
State's rural medical residency programs can produce only 16 to 18 new
family physicians each year. The number of residency applications has
decreased in recent years. Strategies: addition of an osteopathic
medical school, rural residency programs, State support for family
practice GME, physician placement services, State loan repayment
program, J-1 Visa, reform medical liability.
Center for Health Workforce Studies, University at Albany, State
University of New York. (2004). California physician workforce: supply
and demand through 2015.
http://www.ucop.edu/healthaffairs/reports/Final%20Report%20-
%20California%20Physician%20Workforce 12 20042.pdf.
California is likely to face a 5 percent-16 percent shortage of
physicians by 2015. Some communities are likely to experience more
serious shortages than others. Strategies to address projected
shortages and mal-distribution include: (1) increasing the supply by
increasing medical school capacity, graduate medical training capacity,
incentives to encourage migration to the State and to retain physicians
currently practicing in the State; (2) increasing the productivity and
capacity of the existing physician workforce by expanding the supply
and use of non-physician clinicians, new technologies and increasing
the use of treatment protocols and utilization review; (3) increasing
the diversity of the physician workforce; (4) promoting a more
effective environment for physician workforce planning and policies by
increasing data collection and monitoring physician requirements,
tracking physician supply, comprehensive re-assessment every 5 years,
statewide process for physician workforce planning; (5) promoting
programs and policies such as identification and publication of
shortage areas by specialty, physician loan-repayment and placement,
targeted site development grants, medical education and training in
shortage areas, increasing reimbursement rates in shortage areas.
Chen, F.M., Fordyce, M.A, Hart, L.G. (2005). WWAMI physician workforce
2005. WWAMI Center for Health Workforce Studies, Working Paper #98.
http://www.fammed.washington.edu/CHWS/reports/CHWSWP98%20Chen.pdf.
The UWSOM currently produces approximately 175 physicians a year
and over 60 percent of graduating students stay within the five-state
area to practice. Almost 50 percent of graduating students pursue
careers in primary care. Twenty percent of WWAMI graduates will
practice in federally-designated Health Professional Shortage Areas.
This analysis utilized the 2005 AMA Master File to determine the
population-based supply of physicians at the State and county level, by
discipline of physician and whether they graduated or trained at UWSOM.
Currently there are 22,578 physicians in the five-state WWAMI region.
Of these, 18,794 are clinically-active. Two-thirds (12,718) are in
Washington. Wyoming has the smallest number (830).
Council on Graduate Medical Education. (2005). Seventeenth report:
minorities in medicine: an ethnic and cultural challenge for physician
training.
http://www.cogme.gov/17thReport/17.htm.
Findings: ``Family income'' is the most influential factor in
determining whether a high school senior will be ``very well
qualified'' for college, based on class rank, grade point average and
scores on standardized tests. Parents' education and income levels
affect academic achievement of children. Disproportionate numbers of
``underrepresented minority'' children live in single-parent and low-
income households. Although some programs promote children's interest,
academic achievement, and career choices in science and health, a need
exists for organizations to partner with media, advertising and
marketing firms to develop and disseminate culturally appropriate
messages targeted to minority and disadvantaged youth to encourage
academic persistence and achievement and interest in medical careers.
Council on Graduate Medical Education. (2005). Sixteenth report:
physician workforce policy guidelines for the United States, 2000-2020.
http://www.cogme.gov/pubs.htm.
The supply of practicing physicians is expected to rise 24 percent
from 781,200 to 971,800 between 2000 and 2020. Growth is expected to
slow after 2010 due to the aging of the workforce and the relatively
level number of new physician entrants since 1980. At the same time the
demand for physicians is likely to grow more rapidly than the supply
and the need for services is expected to increase. Considering supply
and need, a shortage of 96,000 is projected in 2020. Factors, such as
changing lifestyles, increase in the use and expected increases in the
Nation's wealth, are included in this report. Other factors not
included are: potential increase in non-patient care activities, change
in practice patterns for physicians over 50, departures due to
liability concerns, limiting the number of patients (``boutique
medicine'') and individuals with chronic illnesses living longer.
Council on Graduate Medical Education. (1998) Tenth report: physician
distribution and health care challenges in rural and inner-city areas.
http://www.cogme.gov/rpt10.htm.
Findings include the following: The lack of health insurance
presents the greatest barrier to medical care. Safety net programs such
as CHCs and the NHSC are essential mechanisms for insuring access to
health care for underserved populations. Growth in the number of
physicians in the United States has not eliminated the problem of
geographic mal-distribution. The small number of family physicians has
contributed to the shortage of rural physicians. PAs and ANPs play an
important role in providing medical care in rural underserved areas.
CHCs and group practice arrangements may be the most viable model for
increasing care in underserved areas.
Grumbach K., Coffman, J.M., Young, J.Q., Vranizan, K., Blick, N.
(1998). Physician supply and medical education in California: a
comparison with national trends. University of California, San
Francisco, Medical School, Department of Family and Community Medicine.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1304984.
This study concluded that California has an ample supply of
physicians in the aggregate, but too many specialists, too few
underrepresented racial/ethnic minority physicians, and poor
distribution of physicians across the State. These factors will
continue to exert inflationary pressures on the health care system
without improving access to care. Major policy changes are needed to
address the imbalance.
Grumbach, K., Coffman, J., Liu, R., Mertz, E. (1999). Strategies for
increasing physician supply in medically underserved communities in
California. California Policy Research Center Brief Series, Center for
California Health Workforce Studies.
http://www.ucop.edu/cprc/MDsupply.html.
This report recommends three types of strategies to increase the
physician supply in underserved areas: (1) practice-environment to make
practice in shortage areas more attractive (2) medical education to
address the training experiences of physicians (3) applicant pool to
target the types of students who enter medical school. Practice-
environment interventions have the quickest ``pay off'' in improving
physician distribution because they target the point when physicians
are ready to enter practice. Medical education and applicant-pool
strategies are integral to a comprehensive plan but take longer to
yield results.
Hart, L.G., Lishner, D.M., Larson, E.H., Chen, C., Andrilla, H.A.,
Norris, T.E., Schneeweiss, R., Henderson, T.M. and Rosenblatt, R.A.
(2005). Pathways to rural practice: a chart book of family medicine
residency training locations and characteristics. http://
www.ask.hrsa.gov/detail.cfm?PublD=ORHP00324.
A survey of U.S. family medicine residencies was conducted in
January 2000. Of the 453 questionnaires sent, 435 responded (96
percent). Only 33 of the responding programs (7.6 percent) were located
in rural areas; predominantly in community hospitals. Over one-third of
the urban programs listed rural training as an important part of their
mission; however, only 2.3 percent of their training took place in
rural areas. For the Nation as a whole, 7.5 percent of family medicine
residency training occurred within rural areas, although 22.3 percent
of the U.S. population lives in rural places. The number of rural
residencies has declined since the survey was conducted. Unless
significant efforts are made to increase rural residency training,
rural physician shortages are likely to persist.
Institute of Medicine of the National Academies. (2005). Quality
through collaboration: the future of rural health care. National
Academies Press.
This report discussed improvements in the three broad areas of the
pipeline to increase the size of a quality rural workforce: (1)
attracting rural students to health careers, (2) providing formal
education programs, and (3) recruiting and retaining trained health
professionals in rural areas. (p. 89)
Measures to attract rural students to health careers involve
enrichment of schooling for pre-collegiate students, ensuring that
basic science is part of the curriculum, and ensuring that students
have positive exposure to role models and career paths in rural health
care delivery. (p. 91)
It is important to create opportunities for members of minority and
disadvantaged populations. Programs administered by HRSA and improved
admissions processes can assist in this effort. (p. 93)
For physicians, two factors are strongly predictive of a future
career in rural health: a rural background and plans to enter family
medicine. (Rabinowitz and Taylor, 2004). Medical schools that make a
strong commitment to educating physicians for rural practice quite
successful track records. (p. 94)
Ricketts, T.C. (2005). Workforce issues in rural areas: a focus on
policy equity. American Journal of Public Health, 95, 42-48.
http://www.ajph.org/cgi/content/abstract/95/1/42.
Rural communities in the United States are served by fewer health
care professionals than urban or suburban areas. This review of the
geographic distribution of health professionals and policies and
programs that influence practice location decisions identifies three
categories of policy levers: coercive, normative and utilitarian; and
recommends a balanced use of the three approaches.
Southworth, M. (2004). Alaskan's physician workforce: an overview, a
summary of training backgrounds, and the impact of the WWAMI program.
Thesis submitted for degree of Master of Public Health, University of
Washington.
Alaska has 1,304 physicians with an active Alaska medical license
that were reviewed. 93.7 percent MD degrees, 6.3 percent DO degrees;
76.6 percent at least one board certification; 30.2 percent women; 24.6
percent addresses in rural communities; osteopaths 1.6 percent of rural
physicians and 4.6 percent of urban physicians; women 34.3 percent
rural and 28.8 percent urban; generalists 43.7 percent; surgical 21.9
percent; medical specialists 8.0 percent; other fields 26.4 percent; 29
percent fewer generalists per 100,000 population in rural communities.
9.9 percent of Alaska physicians received degrees at UWSOM; 9.6 percent
from four other schools; 9.4 percent U.S. military postgraduate
training. 52.6 percent of UWSOM graduates are generalists and 24.1
percent are in rural communities. Alaska's physician workforce is
growing but geographically mal-distributed.
Taylor, P. Utah links Federal funding for graduate medical education to
State's physician workforce needs. Publication produced for U.S.
Department of Health and Human Services, Health Resources & Services
Administration, Office of Rural Health Policy. http://
ruralhealth.hrsa.gov/pub/UtahGME.asp.
A state-chartered commission in Utah is linking Utah's GME funding
and statewide physician workforce needs. The Medicare GME demonstration
project gives the Utah Medical Education Council authority to receive
and disburse all Utah Medicare Direct Medical Education payments. One
goal of the demonstration is to increase the number of graduating
physicians who choose to practice in rural areas.
U.S. Department of Health and Human Services, Health Resources and
Services Administration, Bureau of Health Professions, National Center
for Health Workforce Analysis. (Spring 2003). Changing demographics:
implications for physicians, nurses, and other health workers.
http://bhpr.hrsa.gov/healthworkforce/reports/changedemo/default.htm.
The findings of the literature and two demand forecasting models:
the Physician Aggregate Requirements Model (PARM) and the Nursing
Demand Model (NDM) are: aging population will increase the demand for
physicians per 1,000 from 2.8 in 2000 to 3.1 in 2020. Between 2000 and
2020 the percentage of patient care hours spent with minority patients
will rise from 31 to 40 percent. Increases under five scenarios are
projected: status quo (33 percent), baseline (28 percent), universal
coverage (40 percent), 100 percent HMO (36 percent) and non-minority
rates (37 percent).
U.S. General Accounting Office (October 2003). Physician workforce:
physician supply increased in metropolitan and non-metropolitan areas
but geographic disparities persisted. Report to the Chairman, Committee
on Health, Education, Labor, and Pensions, U.S. Senate. GAO-04-124.
http://www.gao.gov/new.items/d04124.pdf.
The GAO analyzed data on physician supply and geographic
distribution from 1991 and 2001. The U.S. physician population
increased 26 percent, which was twice the rate of total population
growth, between 1991 and 2001. The average number of physicians per
100,000 people increased from 214 to 239 and the mix of generalists and
specialists in the national physician workforce remained about one-
third generalists and two-thirds specialists. Non-metropolitan counties
with a large town (10,000 to 49,000 residents) had the biggest increase
in physicians per 100,000 people of all county categories but their
supplies were still less than large and small metropolitan counties in
1991 and 2001.
Utah Medical Education Council, State of Utah. (2006). Utah 's
physician workforce: a study on the supply and distribution of
physicians in Utah.
http://www.utahmec.org/physicians.htm.
The UMEC conducted a survey of all State licensed physicians. Of
4,484 physicians working in Utah only 3,894 were active patient care
providers. The characteristics of the Utah physician workforce mirror
the national workforce. Over 55 percent of the physicians practicing in
Utah had had some previous contact with the State. Only 12 percent of
Utah physicians provide services to the 25 rural counties in the State.
Utah will need to recruit up to 270 physicians per year to meet the
projected demand.
Wisconsin Hospital Association and the Wisconsin Medical Society.
(2004). Who will care for our patients? Wisconsin takes action to fight
a growing physician shortage.
http://www.wha.org/physicianshortage3-04.pdf.
There is a shortage of primary care physicians in rural Wisconsin
and inner city Milwaukee. Non-primary specialty physicians are in
demand and are hard to recruit on a statewide basis. General surgeons
and radiologists are critically needed in rural areas. The unmet needs
are projected to grow. By 2015, demand is expected to increase by 13.5
percent for primary care physicians and 20 percent for all other
physicians. Action plan: enroll students, develop new care delivery
models, attract and retain physicians, enhance funding, create a
medical education infrastructure.
APPENDIX D. RESOURCE LIST
Alaska Department of Health and Social Services, Office of the
Commissioner, Health Planning and Systems Development, and University
of Alaska Anchorage Center for Rural Health. (2006). Status of
recruitment resources and strategies.
http://hss.state.ak.us/commissioner/healthplanning/publications.
Alexander, C., Fraser, J., Simpkins, B., Temperley, J. (2003). Health
career promotion in the New England area of New South Wales: a program
to support high school career advisers. Australian Journal of Rural
Health, 11(4):199-204.
American Academy of Family Physicians. Rural practice, keeping
physicians in. (Position Paper). (Retrieved 6/7/2006).
http://www.aafp.org/online/en/home/policy/policies/r/
ruralpracticekeep.html.
American Medical Association, Center for Health Policy Research.
(2003). Physician socioeconomic statistics 2001, Tables 13 and 14.
Association of American Medical Colleges, Center for Workforce Studies.
(2006). Key Physician Data by State. http://www.aamc.org/workforce/
statedata.pdf.
Association of American Medical Colleges. (2004). COGME report predicts
physician shortage. http://www.aamc.org/newsroom/reporter/nov04/
cogme.htm.
Association of American Medical Colleges. (2004). Rural medicine
programs aim to reverse physician shortage in outlying regions.
http://www.aamc.org/newsroom/reporter/nov04/rural.htm.
Association of American Medical Colleges. (2006). Notes from conference
May 4-5, 2006. Physician Workforce Research Conference: 2020 Vision--
Focusing on the Future.
Bacon T.J., Baden D.J., Coccodrilli L.D. (2000). The national area
health education center program and primary care residency training.
Journal of Rural Health, 16(3):288-294.
Barrans, D. (2006). Alaskan participation in the WICHE professional
student exchange program. Memorandum to members of Alaska Physician
Supply Task Force. Alaska Advantage Programs, Alaska Commission on
Postsecondary Education.
Booker, J.M., Garrett, C. and Helmuth, B. (1995). A survey of primary
care providers in Alaska.
Boulger J.G. (2000). Stability of practice location among UMD family
physicians in Minnesota. Minnesota Medicine. 83(2):48-50.
Bowman, R.C. (2005). Bright future rankings. University of Nebraska
Medical Center. www.unmc.edu/Community/ruralmeded/bright future
rankings.htm.
Bowman, R.C. (2005). Flawed physician workforce ``beliefs.'' University
of Nebraska Medical Center.
www.unmc.edu/Community/ruralmeded/flawed physician workforce.htm.
Bowman, R.C. (2005). Medical school expansion 2004-2017. University of
Nebraska Medical Center.
www.unmc.edu/Community/ruralmeded/expansion medical schools.htm.
Bowman, R.C. Physician distribution in the United States. University of
Nebraska Medical Center. (Retrieved 4/5/2006)
www.unmc.edu/Community/ruralmeded/physician distribution in the us.htm.
Bowman, R.C. (2005). Ranking medical schools and FP residency programs.
University of Nebraska Medical Center.
http://www.unmc.edu/Community/ruralmeded/ranking rural.htm.
Casey, B.R, Jones, J., Gross, D.A., Dixon, L. (2004). Rural Kentucky's
physician shortage: strategies for producing, recruiting and retaining
primary care providers within a medically underserved region. Revised
for publication in the Journal of the Kentucky Medical Association,
September 2005. University of Kentucky, Center for Rural Health.
http://www.mc.uky.edu/RuralHealth/Research/WhitePaperJKMArvsd.pdf.
Cejka Search. (2005). Physician shortage assessments should reflect
economics rather than demographics. http://www.cejkasearch.com/news/
default.htm.
Center for Health Policy, Research & Ethics. (2000). The National
Health Service Corps: ``essential'' but unseen. George Mason
University, Fairfax, Virginia.
Center for Health Workforce Studies, University at Albany, State
University of New York. (2004). California physician workforce: supply
and demand through 2015.
http://www.ucop.edu/healthaffairs/reports/Final%20Report%20-
%20California%20Physician%20Workforce 12 20042.pdf.
Chan, B.T.B., Degani, N., Chrichton, T., Pong, R.W., Rourke, J.T.,
Goertzen, J., McCready, B. (2005). Factors influencing family
physicians to enter rural practice. Canadian Family Physician, vol. 51.
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APPENDIX E. INDIVIDUAL CONTRIBUTORS, PERSONS CONSULTED, COMMENTERS,
REVIEWERS, AND PERSONS WHO ATTENDED TASK FORCE MEETINGS
Diane Barrans, Executive Director, Alaska Commission on Post-Secondary
Education
John F. Bringhurst, CEO, Petersburg Medical Center
Liz Connell, Legislative Assistant, Office of Senator Ted Stevens
John Coombs, MD, MNS, University of Washington School of Medicine,
WWAMI
Paul Davis, MD, Alaska Family Medicine Residency
Gar Elison, Executive Director, and staff, Utah Medical Education
Council
Leslie Gallant, Executive Administrator, Alaska State Medical Board
Tim Gilbert, MPH, Alaska Native Tribal Health Consortium
Jan Harris, MA, MSHA, UAA, School of Nursing
Gary Hart, Ph.D., Fred Chen, MD, Eric Larson, Ph.D., UW Rural Health
Research Center
Tom Hunt, MD, Medical Director, Anchorage Neighborhood Health Center
Marilyn Kasmar, RNC, MBA, Executive Director, Alaska Primary Care
Association, and staff members Pat Fedrick and Richard Moore, PA-C
Beth Landon, MBA, MHA, Director, Alaska Center for Rural Health
Peter Marshall, MD, private practice, North Pole. Chairman, Alaska
WWAMI
Admissions Committee
Kathy Murray, BA, MLS, AHIP, UAA Health Sciences Library
Richard L. Neubauer, MD, Internal Medicine
Tom Nighswander, MD, WWAMI Program and ANMC
Theresa and Tom Obermeyer, JD, Anchorage
Byron Perkins, D.O., Association President, Alaska Osteopathic Medical
Association
Tom Ricketts, Ph.D., University of North Carolina, Sheps Center
John Riley, MS, PA-C, Alaska MEDEX Program
Meredith Sumpter, Legislative Correspondent, Office of Lisa Murkowski
Leif Thompson, MD, Bristol Bay Area Health Corporation
Suzanne Tryck, Alaska WWAMI Coordinator
APPENDIX F. ACRONYM LIST
3RNET..................................... Rural Recruitment and
Retention Network
AA........................................ Active License Status
AAHC...................................... Alaskans for Access to
Health Care (ACCESS)
AAMC...................................... Association of American
Medical Colleges
ACRH...................................... Alaska Center for Rural
Health
AFMR...................................... Alaska Family Medicine
Residency
AHEC...................................... Area Health Education Center
AKDHSS.................................... Alaska Department of Health
and Social Services
AKOMA..................................... Alaska Osteopathic Medical
Association
AMA....................................... American Medical Association
ANMC...................................... Alaska Native Medical Center
ANTHC..................................... Alaska Native Tribal Health
Consortium
APCA...................................... Alaska Primary Care
Association
APCO...................................... Alaska Primary Care Office
ASHNA..................................... Alaska State Hospital and
Nursing Home Association
ASMA...................................... Alaska State Medical
Association
AP&S...................................... Alaska Physicians and
Surgeons
BHPr...................................... Bureau of Health Professions
CEO....................................... Chief Executive Officer
CEU....................................... Continuing Education Units
CHC....................................... Community Health Center
COGME..................................... Council of Graduate Medical
Education
DHSS...................................... Department of Health and
Social Services
DO........................................ Doctor of Osteopathy
FTE....................................... Full Time Equivalent
GDP....................................... Gross Domestic Product
GME....................................... Graduate Medical Education
GMENAC.................................... Graduate Medical Education
National Advisory Committee
HMO....................................... Health Maintenance
Organization
HPSA...................................... Health Professional Shortage
Area
HPSD...................................... Health Planning and Systems
Development
HRSA...................................... Health Resources and
Services Administration
IHS....................................... Indian Health Service
LRP....................................... Loan Repayment Program
MD........................................ Allopathic Physician
MMS....................................... Massachusetts Medical
Society
MNS....................................... Master in Nutritional
Science
MPH....................................... Masters in Public Health
MUA....................................... Medically Underserved Areas
NHSC...................................... National Health Service
Corps
OHSU...................................... Oregon Health and Science
University
PSAP...................................... Physician Shortage Area
Program
PSEP...................................... Professional Student
Exchange Program
R/UOP..................................... Rural/Underserved
Opportunities Program
SEARCH.................................... Student/Resident Experiences
and Rotations in Community
Health
SLRP...................................... State Loan Repayment Program
UA........................................ University of Alaska
UAA....................................... University of Alaska
Anchorage
U.S. DHHS................................. United States Department of
Health and Human Services
WICHE..................................... Western Interstate
Commission on Higher
Education
WWAMI..................................... Washington, Wyoming, Alaska,
Montana, and Idaho
(regional school of
medicine based at the
University of Washington)
(For more information on Securing an Adequate Number of Physicians
for Alaska's Needs, a Report of the Alaska Physician Supply Task Force,
contact: Pat Carr, Health Planning and Systems Development, (907) 465-
8618, pat [email protected]. This report is also available on the
Web: http://www.hss.state.ak.us/commissioner/PhysicianSupply.htm.)
[Whereupon, at 12:00 p.m., the hearing was adjourned.]