Health Center Workforce Challenges& One Solution on Alaska’s Horizon:

HCPLRIP

Presentation for theAssociation of

Tribal Health Directors February 17, 2009

Goal – Educate & Activate Re:

APCA

CHC model

Workforce Shortage Challenge

CHC Legislative Request

Statewide Legislative Request HCPLRIP

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Alaska Primary Care Association

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CommunityHealth Centers

CHC Model

Medically underserved communities / populations

Board governed / advised (51% patients) Not-for-profit organizations Local governments Tribal organizations

CHCs are open to all regardless of insurance statusor ability to pay – offer sliding fee scale

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CHC Model

Quality, comprehensiveprimary care

“Primary Care” includes basic Medical care Dental services Behavioral health care

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CHC network in Alaska is statewide 26 CHCs

13 are Tribal CHCs 141 CHC clinic sites

103 are Tribal CHC clinic sites 80,000+ patients 331,000 patient visits 900+ clinic employees

CHC Model

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

Illanka Community Health Center, Cordova7

13 Tribal CHCs with 103 Sites

Aleutian Pribilof Islands Association 1Bristol Bay Area Health Corporation 7Council of Athabascan Tribal Governments 9Eastern Aleutian Tribes 9Maniilaq Association 11Native Village of Eyak 1Norton Sound Health Corporation 15Seldovia Village Tribe 2Southcentral Foundation 2SouthEast Alaska Regional Health Consortium 11Tanana Chiefs Conference 5Yakutat Tlingit Tribe 1Yukon Kuskokwim Health Corporation 298

CHC Delivery Sites in Alaska

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78% of Alaskan CHC Patients areLow Income

U.S. Department of Health and Human Services, HRSA. Bureau of Primary Health Care Section 330 Grantees Uniform Data System (UDS) Calendar Year 2007 Data Alaska Rollup Report.

CHC Patient Income Levels

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Most Alaskan CHC Patients areUninsured or Publicly Insured

U.S. Department of Health and Human Services, HRSA. Bureau of Primary Health Care Section 330 Grantees Uniform Data System (UDS) Calendar Year 2007 Data Alaska Rollup Report.

CHC Patients: Insurance Status

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2006 – 2007 CHC Practitioner Numbers

2006

31482913

2007 Practitioner Type

32 MDs / DOs48 PAs32 NPs16 Dentists

U.S. Department of Health and Human Services, HRSA. Bureau of Primary Health Care Section 330 Grantees Uniform Data System (UDS) Calendar Years 2006 and 2007 Data Alaska Rollup Reports. 13

Lost in Past 3 Years at CHCs (estimated)

# LostPractitioner Type

28 MDs / DOs46 PAs28 NPs 6 Dentists21 LCSWs16 Other MLPs

Alaska Primary Care Association, Workforce Survey, February 2009. Findings are estimates based on convenient sampling. Contact David Wilson for more information: (907) 929-2739 or David@alaskapca.org.

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Current Vacancies at CHCs (estimated)

# Vacant Practitioner Type

22 MDs / DOs20 PAs26 NPs 6 Dentists10 LCSWs12 Other MLPs

Alaska Primary Care Association, Workforce Survey, February 2009. Findings are estimates based on convenient sampling. Contact David Wilson, APCA, for more information: (907) 929-2739 or David@alaskapca.org.

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High Vacancy Rates Plague CHCs

Alaska CHC physicians 2% of state total

Alaska CHC physician vacancies 10% of state total

2007 UDS Report, HRSA; and Alaska Health Workforce Vacancy Study, 2007, Beth Landon, Alaska Center for Rural Health. 16

Turnover is High / Recruitment is Slow

Practitioner is employed 2 - 4 yrs MD / DO vacancy 9 -12 mos PA vacancy 6 - 9 mos NP vacancy 9 -12 mos LCSW vacancy 18 mos

Alaska Primary Care Association, Workforce Survey, February 2009. Findings are estimates based on convenient sampling. Contact David Wilson, APCA, for more information: (907) 929-2739 or David@alaskapca.org.17

National Shortage:Giant Problem

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The Shortage Problem:Impacting CHCs

2% U.S. medical students choose primary care¹ 9% of physicians practice in rural areas

– But 20% of the population resides in rural areas²

150,000 general dentists in practicing in US– But only 14% practice in rural areas²

CHC patients grew 57% from 2000 to 2006³

19 ¹Journal of the American Medical Association, September 2008. ²DHSS Heath Planning & Systems Development, Robert Sewell. ³HRSA, Bureau of Primary Health Care Section 330 Grantees Uniform Data System Calendar Years 2000-2006.

A Problem thatMust Be Resolved

Incentives elsewhere have stronger pull Routinely lose candidates Question of incentives and loan repayment

often first question Alaskan CHCs can’t compete Alaska can’t compete

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2 Legislative Solutionsto Address Immediate Problem

1. CHCs 2. Statewide

HCPLRIPCHCStateSupport

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CHC State Support

Federal dollars have not kept pace

Cost for uncompensated care is significant

All but a dozen states support CHCs

Wise investment

Nationally, medical expenses for CHC patients are41% lower compared to patients seen elsewhere.22

FY10 CHC State Support Request

Workforce $1.5 million – local recruitment (O) $120,000 – statewide tools (C)

Energy $5.6 million – energy assistance

Senior Access $155,000 – added to $350,000 line item (O) $500,000 – outreach infrastructure (C)

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HCPLRIP

Health Care ProfessionsLoan Repayment & Incentive Program

Shortages are StatewideShortages are Statewide

Estimated VacanciesEstimated Vacancies 10.3% Statewide10.3% Statewide 16.5% Tribal Health Organizations16.5% Tribal Health Organizations 13.9% Behavioral Health13.9% Behavioral Health

29% of all vacancies29% of all vacancies Shortages: all 119 occupations

25 Alaska Health Workforce Vacancy Study, 2007, Beth Landon, Alaska Center for Rural Health.

Shortages are SeriousShortages are Serious

Without intervention, shortage will Without intervention, shortage will become a public health crisis.become a public health crisis.

26 Rod Betit, Alaska State Hospital and Nursing Home Association, discussion at ASHNHA Annual Meeting, Talkeetna, Alaska., Fall 2008.

Tribal / Rural Recruitment is Tough

Remote locations Cost of living Lack of housing Competing salaries Shrinking pool NHSC &IHS loan repayment

issues Lack of state-sponsored

incentives27

Case in Point: Dental Shortage

$35K recruitment cost Vacancy rate

10% all 15% rural 42% tribal

Average vacancy 19 months

28 Alaska Health Workforce Vacancy Study, 2007, Beth Landon, Alaska Center for Rural Health.

Statewide vacancy rate of 24% (51% tribal)

Average vacancy length is 15 months

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Case in Point: Pharmacist Shortage

Alaska Health Workforce Vacancy Study, 2007, Beth Landon, Alaska Center for Rural Health.

$126K recruitment cost (family medicine)

Vacancy rate 11.7% all 28.4% tribal

Average vacancy 17.8 months

375 FTE shortage 30

Case in Point: Physician Shortage

Occupational GroupsStatewide Estimates

Positions VacanciesVacancy

RateTribal

VacancyAll Occupations 34738 3529 10.2% 16.5%Physicians 1931 226 11.7% 27.1%Professional Nurses 7139 696 9.8% 15.5%CNA/LPN/PCA/HHA 1762 111 6.3% 14.3%Dentist/Pharmacists/ Therapists

2281 404 17.7% 42.9%

Behavioral Health 7450 1033 13.9% 14.5%Allied Health 5523 434 7.9% 17.1%Public Health/Nutrition 189 ND ND 15.2%Managers 2947 160 5.4% 7.6%Health Information/ Reimbursement

4451 253 5.7% 11.3%

Statewide Vacancy Rates

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HCPLRIP Planning Group

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

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Support for Service Options

Support forService

Loan Repayments Scholarships Resident

SupportDirect

IncentivesLoans forService

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Prospects

Participants

Trained Professionals

AttritionRetirement

Trained Professionals (from Elsewhere)

Active Practitioners

AK HC Workforce____________________________________________________

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Direct Care____________________________________________________

_

Non-Direct____________________________________________________

__

Possibles

Support-for-Service Programstarget those who are farther along in their careers.

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When Practitioners Make Commitments

22 23 24 25 26 27 28 29 30 31 32 33 34 35

-7 - 6 - 5 - 4 - 3 - 2 - 1 0 1 2 3 4 5 6

Years before and after service begins

Medical School Residency

Schola

rship

Pro

gram

s

&Serv

ice-O

ption

Loan

s

Loan

Rep

aymen

t

Progr

ams &

Dire

ct

Incen

tive P

rogr

ams

Service Post-Service Retention

Typical Ages

Reside

ncy S

uppo

rt

Progr

ams

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HCPLRIP Program Elements

Program Elements (see handout)1. Oversight Entity2. Fiscal Agent3. Practitioner Eligibility4. Site Eligibility5. Payment Details6. Program Evaluation7. Resources & Funding

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2 Components: Loan Repayment & Direct Incentives

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10 Occupations included in HCPLRIP

Tier-1 Dentists Pharmacists Physicians

Tier-2 Dental Hygienists Nurses (RN) Nurse Practitioners Physician Assistants Physical Therapists Psychologists Social Workers38

Payment Details

Placement Types: Regular & Hard-to-Fill Amounts

Tier 1 Up to $35,000/year (Regular)Up to $47,000/year (Hard-to-Fill)

Tier 2Up to $20,000/year (Regular)Up to $27,000/year (Hard-to-Fill)

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Payment Details (cont’d)

3-year period of service Quarterly payments following service May re-apply for a 2nd period of service Lifetime participation cap is 6 years

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Funding & Resources

Employer or community match 0% - 100%

May not offset current or expected provider supports

Proposed funding for FY10$7.5 million

$7.5 million: 90 participants (9 in each category)

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Even in tough economic times of low oil revenues…

Economic impact of rural physician Turnover costs Locums: high cost & discontinuity of care Pay-offs

Costs avoided Continuity of care42

…HCPLRIP is worth the cost.

Questions?

Thank you for inviting the APCA!

We are happy to partner with you as we work together to promote access across Alaska.

Shelley Hughes Government Affairs Director

Alaska Primary Care AssociationShelley@alaskapca.org

907-841-163443