Co-Chairs: Representative Sharon Cissna Senator Donny Olson

1. Co-Chairs: Representative Sharon Cissna Senator Donny Olson

2. Filling the Need: Doctors, Dentists & Psychiatrists Check out our new website at: www.akhealthcaucus.org Wednesday, January 24, 2007 Noon to 1:00 PM Butrovich Room, State Capitol A light lunch will be served

3. Agenda • Filling the Need: Doctors, Dentists & Psychiatrists • January 24, 2007 • Introductions/Opening Remarks – Rep. Sharon Cissna and Senator Donny Olson • Medical Education in Alaska - Dennis Valenzeno, Ph.D., Director, Alaska WWAMI Biomedical Program, • Professor and Associate Dean, UAA • Physician’s needs in Alaska - Aron S. Wolf, M.D., M.M.M., of Wolf Healthcare, P.C. • Alaska Dental Workforce - Brad Whistler, D.M.D., State Dental Officer, DHSS • Alaska Area Tribal Dental Services Ron Nagel, D.D.S., M.P.H. Dental Consultant for the Alaska Native Tribal Health Consortium • Securing an Adequate Number of Physicians for Alaska’s Needs - Harold Johnston, M.D., F.A.A.F.P , Program Director, Providence Alaska Family Practice Medical Center • Discussion.

4. Medical Educationin Alaska Dennis Valenzeno, Ph.D. Director, Alaska WWAMI Biomedical Program, Professor and Associate Dean, UAA Alaska Legislative Health Caucus, January 24, 2007

5. Educating a Physician Undergraduate degree • can be in a variety of disciplines 4-year medical school program • confers M.D. degree 3 to 7 years residency training • qualifies for independent practice • specific for specialty

6. Medical Education in Alaska WWAMI is Alaska’s Medical School Admit 10 Alaskans per year Year 1 in Anchorage at UAA Year 2 in Seattle Years 3-4 in any WWAMI state • Alaska Track – nearly all in Alaska Three of four years can be completed in Alaska

7. How Are We Doing? 1. Quality of WWAMI Medical Education #1 ranked Primary Care medical education – 13 consecutive years #1 ranked Rural Health medical education – 15 consecutive years #1 ranked Family Medicine medical educaiton – 15 consecutive years US News & World Report, America’s Best Graduate Schools, 2007 edition

8. How Are We Doing? 2. Graduates Practicing in Alaska Each year 7 to 8 WWAMI graduates begin practice in Alaska Return on investment: 7.5 new physicians for 10 funded positions – 75% National average: <40% Alaska WWAMI Database American Association of Medical Colleges, Key Phys Data by State, Jan 2006

9. How Are We Doing? 3. Alaska WWAMI applicants Alaska WWAMI: 7 to 8 applicants per position most competitive WWAMI site last year excellent qualifications top group of 10 = 2nd group = 3rd group for: MCAT (Medical Coll. Aptitude Test) undergrad GPA (grade point average) Alaska WWAMI Database

10. How Are We Doing? 4. Alaskan Applicant Success - nationwide All US Med Schools: 38% of Alaskan applicants accepted 2ndlowest of all US states AK applicant quality at or above nat’l avg MCAT undergrad GPA American Association of Medical Colleges database 2004

11. (per 10,000 population) How Are We Doing? 5. Public Support for Medical Education Currently Proposed (20) American Association of Medical Colleges database 2004

13. Physician needs in Alaska Aron S. Wolf M.D. MMM.CPE

14. A Growing Changing Need • In the 1950’s, 60’s and 70’s most physicians came to Alaska for their rotations in the Military or The Public Health Service • This changed with the end of the Berry Plan (or physician draft) • It also changed with the change to Native • Self Determination and fewer Service Corps Physicians in Alaska • WWAMI was begun in the 1970 to BEGIN to address the “homegrown “ needs

15. Mental Health Needs • Pre-1962 (API) severe patients sent to Oregon for hospitalization or “housed” in jail • API 1962—but based on 1940’s models • 1970’s—community mental health centers—statewide—22 catchment areas • Originally designed to serve needs of all in the area • With more limited funding their focus has narrowed to the most chronic patients • Psychiatrists traveled as consultants to most of these areas on an intermittent basis • 200’s The use of telemedicine to bring the psychiatrist to the patient

16. Studies of need • 1999 and 2001 studies coordinated by me—for Providence –used the following procedure • Identification of National Needs Guidelines for each medical specialty and sub-specialty • A survey of all practicing Anchorage Physicians---noting their ages and years in practice---issues– fulltime or not—when they might retire or “pull back”—plans to recruit--

17. Study protocols con’t • Development of a “formula” for determining the total number of patients using the private sector of the medical community—ie: military/Native health Care/VA etc.—There was a wider statewide number for specialists • Development of the “Actual” Anchorage data for each specialty • Comparison of this Data with the National Needs Data

18. Findings • An aging of the physician population • A severe lack of primary care physicians-especially internists-as well as family physicians • A severe lack of psychiatrists • Relative needs in all other areas • The problems were MORE severe on the 2nd study in 2001

19. statewide Needs and costs for recruitment and retention of physicians across the state Significant lack of primary care physicians throughout the state SORRAS study by the Sate and UA showed that 16 million dollars are spent annually to recruit physicians and other health care professionals The cost per hire was 28,000 With the need for temporary or locums physicians this drove the cost to 38,000 per hire

20. Issues • High cost of medical education—huge debt for each physician • Poor payment by public programs—medicare and medicaid especially for primary care • Competition for physicians across the country

21. Some ideas for relief • Increase WWAMI positions (Dr. Johnston) • A combined recruiting and retention initiative (ASHPIN) or others • Use of technology/telemedicine • Cooperation between segments of the health care system—private/clinics/hospitals/Native health system/VA and military

22. Alaska Dental WorkforceHealth Caucus – January 24 2007 Brad Whistler, DMD DHSS Division of Public Health Section of Women’s, Children’s and Family Health

23. Alaska Dental Workforce: Current, Active Licenses

24. Alaska Dentists: FY2005 Perspectives • 563 Current, Active Licenses • 457 Current Active Licenses that list an Alaska address • U.S. Dentist to population ratio (ADA, 1999): 1:1,873 (GP/Ped at 1:2,200) • Alaska Dentist to population ratio (SFY2005): 1:1,452 • Dental-Health Professional Shortage Areas (Dental-HPSAs): 1:5,000 or 1:4,000 with high needs

25. Distribution:Heath Professional Shortage Areas (HPSA)

26. Dental Workforce - Demographics

27. Dental Participation in Medicaid, FY2005

28. U.S. Dental Workforce

29. Dental Workforce

30. Dental Workforce: An Economic View“Adequacy of Current and Future Workforce”,A. Jackson Brown (ADA Publication), 2005 • Reviews dental workforce from an “economic” view based on disease, consumer demand, household income, population, education levels, changes in productivity and insurance coverage v. a “needs based approach.” • Acknowledges “graying” of the workforce through 2025 and projects increased part-time dentists from 14% in 2002 to 17% in 2025, however the report concludes that there is an adequate dental workforce through this period. • The report notes that overall access to dental care in the U.S. is excellent and strategies should deal with short-term adjustments than longer term approaches to increase the number of dentists.

31. Alaska Area Tribal Dental Programs Ron Nagel, DDS, MPH Director, AK Dental Clinical and Preventive Support Center Consultant, Alaska Native Tribal Health Consortium www.ANTHC.org

32. DDS Demographics • 4000 dentists graduate and 6000 retire each year (this trend will likely continue and may broaden as baby-boomers leave practice) • Historically only 2-3% of dentists go into public service, so simply producing more dentists has proven to be inefficient in filling positions in underserved areas. • 25% of AK dentists are 55 or over

33. DDS Demographics Continued • 25 -29% annual vacancy rate, and a 30% turnover rate, in AK tribal programs, and climbing. • 140 DDS vacancies in Tribal programs nationally, A 300% increase since 1995 • The vast majority of new dentists are offered loan repayment

34. Conclusions/Recommendations A dwindling number of dentists in Native and rural communities is a great concern A Personal sense of well being and the experience of living and working in a Native community are strongly associated with retention, over financial factors – 2006 Kelly study. Current loan repayment/scholarship monies need to be tied to a career in public service rather than short term tours The oral health workforce needs to be expanded beyond dentists and hygienists

35. Securing an Adequate Number of Physicians for Alaska’s Needs Alaska Physician Supply Task Force Alaska Health Summit December, 2006

36. Task Force Members Co-Chairs: • Richard Mandsager, MD, Previously Director, State of Alaska Director of Public Health. Currently Director of Children’s Hospital at Providence • Harold Johnston, MD, Director, Alaska Family Medicine Residency Members: • Rod Betit, President, Alaska State Hospital and Nursing Home Association • David Head, MD, Medical Director, Norton Sound Health Corporation, and Chair, Alaska State Medical Board, representing Alaska Native Tribal Health Consortium • Jan Gehler, Ph. D., Interim Provost, University of Alaska Anchorage • 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

37. Staff to the Task Force Health Planning and Systems Development Unit in the Commissioner’s Office, Alaska Department of Health and Social Services • Patricia Carr • Alice Rarig • Joyce Hughes • Stephanie Zidek-Chandler • Jean Findley

38. Alaska Physician Supply Task Force • Commissioned January 2006 by UA President Hamilton and the Commissioner of DHSS Karleen Jackson • Addressed two questions: • What is the current and future need for physicians in Alaska? • What strategies have been used and could be used in meeting the need? • Variety of sources of information, including physicians, other experts, and 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.

39. Assessment of Need • The ratio of physicians to population in Alaska is below the national average (2.05 MDs per 1000 population in Alaska vs. 2.38 U.S.) • Alaska should have 10% more physicians per population than the national average because of Alaska’s rural nature, great distances, severe weather, and resulting structural inefficiencies of the health care system • Alaska needs a higher ratio of mid-level providers (advanced nurse practitioners and physician assistants) to physicians than the national average • Shortages: most apparent in internal medicine, medical subspecialties and psychiatry • Alaska currently gains about 78 physicians per year, loses about 40 per year

40. Strategies that Have Been Used to Enhance Physician Supply in Alaska • Residency programs are one of the most effective ways to produce physicians for a state or community. (Alaska Family Medicine Residency places 70% of its graduates in Alaska.) • In 2005, 29 of 73 Alaskan applicants were admitted into medical school. Ten per year attend WWAMI (first year in Alaska), others attend medical schools without state support from Alaska. • Recruitment for physicians is facilitated by the availability of loan repayment programs such as the Indian Health Service and National Health Service Corps loan repayment programs. • Alaska has a number of initiatives to increase interest in medical careers among Alaskans include but these generate too few applicants to replenish Alaska’s shortage, and diversity is inadequate.

41. Figure A. Gain in Alaskan Physicians—Static Doctor to Population Ratio vs. Desired Growth Scenario

43. Recommended Strategies • The Task Force recommends improved monitoring of physician workforce issues and specific strategies and action steps to achieve four goals related to assuring an adequate supply of physicians to meet Alaska’s need. These are detailed in the report: Securing an Adequate Number of Physicians for Alaska’s Needs.

44. 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

45. Goals and Strategies for Securing an Adequate Physician Supply for Alaska’s Needs Major Goal1. Increase the in-state production of physicians by increasing the number and viability of medical school and residency positions in Alaska and for Alaskans.

46. Goal 1. Increase production of physicians…

47. Goal 1. Increase production of physicians…continued…

48. Goal 2. Increase the recruitment of physicians to Alaska by assessing needs and coordinating recruitment efforts.

49. Goal 3. Expand and support programs that prepare Alaskans for medical careers

50. Goal 4. Increase retention of physicians by improving the practice environment in Alaska