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Primary Care on the Last Frontier: The Challenges of Alaska’s Primary Health Care System

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Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Mark Millard

Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Mark Millard

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Primary Care on the Last Frontier: The Challenges of Alaska’s Primary Health Care System Primary Care on the Last Frontier: The Challenges of Alaska’s Primary Health Care System Presentation Transcript

  • Primary Care on the Last Frontier The Challenges of Alaska’s Primary Health Care System
  • Alaska’s Primary Care System: Issues, Trends, and Strategies Overview of Alaska Health Care System  State Health Care Reform Effort  Health Workforce Capacity Issues  Workforce Capacity Improvement Strategies  2
  • Context and History Demographics and Geography are vital to  understanding our health care delivery system. 3
  • Alaska’s Roads Roads are in red. Rivers also make up major transportation corridors. 4
  • Geography and Demographics Alaska is largely inaccessible by road.  Over half of the 670,000 residents live in  Anchorage and the Mat/Su Borough. Rural Alaska is largely isolated, Native, and  sparsely populated. 5
  • History of Health Care in Alaska 1940-50’s the US Public Health Service  (USPHS) established hospitals in response to a Tuberculosis (TB) epidemic. Community Health Aides originated from the  early USPHS TB effort. IHS has played a major role in the provision and  evolution of health care in rural Alaska. 6
  • History of Health Care in Alaska WWII invasion of Attu and Kiska Islands  (Aleutians) sparked a military presence. Military infrastructure has played a significant  role in the development of telemedicine efforts. 7
  • Capacity/Programs and Facilities 118 Community Health Center (CHC) sites  administered by 26 grantees. 13 tribally administered.  2 public entity grantees.  First grantee in 1974.  Major expansion of CHCs from 1998 onward.  10 Tribal health corporations have 6 rural  hospitals, and 220 clinics in regional centers and rural village communities. 8
  • Alaska’s Federally Funded Community Health Centers 1974-2007 Agencies Sites 140 118 120 Cumulative Count 100 80 60 40 26 24 20 5 12 12 0 1970s 1980s 1900s 2000s Year Funding Began 9
  • Capacity/Programs and Facilities The Denali Commission  Leveraging of federal dollars  Upgrading Alaska’s rural primary care facilities  Private primary care clinics/providers  Larger communities have them  Smaller communities generally do not  16 General Acute Care hospitals, and 6  PHS/Tribal Hospitals. (2,417 beds). 11 of the 16 hospitals are Critical Access hospitals. 10
  • Capacity/Providers 1,434 physicians (53% in primary care).  284 PAs (PAs practice under physician  supervision). 450 Advanced Nurse Practitioners (may  practice independently). 251 Community Health Aide Practitioners.  160 Community Health Aides (100 are III and  IV). 11
  • State Primary Care Office Role High degree of collaborative work with the APCA to  support our CHC’s and Primary Care “Safety net” providers. Advocacy within state & with federal partners.  Bill analysis and commentary.  Conduct, participate, and support studies regarding  primary care & primary care workforce (SORRAS, PSTF, planning grant). NHSC Support.  SEARCH program support and J1 visa program  administration. 12
  • State Primary Care Office Role Research and advocacy regarding state  workforce strategies. Designations HPSA/MUA(P).  TA and data support to CHC applicants and  existing programs. TA regarding Medicaid reimbursement,  service integration, professional and facility licensing and capital funding. 13
  • Health Care Reform Efforts State just completed planning grant (we’re a  late-comer to this effort). Conducted a task force to examine physician  supply within Alaska. Conducted an update of Status of  Recruitment Resources and Strategies report. 14
  • Findings from Reform Efforts Alaska has the highest rate of seasonal  variation (22%) in private sector employment. Alaska has some of the lowest rates of  private sector firms offering insurance. Alaska has some of the longest waiting times  for insurance enrollment. 15
  • Findings from Reform Efforts Alaska has unique workforce and employer  characteristics. This makes reliance upon employment-based  coverage strategies problematic. Planning grant exposed problems of  Medicare participation by providers, exacerbating shortages. 16
  • Alaska's private sector employment is far more seasonal than other states 25% 20% 15% 10% 5% 0% J an F eb M a rc h A p ril M ay J une J uly A ug S ep t Oc t No v De c J an 07 p -5% A K 2 1.8 % WY 10 .2 % M E 8 .8 % B a la nc e US 2 .4 % 17
  • Coverage Initiatives Proposed and Initiated Denali KidCare (SCHIP) increased to 175%  FPL from below 150% (2007 session). Governor appointed Health Care Strategies  Planning Council, report due January 1. Coverage bills introduced in legislature  propose supplementing employer-based insurance with State subsidies to individuals for purchase. 18
  • Health Workforce Capacity Issues Alaska has a shortage of 218 physicians or  14% of the expected physician workforce. Frequent barriers to recruitment  Dearth of qualified candidates  Geographic isolation/harsh living conditions.  Alaska invests on average $34,413 for each  successful primary care hire. 19
  • Health Workforce Capacity Issues Costs of temporary traveling providers  (locums expenses) contributed to recruitment costs. Sparse populations add to productivity and  coverage challenges. It is difficult to maintain HPSAs and high  scores in frontier areas. 20
  • Workforce Capacity Improvement Strategies Increase educational/residency slots  University of Alaska  Alaska Family Practice Residency Program  University of Washington  WWAMI program.  Support midlevel practitioner education and  placement. MEDEX program.  21
  • Workforce Capacity Improvement Strategies Expansion of the scope of the Community  Health Aide (CHA)/Practitioner program to include Dental Health Aides and Practitioners and Behavioral Health Aides. Research and leadership support for State  Loan Repayment program efforts. Developed strategies to prioritize service  need. 22
  • Workforce Training and Incentive Efforts Number of WWAMI medical training slots for  Alaskans increased from 10 to at least 20. Bill added legislative intent to include a post  training service requirement. Mental Health Trust Authority with the University  of Alaska make $200,000 available for loan repayment to behavioral health professionals. 23
  • Community Health Aide/Practitioner Program Unique to Alaska.  Origins in the 1950’s. Local village residents  trained to assist with TB epidemic. Expanded to include basic first aid training.  1960’s formal CHA training program  established by IHS and recognized in Federal Statutes. 24
  • Community Health Aide/Practitioner Program Higher level CHAs and CHAPs are Medicaid  reimbursable. Program model expanded to include Dental  Health Aides and Dental Health Aide Therapists. 2004 first graduates. Now 20 DHA’s/12 DHAT’s.  Chronic dental workforce shortages  Poor oral health in Native Villages Behavioral Health Aide program also initiated.  25
  • Prioritizing Services POPULATION >5001 EMS CATEGORY 20-100 101-500 Access Space Guidelines Communi ty Small = 1,535 GSF Level Medium = 1,990 GSF Large = 2460 GSF Designatio n Description Limited air / water access Small Medium Large and/or Road access > 60 miles; Daily air/water access Isolated I & II Considered a subregional Medium Large center and < 60 minutes travel time to next care level Highway II EMS Only Designated Medium < 60 minutes travel time to Itinerant Space2 next care level Highway I 1.Some communities in this population range may be candidates for multi-community or sub-regional centers. While services, staffing & square footage will be unique for each individual subregional center, a general guideline of 10,000 GSF is recommended. 2.500 GSF or designated space in community building, school, etc. 26
  • Prioritizing Services Dedicated Small Medium Large STAFFING Itinerant Clinic Clinic Clinic Space EMT EMT EMT EMT CHA/P Resident Providers CHA/P CHA/P MLP Itinerant Itinerant Itinerant Itinerant PHN Itinerant Itinerant Itinerant Itinerant Dental Dedicated PROGRAMS AND Small Medium Large Itinerant SERVICES Clinic Clinic Clinic Space Basic EMS X X X X Preventive Health Screenings X X X X Other Preventive Health Services X X X Basic Primary Care X X X Limited Laboratory and X X X Pharmacy X X Patient Case Management X X Outreach, Transportation & X X Interpreter X X Community Health X Advanced EMS X Limited Radiological On-site Administration & Support 27