Workforce Policy Updates

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1 Workforce Policy Updates Jon Villasurda, MPH Policy Consultant June 12, 2014

2 Agenda The Need for Workforce Policy Workforce Policy Updates State Federal MPCA Workforce Policy Priority

3 The Need for Workforce Policy

4 Key Facts Only 36% of Michigan physicians practice in primary care. Healthy Michigan Plan will enfranchise up to roughly 500K new people to the healthcare system. Michigan is projected to be 4,400 PCPs short by Many primary care providers will retire within 10 years. Reimbursement is poor for primary care and safety net services. Scope of practice laws in Michigan are outdated and preclude optimal utilization of midlevel providers. Michigan s Graduate Medical Education program doesn t go far enough to benefit Michigan s underserved. The saturation of federally designated Health Professional Shortage Areas (HPSAs) in Michigan covered in next slides.

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8 Workforce Policy Updates * State * Federal

9 Overview Workforce Policy is affected by both budgetary and policy decisions. Budget Hypothetical: Graduate Medical Education (GME) is funded at $4.3 million annually. The next year, however, the legislature and governor decide to boost funding by $1.0 million to increase funding to $5.3 million annually, thereby creating more capacity. Policy Hypothetical: GME currently distributed to teaching hospitals without regard to provider shortages. It s also only available to physicians. However, the legislature and governor decide to require funding to be allocated based on evidencebased provider shortages and to open up funding to multiple provider types, thereby creating capacity overall and in areas of need.

10 State Workforce Policy Updates - Budgetary PREFACE: The budget is nearly finalized in Michigan, but there are still a couple of steps left in the process. All this is reflected in SB 763 (DCH Budget) for FY ). Michigan State Loan Repayment Program: Increased funding from $2.5 million to $3.5 million ($4.5 million when matched with federal funds). Graduate Medical Education: Continues funding at $4.3 million. Primary Care Provider Rate Increase (Medicaid): Reduces the increase by roughly half -- $72.5 million versus $156 million in last Fiscal Year. OB/GYN rate increase (Medicaid): Increases rates to 95% of Medicare levels. HealthyKids Dental: Expands the program into Macomb and Kalamazoo Counties (Kent, Oakland, and Wayne remain without).

11 State Workforce Policy Updates - Policy Michigan State Loan Repayment Program: SB 648/649 (presented to governor) Allows dentists to participate in program. Revises maximum annual repayment per participant to $40k from $28.9k. Establishes a total maximum loan repayment of $200k per participant. Removes the 4-year maximum participation period. Limits preference to general practice, family practice, obstetrics, pediatrics, or internal medicine. Graduate Medical Education: Section 1870 of SB 763 (DCH Budget). Establishes MIDocs, which requires MDCH to work with Michigan-based medical schools to develop freestanding residency training programs in primary care and other ambulatory care-based specialties based on addressing shortage needs. This includes placing physicians in underserved communities. MIDocs is to be created no later than January 10, 2015 and has a startup appropriation of $500k.

12 Federal Workforce Policy Updates NHSC is currently funded exclusively by ACA mandatory funding, which is set to expire at the end of FY President s FY 2015 Budget Proposal: Increases NHSC funding to $810 million (a $527 million increase from FY 2014 levels). This is projected to increase NHSC providers to 15,000 from about 6,700 today. Establishes a new Targeted Support for GME program a competitive grant program aimed at supporting medical residencies that are primary care based and in rural and underserved areas (incorporates the Teaching Health Center GME program). Proposes to extend the Medicaid primary care payment increase (to Medicare levels) through CY 2015 and expands eligibility to mid-level providers (e.g., PAs and NPs). This would exclude ER codes to target primary care.

13 MPCA Workforce Policy Priority

14 MPCA Workforce Policy Priority Michigan should alter its scope of practice law to provide full practice and prescriptive authority to Advance Practice Registered Nurses (APRNs,) specifically by supporting Senate Bill 2 Michigan should explore utilizing mid-level dental providers in underserved areas Michigan should optimally utilize Medicaid-Graduate Medical Education (GME) funds to address workforce shortages by: Strengthening the program s funding Ensuring training slots are commensurate to workforce needs as defined by evidence-based shortages in specialties and geographic areas Expanding eligibility of GME professions (e.g. Nurse Practitioners, Physician Assistants, and Dental Students) Ensuring that teaching institutions receiving Medicaid-GME funds establish collaborative relationships with safety net providers like Health Centers (Federally Qualified Health Centers [FQHC] and FQHC Look-Alikes) and Rural Health Clinics Exploring innovative demonstration projects that shift funds to non-hospital sites Michigan should continue to invest in the State Loan Repayment Program Continued funding for NHSC at the federal level

15 Senate Bill 2 (APRN Scope of Practice) Michigan Senate Bill 2 would do the following: Provide for the licensure of Advanced Practice Registered Nurses (APRNs), who would include certified nurse midwives, certified nurse practitioners, and clinical nurse specialist-certified; and eliminate provisions regarding the specialty certification of nurse midwives and nurse practitioners. It would provide prescriptive authority to licensed APRNs for nonscheduled drugs and Schedule 2-5 controlled substances if s/he meets certain criteria. Essentially, it would provide prescriptive and practice autonomy for APRNs. Senate Bill 2 has passed the Senate, but has yet to be taken up in the House.

16 Senate Bill 2 (APRN Scope of Practice) Why it s needed: Physician shortages, particularly in underserved areas. Increased demand for primary care. APRNs are currently not recognized in the public health code. 90% of a nurse practitioner s scope overlaps with a primary care physician (PCP). Michigan has the 7 th worst restrictive regulatory environment for nurse practitioners (NPs) in the nation according to the American College of Nurse Practitioners. Michigan has the 8 th fewest NPs per 100K population despite having the 12 th most NP schools. A great amount of evidence-based literature shows APRNs provide care comparable to PCPs and are cost-effective ($92K for NPs vs. $162K for PCPs).

17 Graduate Medical Education Despite the positive changes in the state budget, we believe Michigan should further improve its Medicaid GME program. Our midwestern neighbors of Indiana, Iowa, Minnesota, Ohio, and Wisconsin all allow other health professions outside of solely physicians (e.g., Nurse Practitioners and Physician Assistants) to be eligible for Medicaid GME.

18 Dental Therapists Midlevel Dental Providers Dental Therapists have existed for over 100 years around the world; in the US, they re authorized in Alaska and Minnesota (Minnesota enacted the law in 2009 and graduated its first therapist in 2011). They perform basic preventive and restorative care within a limited scope and under the supervision of a dentist, sometimes made analogous to what a physician assistant is to a physician. They earn about half that of a practicing dentist. In Minnesota, requirements include a 2.5 year post-baccalaureate degree program for dental therapy, a dental hygienist license, baccalaureate degree, and 1,000 hours of previous work experience as a clinical dental hygienist. This degree leads to licensure upon an examination and requisite work hours under dentist supervision. Two of the significant practice details of Minnesota dental therapists include: 1) supervision by a dentist (direct or indirect) under the auspices of a collaborative management agreement; and 2) at least 50 percent of their patient base must live in underserved areas

19 Dental Therapists Midlevel Dental Providers Why they re needed: Over half of Michigan s counties (52) are designated as a Medicaid Dental HPSA. Some of these counties have no practicing dentists. A recent study found that simply increasing Medicaid reimbursement rates for dentists does not lead to a significant increase in utilization (if Medicaid rates were increased to 85% of private fees, Medicaid utilization increased only 9%, and 90% of the additional spending was used to pay already participating dentists). The American Association of Public Health Dentistry, the Kellogg Foundation, and Pew Charitable Trusts support the concept of dental therapists as a cost-effective provided in team-based dentistry that can increase access to care. The University of Michigan produced a meta-analysis of literature on dental therapists that show dental therapists provide comparable care to dentists. Minnesota s preliminary evaluation showed increase access to dental care, clinic satisfaction with dental therapists, decreased ER utilization, and costsavings.

20 Other Issues Provider Credentialing Mental Health/Substance Abuse Eliminate the credentialing requirement for licensed mental health professionals to provide substance abuse services to Medicaid beneficiaries. Provider Licensure HB 4688 Would remove licensure in Michigan for dietitians and nutritionists.

21 Resources MPCA Advocacy Center: MPCA eupdate Sign-Up: https://mipca.siteym.com/?eupdatesubscriptions MPCA Policy Priorities: MPCA Statement on FY 2015 DCH Budget passed by Conference Committee: Reports-Recommended-MDCH-Budget-for-FY-2015.htm President s Budget Recommendation for FY 2015:

22 Questions? For further information, please contact: Jon Villasurda, MPH Policy Consultant (517)

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