Physician Recruitment through the Arizona State Loan Repayment Program (SLRP)

Physician Recruitment through the Arizona State Loan Repayment Program (SLRP) July 27, 2016 Arizona Rural Health Conference Flagstaff, Arizona Ana Roscetti, MPH Workforce Section Manager, Arizona Department of Health Services

Arizona Department of Health Services Arizona State Hospital Division of Public Health Services Division of Policy and Operations Public Health Prevention Public Health Preparedness Licensing Services Health Systems Development Women's & Children's Health Nutrition and Physical Activity Tobacco and Chronic Disease Epidemiology & Disease Control Public Health Emergency Preparedness Emergency Medical Services & Trauma System State Laboratory Services Medical Marijuana Program Smoke-Free Arizona AZ Care Check Online Complaint Forms Residential Facilities Childcare Providers Long Term Care Providers Medical Facilities Special Licensing

Bureau of Health Systems Development Mission Statement To optimize the health of Arizona residents by developing and strengthening systems services to expand access to primary care and other services with emphasis on the health needs of underserved people and areas

Bureau of Health Systems Development Core Functions Serves as the Primary Care Office for Arizona Develops and implements strategies for strengthening primary care and the health care delivery system Administers programs to increase the number of providers and improve services in underserved areas Identifies areas that need improved health services and assists with federal/state shortage designations Provides technical assistance to statewide partners

State Data - Arizona 442 Physicians to eliminate 155 primary care HPSAs 441 Dentists to eliminate 172 dental HPSAs 204 Psychiatrists to eliminate 97 mental HPSAs

Workforce Shortages Unmet Healthcare Needs in Arizona Met Unmet Need Mental 33% 67% Dental 35% 65% Primary Care 57% 43% 0% 20% 40% 60% 80% 100% Source: HRSA Data Warehouse, Retrieved from: https://ersrs.hrsa.gov/reportserver?/hgdw_reports/bcd_hpsa/bcd_hpsa_scr50_smry_html&rc:toolbar=false

Workforce Programs National Health Service Corps (NHSC) Loan Repayment Program Arizona Loan Repayment Programs (SLRP) Public or Non-profit Rural, Private Practice J-1 Visa Waiver Program National Interest Waiver Program Nurse Corps Scholarship & Loan Repayment Program

Arizona State Loan Repayment Programs (SLRP) Administered by the Arizona Department of Health Services (ADHS), Arizona Primary Care Office (PCO) Provides loan repayment in exchange for an initial two year commitment in a Health Professional Shortage Area (HPSA) or an Arizona Medically Underserved Area (AzMUA) of the State Available to providers employed by a public or private non-profit or rural private practices located in a HPSA or an AzMUA A.R.S. 36-2172 and A.R.S. 36-2174 are the statutes that govern the programs.

Arizona State Loan Repayment Programs (SLRP) Program Updates: Governor Doug Ducey signed Senate Bill 1194 into law on Feb. 24, 2015. This bill expands the program with the changes effective July 3, 2015 Enhances SLRP through 3 key changes: Expands the eligible disciplines Enhances the award amounts Extends the years of participation The law requires the program to prioritize providers who are residents of Arizona, providers in rural areas and those in areas with high Health Professional Shortage Area (HPSA) scores in Arizona. The law provides eligibility for part-time providers and those providing services via telemedicine. The law provides for an exempt rulemaking until December 31, 2016. The final draft rules are finished and implemented effective April 1, 2016. No additional appropriation resulting from the legislation. Program operates at a combined state/federal funding of $850,000 per year.

Categories Program Before SB 1194 Enhanced Program 2015 Eligible Disciplines Award Amounts Enhanced Arizona State Loan Repayment Programs At-A-Glance Physicians (Family Medicine, Dentists, OB/GYN, Pediatrics, Internal Medicine) PA, NP, Nurse Midwives Up to $40,000/2 year commitment for physicians and dentists per state statute Up to $15,000/2 year commitment for Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives per state statute Physicians (Family Medicine, OB/GYN, Pediatrics, Internal Medicine, Geriatrics, Psychiatry), Dentists PA, NP, Nurse Midwives, Behavioral Health Providers, Pharmacists Up to $65,000/2 year commitment for physicians and dentists Up to $50,000/2 year commitment for advanced practice practitioners Priority consideration given to providers in rural underserved areas, high HPSA score areas, and those who are state residents. Service Years Capped to 4 years per state statute No cap as long as provider continues to have qualifying loans.

Arizona State Loan Repayment Programs (SLRP) Eligible disciplines: Key Requirements for Providers and Service Sites to Qualify: Public, Private Non-Profit or Rural Private Practice Located in a federally designated HPSA or AzMUA (rural private providers) Serve everyone regardless of ability to pay or source of payment Accept AHCCCS, Medicare, Kidscare and qualifying health plans Implement a Sliding Fee Scale for uninured or low income persons at or below 200% of the Federal Poverty Level Guidelines (except free clinic and state prisons)

Arizona State Loan Repayment Programs (SLRP) Eligible disciplines: Recent policy changes per the final draft rules effective April 1, 2016: Change in application submission timelines for new and continuing applications Change in the allocation of funds based on discipline, HPSA score, full-time status, service year of participation and total loan indebtedness Change in the prioritization scoring methodology that determines the order of making awards. Change in timeframe for notification, review and final decision for new applications, renewals, request for change, suspensions and cancellations Change in the process for changing site, full-time to half-time status, loan information, other changes

Arizona State Loan Repayment Programs (SLRP) Application Submission Timelines: New Applications: By June 1 st of each year Renewal Applications: SLRP Participants in HPSA 14 and Above Renewing for 3 rd Year Participation: By April 1 st of each year SLRP Participants Renewing for 4 th year and beyond: By October 1 st of each year Applications must be received during open windows only. ADHS will post the open cycle opening on our website. Providers and Employers must check the website periodically for upcoming cycles. Early or late applications received outside of the open application cycles will be returned. Applicants with incomplete applications will be given a period of time to complete their applications. Any applications deemed incomplete after this period will be withdrawn from the application pool.

Arizona State Loan Repayment Programs (SLRP) Payment Structure for Physicians and Dentists Contract Year of Service Maximum Annual Amount for Full-Time Physician and Dentists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13 Initial two years $65,000 $58,500 $52,000 Third year $35,000 $31,500 $28,000 Fourth year $25,000 $22,500 $20,000 Fifth year and continuing $15,000 $13,500 $12,000 Contract Year of Service Maximum Annual Amount for Part-Time Physician and Dentists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13 Initial two years $32,500 $29,250 $26,000 Third year $17,500 $15,750 $14,000 Fourth year $12,500 $11,250 $10,000 Fifth year and continuing $7,500 $6,750 $6,000

Arizona State Loan Repayment Programs (SLRP) Payment Structure for Other Provider Types Maximum Annual Amount for Full-Time Contract Year of Service Advance Practice Providers, Behavioral Health Providers and Pharmacists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13 Initial two years $50,000 $45,000 $40,000 Third year $25,000 $22,500 $20,000 Fourth year $20,000 $18,000 $16,000 Fifth year and continuing $10,000 $9,000 $8,000 Maximum Annual Amount for Part -Time Contract Year of Service Advance Practice Providers, Behavioral Health Providers and Pharmacists HPSA Score of 18-26 HPSA Score of 14-17 HPSA Score of 0-13 Initial two years $25,000 $22,500 $20,000 Third year $12,500 $11,250 $10,000 Fourth year $10,000 $9,000 $8,000 Fifth year and continuing $5,000 $4,500 $4,000

Arizona State Loan Repayment Programs (SLRP) Primary Care Provider Health Service Priority (New Prioritization) Whether the service site is located in a rural area Yes = 10 points No = 0 points Service site s highest HPSA score as applicable to the applicant s discipline 0 to 26 points Percentage of the service site s total patient encounters that are underserved (total of encounters on Medicaid (AHCCCS), Medicare, Sliding Fee Scale, or free of charge) Greater than 50% = 10 points 35-50% = 8 points 26-34% = 6 points 11-25% = 4 points Less than 10% = 2 points Whether the distance of the service site to the next nearest Sliding Fee Scale clinic providing similar type service as the applicant is greater than or equal to 25 miles Greater than 25 miles = 4 points Less than 25 miles = 0 For the initial application, whether the applicant is newly employed at the service site or by the employer (Newly employed as defined in A.A.C. R9-15-201) Yes = 2 points No = 0 points

Arizona State Loan Repayment Programs (SLRP) Primary Care Provider Health Service Priority (New Prioritization) Whether the applicant is providing services with a patient on-site Yes = 4 points No = 0 points Whether the applicant is a resident of Arizona per A.R.S. 15-1802 (hyperlink to http://www.azleg.gov/ars/15/01802.htm) Yes = 4 points No = 0 points Whether the applicant is a graduate of an Arizona graduate educational institution Yes = 4 points No = 0 points For the initial application, whether the applicant has experience in serving the medically underserved as defined in A.A.C. R9-15-201) Yes = 4 points No = 0 points Whether the applicant is providing services full-time or half-time Yes = 3 points No = 0 points Maximum Points = 71 points

Arizona State Loan Repayment Programs (SLRP) Time-Frames Type of approval Authority (A.R.S. or Overall Time-Trame Time-frame for Applicant to Complete Administrative Completeness Substantive Review (in working days) A.A.C.) Application (in Review (in working working days) days) (in working days) Initial Application R9-15-207 45 20 15 30 Renewal Application R9-15-208 45 10 15 30 Request for Change R9-15-211 15 5 10 Request to suspend a LRP contract Request to waive liquidated damages Request to cancel a LRP contract R9-15-212 15 5 10 R9-15-214 15 5 10 R9-15-215 15 5 10

Partnership and Collaboration Opportunities

Arizona State Loan Repayment Programs (SLRP) DEMAND Actual Applications Received (Historical and Current) 35 30 25 20 15 10 5 0 Applications Received by Submission Deadline SB 1194 6/1/16 New timeline for new application submission June 1 st per the final SLRP draft rules.

Arizona State Loan Repayment Programs (SLRP) PROGRAM GROWTH OVER 3 YEARS CONTRACTED PROVIDERS Discipline FY 2014 FY 2015 FY 2016 Physicians 10 19 22 Dentists 3 7 9 Physician Assistants 2 3 4 Nurse Practitioners 1 4 3 Nurse Midwives 1 1 0 TOTAL CONTRACTED 14 34 43 Total Funding $744,900 $620,000 $1,045,800* Funding Utilization (%) 32% 62% 100% * Total Funding = $1,045,800 ($650,000 state EMS, $200,000 federal, and $195,800 AMSLP)

Arizona State Loan Repayment Programs (SLRP) FY 2017 Data Summary of Applications - 32 applications received, 30 within due date Discipline PsychD 3 PharmD 2 PA 1 Psych NP 1 NP 9 MD 7 DO 2 LCSW 2 DMD 2 CNM 1 Total 30 Average Debt DMD $260,782.00 MD/DO $160,583.00 NP/PA $76,383 BH Providers $80,011 PharmD $56,745 Rural* 14/30 47% HPSA Score 18 and above 9/30 30% HPSA 14 to 16 21/30 70% HPSA below 14 0/30 0% Newly Employed 19/30 63% AZ Residents 26/30 87% Graduate of AZ graduate institution *9 out of 14 are in rural FQHCs Service Site Type Number % FQHC 19 63% FQHC LA 2 7% IHS 3 10% RHC 1 3% Other Non Profit 4 13% Private Practice 1 3% Total 30 100% 10/30 33%

Arizona State Loan Repayment Programs (SLRP) Opportunities to grow the program Private Donations Competitive grant application in Spring 2017 for a 4 year grant period (Sept. 1, 2018 to Aug. 31, 2022). SLRP can request up to $1 million. Opportunity to leverage funds to recruit providers through SLRP (possible federal match for public non-profit providers)

Arizona State Loan Repayment Programs (SLRP) Participate in the Recruitment and Retention Summit Fall 2016 Please sign up at the registration desk. Entities can donate directly to the program. For details, please contact Ana Roscetti at ana.lyn.roscetti@azdhsgov or call 602-542-1066.

Arizona J1 Visa Waiver Program J1 Visa Waiver - a waiver of the two-year foreign residence requirement as it applies to foreign medical graduates (pursuant to Section 214(k) of the Immigration and Nationality Act 8 USC 1184, as amended by PL 103-416). The J1 Visa Waiver Program (aka Conrad State 30 Program) was created in 1994 to help rural and underserved communities across the United States in recruiting primary care providers. The J1 Visa Waiver Program allows foreign physicians to practice in medically-underserved communities without returning to their home residence, thus, allowing them to receive nonimmigrant, H-1B status (temporary worker in specialty occupation) for three years. The U.S. Citizenship and Immigration Services (USCIS) is the Federal Agency that grants J1 Visa Waivers. The Arizona Department of Health Services (ADHS) acts as an Interested Agency in supporting J1 Visa Waiver requests on behalf of J1 physicians willing to practice in medically underserved areas of the State. Thirty (30) slots are available per year (22 primary care, 7 specialist, 1 discretionary). Annual application cycle is from October 1 through November 30.

Arizona J1 Visa Waiver Program Eligible disciplines: MDs in primary care discipline (internal medicine, family or general practice, pediatrics, OB/GYN or psychiatry) or specialists Provider Have an offer of full time employment for 40 hours per week at an eligible service site 3 year minimum obligation Provide primary care or specialty services in an approved site AZ medical license or eligible for an AZ medical license Service Site Located in a designated HPSA, MUA or MUP Accept Medicare and Medicaid Have a non-discriminatory policy in the provision of health services Use a Sliding Fee Scale Demonstrate unsuccessful recruitment efforts of a U.S. citizen physician for at least 6 months prior to the J1 waiver request Operational and providing care for at least six months as of the date of the request

Arizona National Interest Waiver Program (NIW) The Federal National Interest Waiver (NIW) program allows certain foreign workers including foreign physicians (MDs) with advanced degrees or exceptional abilities to work in the United States. The federal guidelines allow states to recommend a national interest waiver to foreign physicians. ADHS act as an interested agency attesting that the foreign physician s work is in the public interest. ADHS will consider requests for ADHS NIW support from J1 physicians meeting the following conditions: Obtained a J1 waiver from USCIS based on ADHS recommendation Practiced at an eligible service site (within designated HPSA/MUA) for at least one year immediately preceding the request for an ADHS NIW support and will continue to practice in the same or similar setting to a total aggregate of 5 years (including J1 obligation) Complied with the ADHS J-1 Visa Waiver Programs policies

THANK YOU Ana Roscetti, MPH Workforce Section Manager, Arizona Department of Health Services ana.lyn.roscetti@azdhs.gov 602-542-1066 azhealth.gov @azdhs facebook.com/azdhs