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Role of Support-for-Service in the Healthcare System: Lessons from Alaska’s SHARP Program

Friday, May 12, 2017   (0 Comments)
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Robert Sewell, Director, Alaska's Sharp Program and Eric Peter, Health Program Associate


Robert will be presenting on this topic at the Spring Primary Care Conference in Spokane




An excellent National Public Radio article was just released on Dr. Adam McMahan, who works for SEARHC and  is a SHARP-1 support-for-service recipient.


Having a sustainable and competent healthcare workforce is critical.  And yet, most states struggle with the enduring problems of clinician shortage, turnover and mal-distribution. In response, Alaska began SHARP in 2009, which proved to be a robust and sustainable support-for-service strategy, one that’s strengthening our healthcare system. SHARP offers both education loan repayment and direct incentive. It features blended funding streams, extended service contracts, clinician-specific budgeting, and more than 57 different participating agencies to date.  SHARP is guided by a collaborative 15-member, statute-required Advisory Council, composed of both interagency and interdisciplinary members. Thus far, SHARP has had 254 clinician-contracts across the range of dental, medical and behavioral health occupations, which have been spread across Alaska, and especially in safety-net settings. This article includes information on:  SHARP’s clinician census, our federal and non-federal partnerships, interagency relations, approaches to funding, and the road ahead. Overall, SHARP is working and we are making progress.  The article concludes with a brief set of lessons learned.




National Trends


Several system drivers are increasing the demand for healthcare nationwide.  Our national population is growing, as are those sub-populations that qualify for Medicaid, Medicare and/or other federal health benefits.  Americans are also getting older, and are thus presenting more co-morbidities, poly-pharmacies and chronic conditions.  At the same time, the level of education loan debt of clinicians is still growing.  These trends make it difficult for training institutions to keep up with the rising healthcare demand, and in several occupations they have not.


Alaska Issues


Alaska also has assorted state-specific concerns.  Our geographic and cultural challenges create disparities in healthcare access.  The rural and village cultures in many of our remote areas create an added demand for healthcare.  Further, although we provide training to the extent we can, our production falls well short of both our extant and projected needs.  Indeed, there are several occupations for which Alaska does not train at all, for example psychiatry, dentistry, surgery, virtually all physician specialties, and pediatric anything.  And for those occupations for which we do train, those practitioners graduate with loan debt like that of their Lower-48 colleagues.  As a result, Alaska has practitioner shortages, maldistributions and extensive turnover.  In turn, those problems degrade (a) institutional memory, (b) continuity of care, and (c) billing revenues.

The Issue and Strategy


SHARP works to increase access to healthcare for the underserved by providing support-for-service to selected practitioners.  Recruitment and retention must remain priorities for our workforce development system.  This is done by providing education loan repayment and/or incentive payment directly to selected clinicians.  SHARP is neither a “placement agency” nor a “headhunter group.”  Rather, SHARP works to strengthen the relationship between the practitioner and the employer.  The overriding issue is access to healthcare, and it is not loan repayment per se.  Support-for-service programs that focus on individual clinicians constitute only one strategy amongst several used to expand access.  As well, education loan repayment and direct incentive are only two tactics of the several possible within that strategy.  However, that strategy and those two tactics can be quite influential.





SHARP’s first clinician participants began service contracts in June 2010 via SHARP-1, which was based on Alaska’s receipt of a competitive HRSA grant.  Known as the State Loan Repayment Program (SLRP), 35 other states also now have this grant.  At present, SHARP-1 contracts are funded via the following sources:  U.S. Health Resources and Services Administration (HRSA) (at 50%), the Alaska Mental Health Trust Authority (AMHTA) (at 16%), and required partial employer-match (at 34%).   Alaska is in its third multi-year SLRP award, providing loan repayment to medical, dental and behavioral health clinicians.  Unfortunately, by design, SLRP has several limitations.  For instance, all SLRP clinicians must serve in federally designated health profession shortage areas (HPSAs). While HPSA designations can support access to care for many in underserved areas, SLRP precludes all facilities and populations that are not designated as HPSAs. As well, SLRP is open only to primary care clinicians (outpatient care, provided by generalists); however Alaska has shortages in numerous other healthcare disciplines.




System leaders in Alaska steadily became aware of both the value and limitations of SHARP-1.  Eventually Alaska created its own support-for-service program, after four years of planning and advocacy.  The Alaska Legislature passed HB 78 into law (AS 18.29) in May 2012, thus creating SHARP-2.  This has been our 75% state-funded component that has offered both loan repayment and direct incentive.  Employer sites, including private practices and hospitals, that were not eligible under SHARP-I, were now eligible to apply for SHARP-2. A total of 83 clinicians were admitted to SHARP-2.  Unfortunately because of substantive use of state GF, SHARP-II was vulnerable to shortfalls in state revenues.  As a result, the application window for SHARP-2 was closed beginning in January 2016.




Regardless of the SHARP-2 opportunity having ended, a wide range of clinicians and healthcare employers have remained very enthusiastic about the program overall.  As a result, opinion leaders have continued to conceptualize new support-for-service options.  Now on the horizon is SHARP-3, a program component that will make SHARP sustainable without being dependent on federal or state funds.  Formal announcement of SHARP-3 is planned for this year (CY’17).  Funding will principally come from the employers and a consortium of other contributors including private foundations, trade associations, government entities, hospital and community foundations, and other sources.  As with SHARP-2, SHARP-3 will not require that clinicians serve in federally designated HPSA locations.




To date, 254 clinician contracts have been issued across a broad range of clinician occupations including physicians, pharmacists and dentists, to nurses, physician assistants, dental hygienists, behavioral health providers and physical therapists.



Clinician contracts are for either two or three-year durations.  Thus far, contract expense totals to $14,207,159, and that has been addressed by the following revenue sources:  Employers ($4,121,982), HRSA ($7,842,683), AS 18.29 GF ($4,773,357) and Other ($5,311,820).


Table-1:  Practitioners



Table-2:  Occupation Categories


Table-3:  Site Locations



Types of Practice Sites


SHARP has provided support-for-service to practitioners in highly varied practice sites.    Examples include:  community hospitals, behavioral health clinics, private primary care clinics, correctional facilities, critical access hospitals, a variety of tribal health entities, our state psychiatric institute, and several community health centers (CHCs).  Thus far, 19 Alaskan CHCs have participated with one or more SHARP clinicians.  Of those, eight CHCs have been tribal entities, while the other 11 have been non-tribals.


Table-4:  CHCs that have Participated



St. Paul Health Center


Maniilaq- Shungnak Clinic




Table-5:  Illustrative Quotes


The program has changed many lives.  Here are a few quotes regarding program impact: 


Dental Director, Yukon-Kuskokwim Health Center

I am very proud of Alaska’s ability to offer this program, and I continue to HIGHLY (recommend) SHARP as a recruiting tool.  I can’t believe the difference it has made.


Nurse Practitioner, Norton Sound Health Corporation

I am so grateful for SHARP's commitment. SHARP has played an enormous role in my decision to serve rural Alaska. I am looking forward to another two years working with the people of Norton Sound Region. Your support is much appreciated!


Clinical Social Worker, Bristol Bay Area Health Corporation

Thank-you for the opportunity to participate in the SHARP program. Although I have remaining student loan debt I feel that SHARP's help in reducing it allowed me to explore more creative employment options than I would have if I had large debts hanging over me. Interestingly that led to me accepting this position in Naknek (split between Naknek and Anchorage) which will allow me to continue to serve rural residents.


Licensed Professional Counselor, Southeast Alaska Regional Health Corporation

Providing this educational support under contract encourages motivated, enthusiastic, adventuresome folks to move here and, more importantly, to stay here. This provides a greater continuity of care to all the clients we serve.


Dentist, Eastern Aleutian Tribes

What the SHARP program did for me was allow me to work treating patients without the stress of making a monthly loan payment.  That was probably the lesser benefit, because it allowed me to practice, to see and get to know patients and to become familiar with the villages that I travel to.  It allowed me to form a bond with the communities that we serve.  To become committed to making sure that these communities receive dental care.  It allowed me to work in building a better, stronger, Dental department for these communities.


Lessons Learned


What are the over-arching “take home” lessons for you that can be derived from Alaska’s SHARP Program thus far?   We believe there are several.


Change is Difficult


Increasing the use of support-for-service requires key system changes.  Some of that will be within state government, while some other changes will be in the external community.  Achieving those will be neither easy nor assured.  And, the early “pilot” or “demonstration” phase is likely to prove the most difficult.


National Labor Markets


Demand for healthcare practitioners is building across the nation.  This means that healthcare professionals, and especially those with advanced degrees, are increasingly responding to national labor market conditions.  Of course, this is sometimes even accelerated by recruiters from elsewhere, whom we believe are becoming increasingly sophisticated.  More generally, like many Americans, these practitioners are often not wed to a particular locale.  On top of that, the pressures of isolated practice sites are real, and clinicians are often quite aware that they can get their “rural experience” outside of Jackson Hole or Vanderbilt; they don’t need go to Kwethluk.


Recruitment and Retention


Successful workforce development efforts focus on both recruitment and retention, and it’s misleading to see the challenge as an “either/or” thing.  By analogy, recall that in order to fill up a tub, you need to both (a) turn on the spigot, and (b) put in the plug.


System of Care


Your support-for-service systems effort must have a multi-disciplinary focus.  Primary care alone does-not-a-system-make.  This means that those SFSPs that myopically and obsessively focus on primary care may be making a big mistake.  Whether a given state can “get away with it” may simply depend on the assets and peculiarities of that state.  In Alaska, we can’t.


Interagency Collaboration


Healthcare workforce is an interagency and inter-disciplinary issue.  Therefore, collaborative interagency structures are required. At the system level, SHARP is guided by a 15-member, statute-required Advisory Council, and also includes several ex-officio.  Further, we have begun an interagency network at the level of the individual employers.  Each employer has an identified Site Representative.  We recommend both the Council, and, the Site Rep structures.  Some issues that SHARP faces are common to many occupations.  One is that workforce development occurs across the lifespan, and so different interagency partners are necessarily involved at different points (e.g. K-12, university, graduate school, residencies, etc.).  As well, program guidance must be informed by varied perspectives, for purposes of both program effectiveness and protection.  Further, the workforce development system’s “flow rate” is impacted by the net productivity of each level of this system. 


Figure-1:  Alaska’s Healthcare Workforce System




All Boats Rise with the Incoming Tide


A state’s healthcare workforce system is necessarily “interdisciplinary,” and many occupations are involved.  Therefore, it is critical to build collaborations and synergies, and to avoid, at all costs, the creation of competition between-disciplines.  Competition between stakeholder groups will weaken your overall effort’s positionality, and will also confuse decision-makers (e.g. legislators).


If there’s a Fast Train going in Your General Direction


Look for and formally connect with other system initiatives wherever possible.  These allied efforts are initiatives that have their own steam, for their own reasons, and have their own stakeholders.  Examples might include Medicaid Expansion, behavioral health – primary care integration, primary care medical home, and/or dental mid-levels.  They all typically depend on a robust, available healthcare workforce.


Only as Good as the Money You Move


Loan repayment and direct incentive strategies are based on the ability to spend money on a person-specific basis: accurately, efficiently, effectively and in a timely manner.  Each clinician is an individual cost-center.  This means there are added challenges in expending funds efficiently and effectively to support your selected clinicians.  Clinician-specific spending presents challenges that are both fiduciary and mechanical.  Those must be regularly addressed, since your program’s success depends on it.  This is mission-critical:  If you fail at this, your whole effort is destined to swiftly collapse.


Blended Funding

For your program’s protection, sustainability and broad ownership, you must continually seek to diversity your funding base.  If the bottom falls out, you will still have (some) funds with which to move ahead.  Further, we strongly recommend that you blend funds at the level of the individual contract.  To date, funding sources have included:  HRSA, AMTHA, Division of Public Health, Division of Behavioral Health, AS 18.29 GF, the Mat-Su Health Foundation, and the Anchorage Neighborhood Health Center.  Perhaps most critically, each clinician contract is now required to include a partial employer match.


More Steering, Less Rowing


Because support-for-service is a very data-rich area, two results are common.  One is opportunity-cost.  Program staffers are typically forced to become increasingly detail-oriented, and thus may lose the opportunity for “bigger-picture” perspectives, and therefore not harvest potential longer-term payoffs.   The other is that public bureaucracies often “want it that way,” which is to say that they often either neglect or refuse to make the basic administrative investments necessary for adequate program operation.  As a result, many SFSPs simply limp along.  In addition, HRSA-SLRP exacerbates this problem by not providing any funds for program administration as part of its federal “SLRP grants.”  And so, as in the view of Osborne & Gaebler (Reinventing Government, public managers must consciously and continuously strive to “steer more, and row less.”

Data Management


Successful support-for-service programs must effectively manage several kinds of data, and for several reasons.  Some data-collection is required by the assorted funders, and some is dictated by the needs of basic program management, planning and development.  In addition, there is invariably an assortment of inquisitive stakeholders in these very visible, very interagency efforts.  The result is that your program will likely need to produce many reports on an ongoing, ad hoc basis.  Illustrative data categories include:  clinician demographics, attributes and backgrounds; productivity measures, employer metrics and features; budget and expenditure data; as well as assorted stakeholder, system impact and satisfaction indices.  Plan on it.


One Size Does Not Fit All

It’s important for your program to become as flexible as regards both eligibility criteria and benefit type.  For us, this has the creation of two options:  loan repayment and direct incentive.  The reason is that different clinicians are in fact different.  For instance, about 20% of physicians leave medical school with no loan debt at all, and as well some mid-career physicians are eventually able to pay off moderate debt loads.  This means that if your SFS program only offers “loan repayment” then you have made yourself instantly irrelevant to a large subset of practitioners.


Ancillary Benefits

There are also several added side-benefits that result from using support-for-service strategies, benefits which accrue to the practitioner, the employer and/or to the service system.  For the clinician, the loan repayment benefit is exempt from federal personal income tax.  Further, accelerated loan pay-down has a huge financial amplifier because it also eliminates rather large, previously scheduled interest costs.  For the employer, increased recruitment and retention allows cost-avoidance by minimizing use of temporary staffing arrangements, such as very expensive locum tenens.  As well, retention of institutional memory, continuity-of-care and revenue capacity are all further enhanced.  For the economy, there are also substantial added economic multiplier effects (aka ripples); ones that create further jobs in healthcare and in the general community.


Plan for the Long-Term


Successful support-for-service programs (SFSPs) plan for the long-term.  One reason is that the problems of workforce recruitment and retention are deeply entrenched, having been produced by several macro-causes at both the state and national levels.  SFSPs are not a “gig,” something “to do” for a year or two and then the problem’s solved.  A second reason is that the training-and-career trajectory of higher-level practitioners is a many-years process.  To impact those trajectories requires a continued, multi-year program focus.   Finally, some SFSP tactics are more influential than other ones, and the reasons for this are rooted in assorted personal and professional “developmental factors.”  To gage the truth of this, just think back to all the challenges that you had to work through on the way to your own final graduation and licensure.  The following graphic of physician training illustrates that many-year sojourn.


Figure-2:  Example of Physician Training



In order to have an impact, your program must operate, and even thrive, over the long-term.  This means that you must achieve “institutionalization” of your effort, or what is commonly now called “sustainability.”  Several experts have described some of the generic factors that go into maintaining programs and their benefits over the long-term.  For example, the Center for Public Health Systems Science, at Washington University in St. Louis suggests the following: 


·         Environmental Support:  A supportive internal and external climate for your program.

·         Funding Stability:  Establishing a consistent financial base for your program

·         Partnerships:  Cultivating connections between your program and its stakeholders

·         Organizational Capacity:  Having the internal support and resources needed to effectively manage your program and its activities.

·         Program Evaluation:  Assessing your program to inform planning and document results.

·         Program Adaptation:  Taking actions that adapt program to ensure ongoing effectiveness.

·         Communications:  Strategic communication with stakeholders and public about program.

·         Strategic Planning:  Using processes that guide your program’s direction, goals and strategies.


NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.


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