AN ACT Relating to rural health care; adding a new section to Title 28A RCW; adding a new chapter to Title 48 RCW; adding a new chapter to Title 70 RCW; providing an effective date; and declaring an emergency.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

PART I

NEW SECTION. Sec. 1. The legislature finds that residents of rural communities are having extreme difficulties in locating and purchasing affordable health insurance. The legislature further finds that many rural communities have sufficient funds available to pay for needed services, but those funds are expended elsewhere causing insufficient funding of local health resources. As part of the solution to this problem, rural communities need to be able to structure their local health service to better serve local residents. The legislature further finds that while rural communities need well financed and organized health care, it is also necessary to create safeguards to ensure that the health care service arrangements meet prudent financial solvency tests.

NEW SECTION. Sec. 2. Unless the context clearly requires otherwise, the definitions in this section apply throughout this chapter.

(1) "Rural community" means any grouping of consumers, sixty percent of whom reside in areas outside of a standard metropolitan statistical area as defined by the United States bureau of the census.

(2) "Consumer" means any person enrolled and eligible to receive benefits in the rural health care service arrangement.

(3) "Rural health care service arrangement" means any arrangement which is established or maintained for the purpose of offering or providing through the purchase of insurance or otherwise medical, surgical, or hospital care or benefits in the event of sickness, accident, or disability in a rural community under the authority of this chapter. At least fifty-one percent of the board of directors must be elected by the adult consumers of the health services.

NEW SECTION. Sec. 3. (1) Beginning January 1, 1991, rural communities are authorized to form rural health care service arrangements, subject to the rules adopted by the insurance commissioner.

(2) The insurance commissioner shall adopt rules, under chapter 34.05 RCW, governing the formation and administration of rural health care service arrangements. The insurance commissioner, during the development of rules, shall consult with representatives of rural communities, rural health care providers, rural business leaders, and rural elected officials. The insurance commissioner shall also consider the unique and divergent nature of rural communities when designing and implementing the rural health services arrangement.

(3) Entities providing coverage in this state on the effective date of this act shall be allowed eight months from the effective date of this act to come into compliance, provided they are located primarily in rural areas and inform the insurance commissioner of their intent to qualify under the rural health care service arrangement.

(4) Rural health care service arrangements shall be subject to the statutes and regulations governing health care service contractors as defined in RCW 48.44.010, except for the following:

(a) Reserve requirements to be imposed on rural health care service arrangements shall be twenty-five percent of the aggregate contributions in the current fiscal year or twenty-five percent of the claims paid in the preceding fiscal year, whichever is greater.

(b) In order to obtain authority from the insurance commissioner to operate as a rural health care service arrangement, an entity must present applications from not less than five employers and evidence that it will provide similar benefits for not less than two hundred separate individuals and that the annual gross premiums of contributions to the arrangement will not be less than two hundred thousand dollars.

PART II

NEW SECTION. Sec. 4. The legislature finds that a health care access problem exists in rural areas of the state due to a lack of practicing physicians, physician assistants, and advanced registered nurse practitioners. In addition, many of these rural providers are unable to leave the community for short-term periods of time to attend required continuing education training or for personal matters because their absence would leave the community without adequate medical care coverage. The lack of adequate medical coverage in geographically remote rural communities constitutes a threat to the health and safety of the people in those communities.

The legislature declares that it is in the public interest to recruit and maintain a pool of physicians, physician assistants, and advanced registered nurse practitioners willing and able on short notice to practice in rural communities on a short-term basis to meet the medical needs of the community.

NEW SECTION. Sec. 5. The department shall establish the health professional temporary substitute resource pool. The purpose of the pool is to provide short-term physician, physician assistant, and advanced registered nurse practitioner personnel to rural communities where these health care providers:

(1) Are unavailable due to provider shortages;

(2) Need time off from practice to attend continuing education and other training programs; and

(3) Need time off from practice to attend to personal matters or recover from illness.

The health professional temporary substitute resource pool is intended to provide short-term assistance and should complement active health provider recruitment efforts by rural communities where shortages exist.

NEW SECTION. Sec. 6. (1) The department, in cooperation with University of Washington school of medicine, the state's registered nursing programs, and other appropriate public and private agencies and associations, shall develop and keep current a register of physicians, physician assistants, and advanced registered nurse practitioners who are available to practice on a short-term basis in rural communities of the state. The department shall periodically screen individuals on the registry for violations of the uniform disciplinary act as authorized in chapter 18.130 RCW. If a finding of unprofessional conduct has been made by the appropriate disciplinary authority against any individual on the registry, the name of that individual shall be removed from the registry and that person shall be made ineligible for the program. The department shall include a list of back-up physicians and hospitals who can provide support to health care providers in the pool. The register shall be compiled, published, and made available to all rural hospitals, public health departments and districts, and other appropriate public and private agencies and associations. The department shall coordinate with existing entities involved in health professional recruitment when developing the registry for the health professional temporary substitute resource pool.

(2) Eligible health care professionals are those licensed under chapters 18.57, 18.57A, 18.71, and 18.71A RCW and advanced registered nurse practitioners licensed under chapter 18.88 RCW.

(3) Participating health care professionals shall receive:

(a) Reimbursement for travel to and from the rural community and for lodging at a rate determined under RCW 43.03.050 and 43.03.060;

(b) Medical malpractice insurance purchased by the department, or the department may reimburse participants for medical malpractice insurance premium costs for medical liability while providing health care services in the program, if the services provided are not covered by the participant's or local provider's existing medical malpractice insurance; and

(c) Information on back-up support from other physicians and hospitals in the area to the extent necessary and available.

(4) The department may require rural communities to participate in health professional recruitment programs as a condition for providing a temporary substitute health care professional if the community does not have adequate permanent health care personnel. To the extent deemed appropriate and subject to funding, the department may also require communities to participate in other programs or projects, such as the rural health system project authorized by this chapter, that are designed to assist communities to reorganize the delivery of rural health care services.

(5) The department may require a community match for assistance provided in subsection (3) of this section if it determines that adequate community resources exist.

(6) The maximum continuous period of time a participating health professional may serve in a community is ninety days. The department may modify or waive this limitation should it determine that the health and safety of the community warrants a waiver or modification. The community shall be responsible for all salary expenses of participating health professionals.

NEW SECTION. Sec. 7. (1) Requests for a temporary substitute health care professional may be made to the department by the local rural hospital, public health department or district, local practicing physician, physician assistant, or advanced registered nurse practitioner, or local city or county government.

(2) The department shall:

(a) Establish a manner and form for receiving requests;

(b) Minimize paperwork and compliance requirements for participant health care professionals and entities requesting assistance; and

(3) The department may apply for, receive, and accept gifts and other payments, including property and services, from any governmental or other public or private entity or person, and may make arrangements as to the use of these receipts to operate the pool. The department shall make available upon request to the appropriate legislative committees information concerning the source, amount, and use of such gifts or payments.

PART III

NEW SECTION. Sec. 8. The legislature finds that the lack of family practice physicians in rural areas of the state and the critical shortage of maternity care services adversely affect access to basic health care services. Rural areas often require more services because the health care needs are greater due to poverty or because these areas are difficult to service due to geographic circumstances. The legislature further finds that encouraging family practice physicians to serve in rural areas of the state and midwives to serve in midwife shortage areas is essential to assure continued access to basic health care services. Studies suggest that physicians recruited from rural areas or physicians who have resident and intern experience in a rural setting tend to make a long-term commitment as rural physicians. The legislature declares that whenever possible rural communities should take an active part in identifying prospective medical students from the local rural community or other rural areas. In this way the community and the prospective physician can form a mutual commitment prior to the individual acquiring a medical education.

The legislature further finds that midwives serve as an important provider of prenatal, interpartum, and postpartum care. Training individuals to become midwives can serve to address the current shortage of providers. The legislature declares that it is in the best interest of the people in this state to promote the availability of midwife services through activities that lead to the recruitment and training of midwives.

NEW SECTION. Sec. 9. Unless the context clearly requires otherwise, the definitions in this section apply throughout this chapter.

(1) "Department" means the department of health.

(2) "Eligible expenses" means legitimate expenses associated with the costs of acquiring an education such as tuition, books, equipment, fees, room and board, and other expenses determined by the department.

(3) "Eligible student" means a student who has been accepted into: (a) A program leading to eligibility for licensure as a physician or osteopathic physician or surgeon and has a declared intention to serve as a family practice or general practice physician in a rural area in the state of Washington upon completion of the educational program; or (b) a program leading to eligibility for licensure as a midwife or certification by a graduate nurse training program as a certified nurse midwife and has a declared intention to serve as a midwife in a midwife shortage area in the state of Washington upon completion of the education program.

(4) "Forgiven" or "to forgive" or "forgiveness" means to render physician services in a rural area or midwifery services in a midwife shortage area in the state of Washington in lieu of monetary repayment.

(5) "Medical school" means a medical school or school of osteopathic medicine and surgery accredited by an accrediting association recognized as such in rule by the department.

(6) "Midwife shortage area" means a geographic area of the state of Washington where: (a) Maternity services are in short supply to the extent to jeopardize favorable birth outcomes for babies born in the area, and (b) midwifery services could help alleviate the shortage. The department shall designate midwife shortage areas consistent with the state-wide midwife access plan provided for in section 18 of this act.

(7) "Midwife training program" means a training program that leads to licensure as a midwife in the state of Washington or certification by a graduate nurse training program in midwifery. The department shall approve training programs by rule under chapter 34.05 RCW.

(8) "Nonshortage rural area" means a nonurban area of the state of Washington that has not been designated as a rural physician shortage area. The state department of health shall identify in rule the nonshortage rural areas of the state.

(9) "Participant" means an eligible student who has received a scholarship under this chapter.

(10) "Program" means the rural physician and midwife scholarship program.

(11) "Prospective medical student" means an individual identified by a sponsoring community who is seeking admission to a school of medicine or osteopathic school of medicine.

(12) "Rural areas" means a rural area in the state of Washington as identified in rule by the department.

(13) "Rural physician shortage area" means rural geographic areas where family practice physicians are in short supply as a result of geographic maldistributions and where vacancies exist in serious numbers that jeopardize patient care and pose a threat to public health and safety. The department shall designate in rule rural physician shortage areas.

(14) "Satisfied" means paid-in-full.

(15) "Scholarship" means a loan that is forgiven in whole or in part if the recipient renders: (a) Physician service as a family practice physician or a general practice physician in a rural area of the state; or (b) midwifery services as a licensed midwife or certified nurse midwife in a midwife shortage area.

(16) "Sponsoring community" means a rural hospital or hospitals as authorized in chapter 70.41 RCW, a rural health care facility or facilities as authorized in chapter 70.175 RCW, or a city or county government or governments.

NEW SECTION. Sec. 10. The rural physician and midwife scholarship program is established for students pursuing medical and midwifery training. The program shall be administered by the department in consultation with the school of medicine at the University of Washington and other appropriate private and public entities. In administering the program, the department shall have the following powers and duties:

(1) Select students to receive scholarships to attend schools of medicine, schools of osteopathic medicine, or training programs in midwifery with the assistance of a screening committee;

(2) Adopt rules and guidelines to implement this chapter;

(3) Publicize the program, particularly emphasizing individuals residing in rural and midwifery shortage rural areas of the state;

(4) Collect and manage repayments from students who do not meet their services obligations under this chapter;

(5) Solicit and accept grants and donations from public and private sources for the program; and

(6) Develop criteria for a contract for service in lieu of the five-year service where appropriate, that may be a combination of service and payment.

NEW SECTION. Sec. 11. (1) The department shall establish a planning committee to develop criteria for the screening and selection of recipients of the scholarships. The planning committee shall be comprised of at least representatives from the following entities: Rural physicians and hospitals, health care clinics, local health districts and departments, agencies involved in physician recruitment, the University of Washington school of medicine, licensed and certified nurse midwives, and other entities involved in rural health and midwifery issues.

(2) For prospective physicians, the selection criteria shall include requirements that recipients declare an interest in serving in rural areas of the state of Washington. Preference for scholarships shall be given to students who reside in rural areas of the state prior to admission to the medical training program. Highest preference shall be given to students seeking admission who are recommended by sponsoring communities and who declare the intent of serving as a physician in a rural area.

(3) For prospective midwives, the selection criteria shall include requirements that the recipient declare an interest in serving in midwife shortage areas of the state of Washington.

NEW SECTION. Sec. 12. A new section is added to Title 28A RCW to read as follows:

The school of medicine at the University of Washington shall develop and implement a policy to establish a designated number of admission openings each year for prospective medical students from rural areas of the state who agree to serve for at least three years as family practice physicians in rural areas of Washington after completion of their medical education and have applied for and meet the qualifications of the program, under section 10 of this act. Should the school of medicine be unable to fill any or all of the designated openings, due to a lack of applicants who meet minimum qualifications, they may admit students not eligible for preferential admission under this section.

NEW SECTION. Sec. 13. The department may award scholarships to eligible students from the funds appropriated to the department for this purpose, or from any private donations, or any other funds given to the department for this program. Scholarships for physicians may be awarded contingent upon acceptance to a medical school. The amount of the scholarship awarded an individual shall not exceed fifteen thousand dollars per academic year for physicians and four thousand dollars per academic year for midwives. Scholarship awards are intended to meet the eligible financial expenses of eligible students. Students are eligible to receive scholarships for a maximum of five years for physicians and three years for midwives while continually enrolled in an approved medical school or midwifery training program. The department may require the sponsoring community located in a nonshortage rural area to financially contribute to the eligible expenses of a medical student if the student will serve in the nonshortage rural area.

NEW SECTION. Sec. 14. The department may provide technical assistance to rural communities desiring to become sponsoring communities. Such assistance should include, but not be limited to: The identification of prospective students, assisting prospective students to apply to medical school and midwifery training programs, making formal agreements with prospective medical students to provide future family practice physician services in the community, forming agreements between rural communities in a service area to share physician and midwifery services, and fulfilling any matching requirements.

NEW SECTION. Sec. 15. In providing health care services the participant shall not discriminate against any person on the basis of the person's ability to pay for such services or because payment for the health care services provided to such persons will be made under the insurance program established under part A or B of Title XVIII of the federal social security act or under a state plan for medical assistance including Title XIX of the federal social security act and agrees to accept assignment under section 18.42(b)(3)(B)(ii) of such act for all services for which payment may be made under part B of Title XVIII and enters into an appropriate agreement with the department of social and health services for medical assistance under Title XIX to provide services to individuals entitled to medical assistance under the plan. Participants found by the department in violation of this section shall be declared ineligible for receiving assistance under the program authorized by this chapter.

NEW SECTION. Sec. 16. (1) Participants in the program incur an obligation to repay the scholarship, with interest set by state law, unless they serve for three years in rural areas or midwife shortage areas of the state of Washington.

(2) The terms of the repayment, including deferral of the interest, shall be consistent with the terms of the federal guaranteed loan program.

(3) The period for repayment shall be three years, with payments accruing quarterly commencing nine months from the date the participant completes or discontinues the course of study or completes or discontinues the required residency.

(4) The entire principal and interest of each payment shall be forgiven for each payment period in which the participant serves in a rural area or a midwife shortage area until the entire repayment obligation is satisfied or the borrower ceases to so serve. Should the participant cease to serve in a rural area or midwife shortage area of this state before the participant's repayment obligation is completed, payments on the unsatisfied portion of the principal and interest shall begin the next payment period and continue until the remainder of the participant's repayment obligation is satisfied. Except for circumstances beyond their control, participants who serve less than three years shall be obliged to repay to the program an amount equal to fifty percent of the total amount paid by the program on their behalf in addition to the unsatisfied portion of principle and interest required by this section.

(5) The department is responsible for collection of repayments made under this section and shall exercise due diligence in such collection, maintaining all necessary records to ensure that maximum repayments are made. Collection and servicing of repayments under this section shall be pursued using the full extent of the law, including wage garnishment if necessary, and shall be performed by entities approved for such servicing by the Washington student loan guaranty association or its successor agency. The department is responsible to forgive all or parts of such repayments under the criteria established in this section and shall maintain all necessary records of forgiven payments.

(6) Receipts from the payment of principal or interest or any other subsidies to which the department as administrator is entitled, which are paid by or on behalf of participants under this section, shall be deposited with the department and shall be used to cover the costs of granting the scholarships, maintaining necessary records, and making collections under subsection (5) of this section. The department shall maintain accurate records of these costs, and all receipts beyond those necessary to pay such costs shall be used to grant scholarships to eligible students.

(7) Sponsoring communities who financially contribute to the eligible financial expenses of eligible medical students may enter into agreements with the student to require repayment should the student not serve the minimum of three years in the community as a family practice or general practice physician. The department may develop criteria for the content of such agreements with respect to reasonable provisions and obligations between communities and eligible students.

(8) The department may make exceptions to the conditions for participation and repayment obligations should circumstances beyond the control of individual participants warrant such exceptions.

NEW SECTION. Sec. 17. (1) The department, in consultation with the University of Washington school of medicine, shall develop a plan for increasing rural training opportunities for students in medicine. The plan shall provide for direct exposure to rural health professional practice conditions for students planning careers in rural medicine.

(2) The department and the medical school shall:

(a) Inventory existing rural-based clinical experience programs, including internships and residencies, and other training opportunities available to students pursuing degrees in medicine;

(b) Identify where training opportunities do not currently exist and are needed;

(d) Review private and public funding sources to finance rural-based training opportunities and make recommendations on funding needs.

(3) The department shall report to the house of representatives and senate standing committees on health care by December 1, 1990, with their findings and recommendations including needed legislative changes.

NEW SECTION. Sec. 18. The department, in consultation with training programs that lead to licensure in midwifery and certification as a certified nurse midwife, and other appropriate private and public groups, shall develop a state-wide plan to address access to midwifery services.

The plan shall include at least the following: (1) Identification of maternity service shortage areas in the state where midwives could reduce the shortage of services; (2) an inventory of current training programs and preceptorship activities available to train licensed and certified nurse midwives; (3) identification of gaps in the availability of training due to such factors as geographic or economic conditions that prevent individuals from seeking training; (4) identification of other barriers to utilizing midwives; (5) identification of strategies to train future midwives such as developing training programs at community colleges and universities, using innovative telecommunications for training in rural areas, and establishing preceptorship programs accessible to prospective midwives in shortage areas; (6) development of recruitment strategies; and (7) estimates of expected costs associated in recruitment and training.

The plan shall identify the most expeditious and cost-efficient manner to recruit and train midwives to meet the current shortages. Plan development and implementation shall be coordinated with other state policy efforts directed toward, but not limited to, maternity care access, rural health care system organization, and provider recruitment for shortage and medically underserved areas of the state.

The department shall submit a copy of the plan to the senate and house of representatives health care committees by December 1, 1990.

NEW SECTION. Sec. 19. By September 1, 1995, the department shall review the continuing need for the program and recommend the need for its continuation. It shall report its findings to the senate and house of representatives committees on health care by December 1, 1995.

NEW SECTION. Sec. 20. Sections 1 through 3 of this act shall constitute a new chapter in Title 48 RCW.

NEW SECTION. Sec. 21. Sections 4 through 11 and 13 through 19 of this act shall constitute a new chapter in Title 70 RCW.

NEW SECTION. Sec. 22. This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and shall take effect May 1, 1990.