SECOND SUBSTITUTE SENATE BILL NO. 6418
AS AMENDED BY THE FREE CONFERENCE COMMITTEE
C 271 L 90
State of Washington 51st Legislature 1990 Regular Session
By Senate Committee on Ways & Means (originally sponsored by Senators Barr, Warnke, West, Wojahn, Patterson, Rinehart, Smitherman, Newhouse, Owen, Smith, Amondson, Bauer, DeJarnatt, Williams, Talmadge, Hansen, Conner, Madsen and Kreidler; by request of Governor)
Read first time 2/6/90.
AN ACT Relating to rural health care; adding a new section to Title 28B RCW; adding a new section to chapter 70.175 RCW; adding a new chapter to Title 70 RCW; adding a new chapter to Title 48 RCW; creating new sections; making an appropriation; and declaring an emergency.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
NEW SECTION. Sec. 1. 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, pharmacists, 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, pharmacists, 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. 2. The department shall establish the health professional temporary substitute resource pool. The purpose of the pool is to provide short-term physician, physician assistant, pharmacist, 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. 3. (1) The department, in cooperation with University of Washington school of medicine, the state's registered nursing programs, the state's pharmacy programs, and other appropriate public and private agencies and associations, shall develop and keep current a register of physicians, physician assistants, pharmacists, 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, rural pharmacies, 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, 18.64, 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 in chapter 70.175 RCW, 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. 4. (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, community health clinic, local practicing physician, physician assistant, pharmacist, 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
(c) Respond promptly to all requests for assistance.
(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.
NEW SECTION. Sec. 5. The legislature finds that the lack of primary care physicians in some 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 primary care 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. The legislature further finds that the availability of pharmacy services in rural areas is important to assure that rural people have access to needed medications to support good health.
NEW SECTION. Sec. 6. Unless the context clearly requires otherwise, the definitions in this section apply throughout this chapter.
(1) "Board" means the higher education coordinating board.
(2) "Department" means the department of health.
(3) "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.
(4) "Eligible student" means a student who has been accepted into: (a) A program leading to eligibility for licensure as a physician under chapter 18.71 RCW or osteopathic physician or surgeon under chapter 18.57 RCW, and has a declared intention to serve as a primary care physician in a rural area in the state of Washington upon completion of the educational program; (b) a program leading to eligibility for licensure as a midwife under chapter 18.50 RCW, or certification by a graduate nurse training program as an advanced registered nurse practitioner certified nurse midwife, licensed as a registered nurse under chapter 18.88 RCW 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; or (c) a program leading to eligibility for licensure under chapter 18.64 RCW and has declared an intention to serve as a pharmacist in a pharmacist shortage area of the state.
(5) "Forgiven" or "to forgive" or "forgiveness" means to render physician services in a rural area, pharmacy services in a pharmacist shortage area, or midwifery services in a midwife shortage area in the state of Washington in lieu of monetary repayment.
(6) "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.
(7) "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 identify midwife shortage areas consistent with the state-wide midwife access plan provided for in section 16 of this act.
(8) "Midwife training program" means a training program that leads to licensure as a midwife in the state of Washington or certification as a nurse-midwife who is qualified to practice as an advanced registered nurse practitioner under chapter 18.88 RCW. The department shall approve training programs by rule under chapter 34.05 RCW.
(9) "Nonshortage rural area" means a nonurban area of the state of Washington that has not been designated as a rural physician shortage area. The department shall identify the nonshortage rural areas of the state.
(10) "Participant" means an eligible student who has received a scholarship under this chapter.
(11) "Pharmacy school" means a pharmacy school accredited by an accrediting association recognized as such in rule by the department.
(12) "Pharmacist shortage area" means a rural area where pharmacists are in short supply and where their limited numbers jeopardize the public health and safety.
(13) "Program" means the rural physician, pharmacist, and midwife scholarship program.
(14) "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.
(15) "Rural areas" means a rural area in the state of Washington as identified by the department.
(16) "Rural physician shortage area" means rural geographic areas where primary care physicians are in short supply as a result of geographic maldistributions and where their limited numbers jeopardize patient care and pose a threat to public health and safety. The department shall designate rural physician shortage areas.
(17) "Satisfied" means paid-in-full.
(18) "Scholarship" means a loan that is forgiven in whole or in part if the recipient renders: (a) Physician service as a primary care physician in a rural area of the state; (b) midwifery services as a licensed midwife or certified nurse midwife in a midwife shortage area; or (c) pharmacy services as a pharmacist in a pharmacist shortage area.
(19) "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. 7. The rural physician, pharmacist, and midwife scholarship program is established for students pursuing medical and midwifery training. The program shall be administered by the board in consultation with the department, the school of medicine at the University of Washington and other appropriate private and public entities. In administering the program, the board shall have the following powers and duties:
(1) Select students to receive scholarships to attend schools of medicine, schools of osteopathic medicine, schools of pharmacy, 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 shortage areas, pharmacist shortage areas, 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. 8. (1) The board 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 department, the University of Washington school of medicine, licensed and certified nurse midwives, pharmacists, 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.
(4) For prospective pharmacists, the selection shall include requirements that recipients declare an interest in serving in pharmacist shortage areas of the state of Washington.
NEW SECTION. Sec. 9. A new section is added to Title 28B RCW to read as follows:
The school of medicine at the University of Washington shall develop and implement a policy to grant admission preference to prospective medical students from rural areas of the state who agree to serve for at least five years as primary care 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 7 of this act. Should the school of medicine be unable to fill any or all of the admission openings due to a lack of applicants from rural areas who meet minimum qualifications for study at the medical school, it may admit students not eligible for preferential admission under this section.
NEW SECTION. Sec. 10. The board may award scholarships to eligible students from the funds appropriated to the board for this purpose, or from any private donations, or any other funds given to the board 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 and pharmacists. 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 pharmacists and midwives while continually enrolled in an approved medical school, pharmacy school, or midwifery training program. The board 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. 11. 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, pharmacy school, and midwifery training programs, making formal agreements with prospective medical students to provide future primary care physician services in the community, forming agreements between rural communities in a service area to share physician, pharmacy, and midwifery services, and fulfilling any matching requirements.
NEW SECTION. Sec. 12. 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 board or the department in violation of this section shall be declared ineligible for receiving assistance under the program authorized by this chapter.
NEW SECTION. Sec. 13. (1) Participants in the program incur an obligation to repay the scholarship, with interest set by state law, unless they serve for five years in rural areas, pharmacist shortage 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, pharmacist shortage area, or 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, pharmacist shortage 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 five years shall be obliged to repay to the program an amount equal to twice the total amount paid by the program on their behalf in addition to the unsatisfied portion of principal and interest required by this section.
(5) The board 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 board 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 board as administrator is entitled, which are paid by or on behalf of participants under this section, shall be deposited with the board 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 board 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 five years in the community as a primary care physician. The board may develop criteria for the content of such agreements with respect to reasonable provisions and obligations between communities and eligible students.
(8) The board 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. 14. The legislature finds that a shortage of physicians, nurses, pharmacists, and physician assistants exists in rural areas of the state. In addition, many education programs to train these health care providers do not include options for practical training experience in rural settings. As a result, many health care providers find their current training does not prepare them for the unique demands of rural practice.
The legislature declares that the availability of rural training opportunities as a part of professional medical, nursing, pharmacist, and physician assistant education would provide needed practical experience, serve to attract providers to rural areas, and help address the current shortage of these providers in rural Washington.
NEW SECTION. Sec. 15. (1) The department, in consultation with at least the higher education coordinating board, the state board for community college education, the superintendent of public instruction, and state-supported education programs in medicine, pharmacy, and nursing, shall develop a plan for increasing rural training opportunities for students in medicine, pharmacy, and nursing. The plan shall provide for direct exposure to rural health professional practice conditions for students planning careers in medicine, pharmacy, and nursing.
(2) The department and the medical, pharmacy, and nurse education programs shall:
(a) Inventory existing rural-based clinical experience programs, including internships, clerkships, residencies, and other training opportunities available to students pursuing degrees in nursing, pharmacy, and medicine;
(b) Identify where training opportunities do not currently exist and are needed;
(c) Develop recommendations for improving the availability of rural training opportunities;
(d) Develop recommendations on establishing agreements between education programs to assure that all students in medical, pharmacist, and nurse education programs in the state have access to rural training opportunities; and
(e) Review private and public funding sources to finance rural-based training opportunities.
(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. 16. 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. 17. 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. 18. A new section is added to chapter 70.175 RCW to read as follows:
The department may develop and implement a rural health care plan and may approve hospital and rural health care facility requests to be designated as essential access community hospitals or rural primary care hospitals so that such facilities may form rural health networks to preserve health care services in rural areas and thereby be eligible for federal program funding and enhanced medicare reimbursement.
NEW SECTION. Sec. 19. After consulting with the higher education coordinating board, the governor may transfer the administration of the rural physician, pharmacist, and midwife scholarship program to another agency with an appropriate educational mission.
NEW SECTION. Sec. 20. The legislature finds that the residents of rural communities are having difficulties in locating and purchasing affordable health insurance. The legislature further finds that many rural communities have sufficient funds to pay for needed services, but those funds are being expended elsewhere causing insufficient funding of local health services. As part of the solution to this problem, rural communities need to be able to structure the financing of local health services to better serve local residents. The legislature further finds that as rural communities need well financed and organized health care, it is in the interest of residents of rural communities that existing unauthorized entities comply with appropriate fiscal solvency standards and consumer safeguards, and that those entities be given an opportunity to come into compliance with existing state laws.
NEW SECTION. Sec. 21. The insurance commissioner shall establish a committee to recommend to the governor and legislature methods to improve the availability of affordable health insurance or coverage in rural communities. The recommendations shall consider (1) the unique and varied nature of rural communities, (2) methods to maximize the retention of local health expenditures in rural communities, (3) the need of rural communities to have sufficient control over the health services in their communities so that they may improve the quality and have the appropriate quantity of those health services, (4) financial stability and consumer protection issues, and (5) the feasibility of such recommendations. The committee shall examine methods of improving the way currently authorized carriers address rural health issues and shall examine the use of alternative arrangements specifically adapted to rural communities including, but not limited to, the use of local service contractors in combination with other entities authorized under Title 48 RCW.
The committee shall include the insurance commissioner or the commissioner's designee and representatives of rural communities, rural health providers, entities authorized under title 48 RCW, the department of health, and other individuals, as appointed by the insurance commissioner.
These recommendations shall be submitted to the governor and legislature no later than November 1, 1990.
The committee established under this section shall dissolve on January 1, 1991.
NEW SECTION. Sec. 22. Unless the context clearly requires otherwise, the definitions in this section apply throughout this chapter.
(1) "Rural community" means any grouping of consumers, seventy-five percent of whom reside in areas outside of a standard metropolitan statistical area as defined by the United States bureau of census.
(2) "Consumer" means any person enrolled and eligible to receive benefits in the rural health care arrangement.
(3) "Rural health care service arrangement" or "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, as defined in this section, that is subject to the jurisdiction of the insurance commissioner but is not now a currently authorized carrier.
NEW SECTION. Sec. 23. Rural health care service arrangements existing on the effective date of this act may continue in full operation only so long as they comply with all of the following:
(1) Within ten days following the effective date of this act, all rural health care service arrangements shall inform the insurance commissioner of their intent to apply for approval to operate as an entity authorized under chapter 48.44 RCW or intend to merge with an entity authorized under Title 48 RCW or merge with an entity defined in this section;
(2) The arrangement submits an application for approval as an entity authorized under chapter 48.44 RCW by May 1, 1990;
(3) The arrangement has one hundred thousand dollars on deposit with the insurance commissioner by July 1, 1990;
(4) The arrangement has one hundred fifty thousand dollars on deposit with the insurance commissioner by September 1, 1990; and
(5) The arrangement complies with all reasonable requirements of the insurance commissioner excluding the deposit requirement, except as outlined in this section.
If such rural health care service arrangements fail to comply with any of the above requirements, or if during the application process an entity engages in any activities which the insurance commissioner reasonably determines may cause imminent harm to consumers, the entity may be subject to appropriate legal action by the insurance commissioner pursuant to the authority provided in Title 48 RCW.
A rural health care service arrangement which comes into compliance with Title 48 RCW through the method outlined in this chapter shall be subject to all applicable requirements of Title 48 RCW except that the deposit requirements shall not be increased until May 1, 1991.
NEW SECTION. Sec. 24. The insurance commissioner, pursuant to chapter 34.05 RCW, may promulgate rules to implement sections 22 and 23 of this act.
NEW SECTION. Sec. 25. The sum of forty-nine thousand dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1991, from the general fund to the insurance commissioner for the purposes of section 21 of this act.
NEW SECTION. Sec. 26. 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 immediately.
NEW SECTION. Sec. 27. Sections 20 through 24 of this act shall constitute a new chapter in Title 48 RCW.
NEW SECTION. Sec. 28. Any additional expenditures incurred by the University of Washington from provisions of this act shall be funded from existing financial resources.
NEW SECTION. Sec. 29. Sections 1 through 8, 10 through 17, 19 and 28 of this act shall constitute a new chapter in Title 70 RCW.
NEW SECTION. Sec. 30. If specific funding for the purposes of sections 1 through 19 of this act, referencing this act by bill number, is not provided by June 30, 1990, in the omnibus appropriations act, sections 1 through 19 of this act shall be null and void.