January 31, 2019
New Hampshire’s economy is remarkably strong, with historic revenue estimates and a record low unemployment rate. At the same time, a workforce shortage is slowing the state’s economic potential, jeopardizing the ability of our businesses (both profit and not-for-profit) to thrive, fulfill their missions, and serve those in need. This workforce shortage is most prominent in health care, where a lack of clinicians and direct care providers limits Granite Staters’ access to services, causing a rationing of needed care and added health care costs systemwide. In 2019, the Granite State is uniquely positioned to invest in recruiting, retaining, and advancing our health care workforce. That is why a coalition of provider organizations, health care advocates, and health policy experts have created the proposal outlined below and contained in SB 308. This proposal will incent students to seek health care degrees and remain in New Hampshire upon graduation; remove career advancement barriers for our dedicated direct care providers; and equip health care organizations with the tools necessary to secure skilled clinicians.
In the 2018 legislative session, more than 50 bills addressed health care workforce shortages, but most did not pass because the conversations, while earnest, were not supported by a unified message. Nonetheless, the State has made great strides through significant investments in our health care infrastructure to increase mental health and substance use disorder treatment capacity and promote integrated care delivery through the integrated delivery networks; the hub and spoke model; and the new 10-year mental health plan. These investments and the proposed legislation, however, do not address one fundamental challenge: New Hampshire does not have the workforce to meet either the current health care needs of our residents or the State’s goal of truly integrating primary care, behavioral health, substance use disorder treatment, and oral health.
The findings on vacancies across Granite State health care organizations are startling. Fifteen community health centers (CHCs) reported over 100 staff vacancies. The clinical vacancies include physicians (MDs or DOs), family practice, internal medicine, pediatricians, obstetricians, gynecologists, psychiatrists, nurse practitioners (NPs), psychiatric NPs, certified nurse midwives, and physician assistants (PAs). These clinicians provide integrated behavioral health, substance use disorder, and primary care. The state’s 10 community mental health centers (CMHCs) currently have 217 clinical vacancies; their vacancy rate has grown by over 20% in the past 24 months. The lack of access to community-based care (provided by CHCs and CMHCs) has far-reaching impact on our health care system, including backup in local emergency rooms while individuals in mental health crisis wait for hospital beds. Nursing homes are taking beds offline due to their lack of staff, and the Developmental Disabilities system reports hundreds of job vacancies every month. Shortages of workers including personal care aides, home health aides, and nursing assistants threaten access to care for vulnerable adults and those with serious physical and developmental disabilities.
New Hampshire is amidst a demographic shift that necessitates immediate action by our elected officials. We are one of the oldest (by age) states in the nation. By 2030, almost one-third of Granite Staters will be over the age of 65, and a large part of this population will require long-term services and supports (LTSS) at some point, either at home or in an institution or community-based setting. Yet, despite the surging elderly population, New Hampshire’s spending on LTSS declined between 2011 and 2016. During a recent analysis of the Choices for Independence (CFI) Waiver, the Department of Health and Human Services (DHHS) cited the lack of qualified workers as a key factor in why many services were not provided. In many cases providers were authorized to serve eligible people in need but could not, due to a lack of workforce. As the elderly population grows larger than the workforce who can assist them, we cannot afford to delay action any longer.
The legislative package outlined below combines key policy and budget initiatives designed to alleviate New Hampshire’s health care workforce crisis. State government has the tools to make real progress, including the ability to invest in innovative programs that already exist. Because of our strong economy, now is the time to build a stable foundation for the future. We propose the following investments in our health care workforce:
- Health Care Pipeline Investments: Over half of New Hampshire’s high school graduates are leaving the state to attend a four-year college – the highest rate in the country. Those who leave will often not return to start their families and their careers. Our state needs consistent state capital and operating budget to invest in our health care pipeline, in order to compete with surrounding New England states. To retain our youth, New Hampshire must invest in more programs that provide students with in-state connections and prepare them to secure a future here (i.e. shadowing experiences, volunteer opportunities, and summer educational programs).
Practicing health care professionals require continuing education opportunities that expose them to the realities of clinical practice and prepare them for career advancement, while accommodating their busy schedules. To achieve financial viability, our young professionals seek opportunities for tuition reimbursement and continuing education funding. We propose investing in targeted scholarships with service commitments and career advancement programs to complement Governor Sununu’s proposal of reintroducing the Licensed Practical Nurse Program; increasing the number of nursing and therapist graduates; expanding Licensed Alcohol and Drug Counselor programs; and collaborating with the “65 x 25” public partnership designed to increase post-secondary education and credentialing. In order to train the next generation of health care workers, we propose investing in current programs that can grow the workforce, such as New Hampshire Area Health Education Centers (AHECs).
New Hampshire competes nationally to recruit and retain primary care providers, including family physicians, psychiatrists, psychiatric nurse practitioners, and dentists. Health care practices across the state need support to promote their vacancies to prospective providers. An efficient solution is developing a unified brand message and a centralized marketing campaign that practices throughout the state can use to amplify visibility for all New Hampshire vacancies. Bi-State Primary Care Association’s Recruitment Center has established systems in place to reach potential candidates to support practices with their recruitment needs. We propose investing $500,000 in the Recruitment Center to collaboratively develop the brand message and implement a robust national outreach campaign that will draw additional providers to the state.
The State Office of Rural Health (SORH), situated within DHHS, offers technical assistance to rural health care organizations and provides health care-related information to rural health care stakeholders. The SORH is the only state agency tasked with tracking health care vacancies statewide and planning for current and future health care workforce demands. Current statute allows the SORH to collect data from willing licensees that it then uses to advise legislators, policymakers, and the Commission on Primary Care Workforce on health care workforce needs. However, response is considered optional; therefore, the response rate is so low, the data is rendered useless. We propose requiring health care professionals to respond to the SORH survey during the licensure process to ensure that the State has accurate data to inform our policymakers.
- Advanced Training Programs: Most primary care, behavioral health, and substance use disorder treatment is provided in community settings; yet doctors, nurses, and other advanced practitioners traditionally train in hospital-based residency and fellowship programs located in larger cities. To increase access to care in medically underserved communities, New Hampshire must establish more accredited community-based advanced training in these areas so that health professionals can gain a better understanding of the populations they will ultimately serve. We propose expanding the Nurse Practitioner Fellowship Program, hosted by Lamprey Health Care in Newmarket. Through a formal mentoring and precepting program, family nurse practitioners gain confidence and competence by working with patients who have complex health care needs (in large part because they face numerous barriers to receiving preventative health care treatment for existing conditions). We also propose replicating the Teaching Health Center Graduate Medical Education Program in New Hampshire, to provide training in community-based ambulatory care settings such as community health centers. An investment in establishing accredited residency/fellowship programs will help our state compete to attract and retain health care professionals.
- Investment in the State Loan Repayment Program (SLRP): This program is administered by DHHS and provides funding to health care professionals who work in medically underserved areas for a minimum of three years as full-time clinicians. It is the most effective tool for practices in rural and underserved areas of the state to attract and retain providers. However, the program is extremely limited in both size and scope: it currently offers fewer than 50 new contracts per year and has been historically funded at $169,000 per year. We propose investing $5 million in the next biennium that will enable DHHS to expand eligible clinician types, generate over 200 contracts with clinicians, add an additional FTE to assist in managing the contracts, and better position health care providers to recruit and retain clinicians in underserved areas throughout New Hampshire.
- Investment in Medicaid providers: New Hampshire pays among the lowest Medicaid reimbursement rates in the nation; and most Medicaid providers have not received a rate increase in many years. Low reimbursement remains a threat to New Hampshire’s Medicaid program because it empowers providers in other states to attract clinical staff away from organizations that serve our Medicaid enrollees. For example, our Area Agencies providers, who serve those with developmental disabilities and acquired brain disorders, have not received a Medicaid rate increase in over a decade. Without a rate increase in the next biennium, individuals with disabilities will continue to have unmet needs. We propose that as a base line, the State increase reimbursement rates for all Medicaid providers by 5% in 2020, and by 7% in 2021. This rate increase will cost an estimated $35 million in general funds in 2020 and $53 million in 2021. In addition to a base line increase, we propose enhanced rate adjustments for some critical providers, including those who are working in the substance use disorder, mental health, and home care arenas. We also advise establishing a limitation on the county cap (freezing it at the current levels) to ensure that this Medicaid investment will not negatively impact county taxpayers.
- Administrative relief: Administrative burdens weigh down the delivery of care, misdirecting staff dollars and time that might otherwise be spent directly interacting with patients, and driving practices out of Medicaid. Medicaid managed care has dramatically increased administrative costs for Medicaid providers. In addition, statutes designed to address workforce challenges through the promulgation of administrative rules remain unaddressed. We propose crafting a process to reduce administrative burdens: in particular, a program to allow providers or license holders the opportunity to petition the Joint Legislative Committee on Administrative Rules (JLCAR) to suspend unnecessary and/or duplicative administrative rules for up to a year. During this suspension period, state agencies could edit, propose permanent elimination of, or argue for reinstatement of the rule. This process would likely require some additional staff and legal support to the Office of Legislative Services’ Administrative Rules division. We estimate costs of $1 million for the biennium to fund three to four FTEs to support this program.
- Spend down: Spend down requirements within New Hampshire’s Medicaid program obligate low-income consumers to spend down their limited monthly funds to qualify for Medicaid coverage. As a result, they churn in and out of Medicaid. The administrative cost of managing this requirement is a burden on the consumer, providers, Managed Care Organizations, and the State. Adjusting the income requirements for this population will reduce the number of spend down consumers, remove unnecessary administrative burdens, and improve care.
- Background checks: Background checks for new employees should be a small item in the health care workforce challenge, but the current process is slow and requires application review at a central location in Concord. Recent changes in state law now require background checks for additional potential employees. In other states, these background checks are completed online and turned around quickly; and employers and potential employees are not delayed in the hiring process. We proposed directing and supporting the Department of Safety to implement an online background check system as soon as possible.
- Telehealth: Telehealth or telemedicine provides an opportunity to expand access to health care and utilize existing resources more efficiently. However, legacy regulations and disputes over reimbursement rates have slowed the proper deployment of telehealth innovation in New Hampshire. We propose expanding the types of clinicians and facilities eligible to offer telehealth to Medicaid enrollees; reducing the regulatory burdens associated with telehealth; and creating incentives to fund the capital investment needs of our state’s non-profit providers.
As outlined above, SB 308 is a legislative package of policy and budget initiatives that includes an ambitious but achievable set of tools to help New Hampshire make meaningful progress in addressing our systemic health care workforce challenges. Our proposal builds on a multitude of executive branch, legislative, and private sector research reports and reviews. While the cost of this effort is still under consideration, the necessary investment from the State’s general fund will likely be sizable for the next biennium. Some of these dollars, however, will be one-time investments, and these reforms are designed to save the system money over time by controlling future costs.
Our goal is to build a strong consensus in both state government and the legislature to put health care workforce issues at the top of the agenda for the 2019 session. We hope that you will support this systematic approach to addressing our health care workforce crisis. As of January 31, 2019, this health care workforce campaign is supported by the following organizations:
American Physical Therapists Association – NH Chapter
Ascentria In-Home Care
Bi-State Primary Care Association
Brain Injury Association
Commission on Primary Care Workforce Issues
Community Support Network Inc. (CSNI)
Granite Case Management
Granite State Home Health & Hospice Association
Granite State Independent Living
The Institute of Professional Practice, Inc.
LeadingAGE NH and ME
Life Coping Inc.
National Alliance on Mental Illness (NAMI)
New England Rural Health Association
NH Adult Day Services Association
NH Alcohol & Drug Abuse Counselors Association
NH Area Health Education Center Program
NH Association of Community Action Agencies
NH Association of Counties
NH Catholic Charities
NH Children’s Behavioral Health Collaborative
NH Community Behavioral Health Association
NH Dental Hygienists’ Association
NH Health Care Association
NH Hospital Association
NH Independent Case Management Association
NH Medicaid Medical Care Advisory Committee (MCAC)
NH Medical Society
NH Nurse Practitioners
NH Nurses Association
NH Providers Association
Planned Parenthood of Northern New England
Senior Nutrition Network of NH
St. Joseph Community Services