State of Nevada Western Interstate Commission for Higher Education (WICHE)
Minutes for October 30, 2013
Disc #2, File #35
Vic Redding – Executive Commissioner, Nevada WICHE
Vance Farrow – Commissioner, Nevada WICHE
Joseph Hardy – Commissioner, Nevada WICHE
Carrie Parker – Deputy Attorney General, Office of the Attorney General
Brody Leiser – Program Analyst, Legislative Counsel Bureau
Melanie Young – Budget Analyst, State of Nevada Administration, Budget and Planning
Jeannine Warner (formerly Sherrick) – Director, Nevada WICHE
Dana Westre – Accountant Technician, Nevada WICHE
Call to order. The meeting was called to order by Commissioner Redding at 3:02 p.m.
Public comment. There was no public comment.
Introduction of guests. Brody Leiser and Melanie Young introduced themselves and were welcomed to the meeting by the commission and staff.
Discussion, recommendations, and action regarding minutes for July 15, 2013, commission meeting. Item was tabled until the next meeting.
Discussion, recommendations, and action regarding certification of Fiscal Year 2014 applicants in the fields of nursing, optometry, pharmacy, physical therapy, physician assistant, and veterinary medicine; Fiscal Year 2013 alternate applicants in the fields of optometry and pharmacy. Ms. Warner stated all applicants were notified per Open Meeting Law (OML) requirements. A total of 90 applications were received this year. There were no questions. Commissioner Farrow moved to approve certification of the applicants. Commissioner Redding seconded. Approved.
Discussion, recommendations, and action regarding veterinary medicine participant W. Winchell’s request for practice extension. Ms. Warner stated the participant was notified per OML requirements. The request is for a 2-3 year practice extension from June 2013. Dr. Winchell holds a specialty license in large animal surgery, and his wife is also a veterinarian, so the state will be getting two veterinarians for returning the one supported by WICHE. They plan to establish a large animal practice in rural Nevada. Ms. Warner added that an annual practice questionnaire will be sent to keep track of Dr. Winchell’s return to Nevada. She recommended approval of a 24-month extension with interest to continue to accrue during this time. If an additional extension is needed, it can be requested at that time. She recommended the extension begin October 31, 2013, and end October 31, 2015. Commissioner Hardy moved to approve the request and include an annual practice questionnaire update. Commissioner Farrow seconded. Approved.
Discussion, recommendations, and action regarding continuation of collection efforts or write-off on collections account F. Rutz (dentistry). Ms. Warner stated the agency attempted to notify Mr. Rutz per OML requirements. He graduated in 1984, and the account has been in collections for quite some time. The account total is $63,367 ($40,800 original principal, $22,167 interest, $400 fees). The account appears to be uncollectible, as the participant has no active dental license in the United States, and he has not been located by the collection agencies after numerous collection attempts. Further, based on file notes, it appears that he is no longer in the United States. She recommended closure of the account.
Commissioner Redding stated there are three options: the account can continue to remain on the agency books; the account can be turned over to the State Controller’s office, which has new tools that can be utilized for collection such as SB 21’s flagging of licensure should the participant try to renew his license in Nevada; or, the account can be written off. Commissioner Redding stated he is in favor of sending the account to the Controller’s office for a last effort at collection and to get it entered into the licensure hold system. Ms. Parker stated she does not know if the new law is retroactive; therefore, it would be a good idea to resubmit the account. Commissioner Hardy moved to turn the account over to the State Controller’s office to enter into the licensure hold system and for last efforts at collection. Commissioner Farrow seconded. Approved.
Follow-up report on extension of time and penalty for HCAP students who 1) do not graduate or 2) graduate but do not pass boards/obtain licensure (ref: NRS 397.0617; NAC 397.030). Ms. Parker stated that NRS 397.0617, subsection 4, states, “If a person returns to this State but does not practice in a medically underserved area of this State…, the three Nevada State Commissioners, acting jointly, shall assess a default charge in an amount not less than three times the portion of the support fee designated as the loan of the person, plus interest.” Also, NAC 397.030, subsection 3, states an extension may be granted if the participant fails to pass his professional examination; however, practice of his profession must begin no later than two years after the administration of the first examination unless an extension is granted. It was noted the participant graduated in May 2010. He has taken the exam approximately twice and failed. Staff will bring the status of his third attempt to pass the examination to the next commission meeting.
Commissioner Hardy asked if there are any HCAP fields that require a residency interposed between the inability to practice and the graduation. Commissioner Redding stated he does not think so; Ms. Warner named the currently supported HCAP fields, none of which have a residency. Referencing subsection 2, Commissioner Redding confirmed with Ms. Parker that a commission extension can be granted for a variety of reasons including “other circumstances,” and that the “other circumstances” can be used by the commission in the case the participant is un-licensable. Commissioner Redding asked if NAC 397.030 grants an “extension” and not a “write-off”, does the commission find itself in the position to have to grant perpetual extensions? Ms. Parker answered she wouldn’t say “have to”, but the commission “could”. Commissioner Redding asked if the only two options are to place the participant into default or grant perpetual extensions. Ms. Parker answered there is a third option, which is the implied authority in the statute to reduce principal. Commissioner Redding asked if the principal could be reduced to zero ($0.00). Ms. Parker responded it would be up to the discretion of the commission. Ms. Warner noted that the 6-month extension granted to the participant at the previous commission meeting ends December 15, 2013, so the results will be brought to the January 2014 commission meeting.
Financial reporting – FY2014, 1st Quarter: CAIS report for operating budget, and Aging Report, Income Statement and Accounts Receivable report for the programs budget. Ms. Westre stated this is the first quarter and not a lot is going on. She asked if the commission had any questions. There were none. Commissioner Redding stated it looks like everything is coming in strong in regard to loan repayments.
Discussion, recommendations, and action regarding the 2015-2017 Loan and Stipend (Programs) Budget: Fields and slots for consideration based on future educational and health care needs of the state. Commissioner Redding stated that ten months from Friday, the agency’s budget request is due to the state budget analysts, and he would like to start a discussion with the commission regarding which fields the agency will fund for the next biennium. Are there fields the agency should expand to or fields that are available that we are not participating in; or, are there fields that have outlived their usefulness as far as workforce and healthcare needs for the state of Nevada that we would look at trimming? Regarding the revenue discussion, where does the commission think the support fees should be spent? What have we done on support fees, and what types of things could we look at?
Regarding support fees, Ms. Warner stated that PSEP has an annual support fee increase based on inflation. The regional WICHE office makes that assessment, the regional commission approves the fee amount, and Nevada WICHE abides by those amounts. For HCAP, the support fees have stagnated since approximately 2009; there have been no increases since that time. She is concerned that the HCAP support fee amounts are not as competitive as they need to be to serve as an incentive to participate in the program. Tuitions have gone up considerably and outstanding student loans are immense in some fields, which make it prohibitive for some of our practitioners to start their own businesses. The cost of education as a whole is increasing. She would like to look at tuition increase trends and compare them to Nevada support fees - what is the comparison and are the HCAP program’s support fees keeping up? What is a fair amount for our health care fields? She plans to talk to stakeholders, to NSHE, and to John Packham’s office about state needs. She will also review the HRSA website and statistics on health care needs for medical fields. There is quite a bit of information available that can be compiled for upcoming meetings.
Commissioner Hardy stated if he were to focus on health care needs, it would be on residencies or graduate medical education (GME) in the state of Nevada. Is there something the commission can do with GME from a state standpoint that would be supportive of a residency? He is thinking about the student who has graduated from medical school but not yet gone to residency. Commissioner Hardy is interested in the concept of helping to offset some of the costs incurred by rural hospitals for a GME using state dollars. GMEs and their associated costs are the reality of medical education. He realizes this might be unusual, but WICHE may be the first to do it to help address the need for physicians in Nevada.
Commissioner Redding stated those points are on target. He asked Ms. Warner to see if any other WICHE states offer any GME support, including residencies and fellowships, through either PSEP or on their own. Are the other states doing anything like that? If there is nothing under the existing PSEP program, could it be structured under our existing HCAP program? Ms. Warner stated the major reason Nevada WICHE does not currently fund physicians is primarily because the medical school is here, and it is correct that the state is losing them to out-of-state residencies. Under either the PSEP or HCAP, if the commission decides to fund physicians, there is always the requirement to return to Nevada regardless of the residencies being out of state. We can get them back that way. It can be done through one of the tuition assistance programs, or develop the loan repayment program and try to entice them into the state, or do both. Commissioner Hardy stated that is a good way to look at it. Even though graduates go away to residency – and almost all of them have to, which is why we cannot get them back – we can come up with a program to return physicians to the state.
Commissioner Hardy brought up in the WICHE legislative committee as well as the WICHE regional meeting that this is going to be a huge problem. There are 500 physicians who graduated from medical school that did not match for any residency. There are 2,000 medical students graduating from one Caribbean area that are U.S. citizens and competing for residencies. In 2017, there will be an inability for any foreign medical graduate to get a residency here if Nevada accepts only United States trained medical students. This will probably not be a wise position to be in. The problem is not with the students, but with the GME; how can Nevada obtain more? He suggested a consortium model for residency that includes building in the rurals. Anytime we get a rural residency rotation, we are improving the health care in, for example, central northern, and eastern Nevada without having to have a full-time doctor there. Commissioner Hardy added he conversed with a sixty-two year old doctor who realized he is the only physician in Lovelock. If anything happened to him, he can’t treat himself. That is also what we are looking at in rural Nevada - who will take care of the physician once we get them there? To obtain a program to enhance a hospital’s ability to fund their residency slot or a residency in toto is what Commissioner Hardy stated he would like to see. Commissioner Redding asked if Commissioner Hardy is thinking more of augmenting them at the residency level, or providing a stipend or tuition assistance so the student returns to Nevada after completing an out-of-state residency. Commissioner Hardy responded both; both are good avenues to take.
In addition to a stipend, Commissioner Farrow suggested perhaps GME support may also be done in partnership with the Primary Care Office’s National Health Service Corps loan repayment program, which recruits physicians into the state. When looking at how we can market to those students who come to school in Nevada from out of state, loan repayment is something they can start to think about. Do they want to commit immediately to Nevada, or wait until years three or four after they are exposed to Nevada and decide it’s a place they would like to stay if, in fact, their residency is somewhere else? Commissioner Redding felt it was an excellent idea and asked Ms. Warner to look into a potential PCO collaboration for the next meeting.
Commissioner Redding asked about the existing Nevada WICHE fields. Historically, during the budget cut years, the commission decided to keep every field active and reduce slots rather than eliminating entire fields. Now that we are in a position where WICHE can start to rebuild, should the commission compare work force needs with the currently existing fields? Commissioner Hardy stated he is looking at the field of physician assistant (PA). There are 60 per class at Touro. Is there still a need to subsidize there? They have been turning them out at Touro and he doesn’t know if there is a need to get PAs back into the state, because they are being trained in state. He also discussed dentistry. With 89 dentists who are allegedly leaving the state because they cannot make a living here, and the dental school who sends them all out of state because there are not enough places to practice in the state, in addition to the money being spent on the dental school, is there a rationale for additional dentists in the state? These are two places he would like to be influenced in a more positive way to continue in those fields.
To address PA, Ms. Warner stated that she will research how many Touro graduates remain in the state to work – what are the retention rates, and what are the state’s future needs for PA? Additionally, John Packham’s office is releasing a new health care book this year which projects the annual employment needs of many different health care fields. These are two approaches to see where the state stands with PA. She commented that should national health care go through, the need for PAs will increase because of the demand on physicians. Commissioner Hardy asked if the 3 slots we currently fund per year make a difference compared to the 60 Touro is turning out? We do need the statistics on how many stay in state. How many do we need to stay in state? We can’t get enough health care professionals. The question is, does WICHE need to spend its dollars on PAs, or on a residency or something else to get doctors to be in Nevada? How is it determined if we need 3 more, or if we need 20 or 40 or 60? Ms. Warner stated if all 60 are leaving the state, we may need to look at increasing the physician assistant field. If they are all staying, we may need to eliminate the field altogether.
In dentistry, specifically for the underserved populations, Ms. Warner stated the need is tremendous. There is quite a bit of data that can be provided to support this. There are many urban dentists serving people with insurance, but WICHE dentists do not serve those areas, they serve the rurals and urban underserved. Commissioner Hardy asked, does the state need to continue funding a dental school for millions of dollars a year to train dentists to go someplace else? He recognized that is why the state put the dental school in place. But, can WICHE do that same kind of thing, doing that somewhere else and get them committed to come to the underserved area if we didn’t have the dental school? He asked Ms. Warner to look at what the retention rate is for the dental school. Ms. Warner stated that the dental school does keep their retention rates of graduates who remain in the state. She thinks retention is somewhat high; however, these dentists try to work with the insured, paying populations, don’t succeed, and then leave the state. That is something to consider. Commissioner Farrow stated, based on the data that he has seen from John Packham’s office, they created the location quotients for all the various health fields where the location quotient is, Nevada’s comparison to the national average for Nevada’s workforce. Under the health care umbrella the field of dentistry is closer to one, if not greater than one, which puts us at saturation point which reiterates Commissioner Hardy’s point of saturation in that field. That is what the data will show when we get it from John.
Commissioner Farrow asked what the field of mental health includes. Ms. Warner stated it is a broad spectrum field with focus on social workers. For example, WICHE has a participant working at Sierra Regional Center, which is a facility to assist people with developmental disabilities. He helps them with life skills. He does a job no one else will do. We keep it flexible. There is a need for psychologists in the state, it is a high need field. However, a $2,000 per year support fee is not much incentive. She would like the commission to look at the support fee amounts and see whether they want to increase it or keep it the same.
Commissioner Farrow asked, regarding the mental health umbrella, does that also consider public health? He discussed support for the field of behavioral health as a whole, namely mental health but broadened by working in more innovative and different approaches to health care. When he was at the school of public health, the school of social work worked hand in hand with what work they were doing. Ms. Warner asked if he meant including public health under mental health, combined? Commissioner Farrow answered yes. When looking at funding in behavioral health issues, and given that Nevada has a school of public health, does the commission want to look at broadening the mental health field with public health? He agreed that GMEs should certainly be a focus moving forward. It needs to be addressed so that the state doesn’t find itself in the physician exporting business.
Commissioner Hardy stated that if he was going to say anything it would be about the rurals not having mental health care. Is there a way to focus WICHE’s mental health subsidy towards a provider that literally focuses on the concept of telemedicine or telemedical help? Can we actually get somebody who is competent and capable of doing it, instead of us just talking about it session after session? Can we develop a niche for somebody to be trained in telemedicine and come back to or stay in Nevada, or sponsor a program or something, which will get telemedicine off the ground and going? There is not going to be enough mental health people traveling the miles to get to the rural population. Maybe it’s time to look at mental health support in a different way - look more at the telemedicine option and develop through WICHE a program. If one person is developed, WICHE has developed a program. Commissioner Redding stated this will be an exciting area to look at.
Commissioner Redding stated another field that he would like Ms. Warner to look at is occupational therapy. An occupational therapy program was once under NSHE but was shed a couple of years ago, not because of the lack of student interest but because of the inability to recruit affordable faculty. He added this program may fit the PSEP model, so if there is workforce information on occupational therapy as well as what the participant support fees would be, please bring that information back to the commission. Commissioner Hardy stated Touro may be the only Nevada occupational therapy school right now. The retention rate may be under Dr. Packham’s study.
Commissioner Redding stated this puts a nice framework together as a good starting point for the discussion to have as WICHE starts to formulate its budget request. He suggested that, given the amount of information that is being asked for, to consider sliding the quarterly meeting schedule a little later after the first of the year to give Ms. Warner time to pull information together.
11. Director’s Report - Letter from dental participant, Rodeo Foundation advertises WICHE, HCAP interviews, new partner(s), Director’s calendar. Ms. Warner stated a letter in the packet from a dental participant was provided for the commission because occasionally we get these nice notes, and this letter demonstrates the type of practitioners the agency strives to get and keep in Nevada. Not only does this participant try to make a difference in his field, but he tries to make a difference in his community and reach out beyond just his world. This demonstrates how the agency’s goals and purpose really are being achieved. The participant is an urban dentist who is located in central Las Vegas where there is significant need for these types of dentists. The commission agreed it was a very good letter.
The Reno Rodeo Foundation started a collaboration with WICHE on one large animal veterinarian. Because of that collaboration, the agency received free advertising on KOH radio. The foundation director, Marie Baxter talked about WICHE and the collaboration. She also discussed the collaboration in her e-newsletter. One of the agency’s goals in marketing is to have its collaborators and stakeholders assisting with our outreach and tell the story for us. She is hoping to get the word out about the PSEP program. We appreciate the free advertising.
With the passing of WICHE’s previous Commissioner, Carl Shaff, there is a need for a second person for the HCAP interviews. Ms. Warner was happy to announce Tabor Griswold from Dr. Packham’s office with the UNR School of Medicine will be assisting with the Loan Repayment program interviews. For the HCAP Loan Forgiveness Program interviews, she will be meeting with someone from AHEC (Area Health Education Centers) to assist with these interviews for nursing and physical therapy. AHEC works at the high school level to develop health care students. If this person is not available, Ms. Griswold has agreed to step in for these interviews. She added her participation assists with her program as well, as they receive quite a bit of information from frontline practitioners. So, we will be able to proceed with our HCAP funding selection.
Ms. Warner stated she will email her calendar to the commission. Last quarter the fiscal year 2014 contracts were processed and sent to continuing participants, and she completed the outreach for PSEP and HCAP. Close to ninety applications were processed. Regarding college fairs, Las Vegas was last week, Reno was Sunday, and the rural fair is the following week. Next quarter will be the HCAP interviews, hopefully in November, their award notifications, contract processing, and working with UNR to develop WICHE’s website. They will be hosting their own website and are going to be able to design WICHE’s site the way it needs to be so it is functional. Those discussions with John Kuhlman will be next quarter.
New Business. November 2013 Regional WICHE Commission meeting: 60th anniversary, State Authorizations Reciprocity Act (SARA), Future agenda items: Develop/modify regulations under Nevada Administrative Code (NAC) 397, Fields/slots for 2014-2017 biennial budget. All three commissioners plan to attend the November Regional WICHE meeting. Commissioner Redding stated at the next meeting there will be a report on the SARA, the State Authorization Reciprocity Agreement. This is an agreement that the legislature passed last session to allow Nevada, if passed here in this body, to enter into a reciprocal agreement with other WICHE states to allow higher education institutes to cross state boundaries. For example, if a college is accredited at the state level in Utah, they would be able to provide educational services in Nevada without going through an independent process here.
Another big item potentially will be coming up on the next agenda, thanks to Ms. Parker for bringing this to our attention. It has been many years since we have looked at our regulations under the NAC. Ms. Parker and Ms. Warner are undergoing a review of the regulations, and if we need to go to the legislative commission to amend, then that process will need to begin shortly after the first of the year with public hearings. It is possible that the next WICHE Commission meeting will be a public hearing for NAC changes as well as the biennial budget.
Commissioner Redding noted there is the SARA meeting in Denver that will include folks working on the reciprocity agreement. NSHE will have a representative there for their interests. Commissioners are welcome, but it’s not a commissioner function and they are not required or expected to attend.
Ms. Parker addressed the commissioners, stating there have been previous concerns about the three attending the Regional WICHE meeting. She reassured them that it is fine for all three to attend, they can discuss what happens at that meeting but cannot discuss what Nevada WICHE should do about it. It is fine to talk about what might go onto a future agenda, but do not discuss a personal position on that item. Commissioner Hardy addressed Ms. Parker, stating if the three Nevada commissioners act as commissioners by making decisions and taking votes on what Regional WICHE does as a WICHE organization but not as a Nevada organization, that that is allowed. Ms. Parker replied that is correct.
Public comment. There was no public comment.
Adjournment. The meeting adjourned at 4:05 p.m.