Fishin’ for Physicians: A SHARP Hook Baited with Financial Incentives
The McMahan Family at Davidson Glacier.
Adam McMahan knew from a young age he wanted to be a physician. He can pinpoint the exact moment he decided to practice medicine in a small rural town.
“I still remember the awe and visceral excitement from this moment,” says McMahan, who now serves Haines and Klukwan as a family physician with the Southeast Alaska Regional Health Consortium (SEARHC). “Since then, I knew that I wanted to practice medicine in a small mountain town.”
After medical school, McMahan, who earned his undergraduate degree from UAF and remained “hooked on the regular sense of awe that came from the cultural diversity and ease of finding adventure in the Interior,” returned to Alaska with a residency at the Alaska Family Medicine Residency—and with $280,000 in student loan debt.
Colleagues suggested he look into the SHARP Program, Alaska’s healthcare workforce recruitment and retention program. The state-run program provides loan reimbursement or direct financial incentives to medical, dental, and behavioral health practitioners who commit to working in designated underserved regions.
“The SHARP program was designed on the state level to help get health practitioners to come and hopefully commit to places that were being underserved,” says Dr. George Bird, a Fairbanks dentist and director of clinical services for the Tanana Chiefs Conference. “Loan repayment has kind of become one of the things you have to have to entice new graduates.”
McMahan says when he began his post-residency job search, he only considered positions with a loan repayment option. SHARP is what ultimately enabled him to fulfill his childhood dream of becoming a small-town doctor.
“Finding support for repaying this student loan debt played an outsized role in my family’s search for opportunities in rural Alaska,” he says. “It was SEARHC’s relationship with the SHARP-1 program and the resulting student loan support that allowed our young family to make a financially responsible transition into my first job as a family physician in Haines.”
“It’s a really strict agreement that, if they back out, the state will go back and get all of the money they’ve been given.”
Even before the COVID-19 pandemic stretched Alaska’s healthcare system to the limit, the industry struggled with a worker shortage. With no in-state medical or dental schools and few medical training programs—not to mention the high cost of living and geographical isolation that affects almost every Alaska industry—attracting and retaining qualified medical professionals has proven difficult.
The SHARP Program helps alleviate those difficulties by making it more attractive for medical professionals to practice in Alaska. First conceived in 2008, SHARP was designed to improve the recruitment and retention of healthcare providers, according to Heidi Hedberg, director of public health for the Alaska Department of Health and Social Services. The program offers financial support to professionals who provide specified healthcare services in clinics whose patient load is at least 30 percent underserved populations, such as the uninsured, Medicaid and Medicare recipients, and certain federal health beneficiaries.
Most practitioners ask about loan repayment during the recruitment process, Bird says. But even if a position is eligible for reimbursement through SHARP, that doesn’t mean a provider is guaranteed to get it.
“You don’t take the job on the condition that you’ll get loan repayment, because those government entities won’t consider loan repayment unless you have a job,” he explains. “I would say most eligible providers get it, but not all do. It has to do with funding cycles and they [Alaska Department of Health and Social Services] spread it around the state.”
“I frequently encountered rural Alaskans struggling with mistrust of Alaska’s healthcare systems… Part of this mistrust stemmed from the experience of repeatedly losing a trusted physician, nurse practitioner, dentist, or psychologist as these clinicians came and went from rural communities.”
There are two versions of SHARP (SHARP-2, which required 75 percent state general funds, sunset in June 2019). The original, SHARP-1, provides loan reimbursement and is funded through a combination of federal HRSA-SLRP grants (the State Loan Repayment Program through the Health Resources and Services Administration of the US Department of Health and Human Services), Alaska Mental Health Trust Authority funds, and an employer match. Eligibility is contingent on clinicians providing direct patient care in an outpatient setting in specified dental, medical, or behavioral health disciplines, according to Hedberg. The clinic must also be a government or nonprofit entity located in a federally designated health professional shortage area. There are currently twenty-seven SHARP-1 employers in twenty-five communities.
SHARP-3, which the Alaska Legislature unanimously approved in 2019, broadens the disciplines eligible for financial support, Hedberg says, to include paraprofessionals, hospitalists, and generalists; providers who work at for-profit clinics are also eligible for assistance, which can be in the form of loan repayment or direct incentive. SHARP-3 is completely employer-funded, and those funds can come from any available source. Neither SHARP-1 nor SHARP-3 has a state general fund appropriation.
Providers must also commit to a two-year service contract for SHARP-1, or three years for SHARP-3, though they can transfer to another health professional shortage area facility during the contract term.
“It’s a really strict agreement that, if they back out, the state will go back and get all of the money they’ve been given,” explains Patty Eissler, director of human resources for Peninsula Community Health Services in Kenai.
Since issuing its first service contract in 2010, SHARP has provided $23 million to more than 250 medical professionals practicing at fifty-seven facilities around the state. Data shows a 97 percent retention rate for providers enrolled in SHARP-1; a year into SHARP-3, there is insufficient data on retention rates.
SHARP isn’t the only loan-reimbursement program available to medical professionals, but it has several features that make it more attractive than federal options.
“The advantage of the SHARP program is that it’s Alaska-centric rather than nationally focused, and that helps us,” Bird says. “And it has a provision where the payments are exempt from federal taxes; not all of the loan repayment programs out there are.”
Minimizing Turnover, Increasing Longevity
The Alaska Department of Labor and Workforce Development’s 2018 economic trends report predicted a 21.4 percent increase in the state’s healthcare industry by 2026, which translates to more than 10,000 new jobs.
But staff turnover and a shortage of available healthcare providers continue to be ongoing problems, particularly in Alaska’s rural areas. Frequent turnover is a strain on clinics. It burdens the remaining staff; additional time, money, and effort must be put toward recruitment and training; and itinerant or temporary physicians must be brought in at increased expense, Hedberg says.
McMahan, who provided itinerant healthcare services to rural communities during his residency, says frequent turnover negatively affects patients as well.
“I frequently encountered rural Alaskans struggling with mistrust of Alaska’s healthcare systems,” he says. “Part of this mistrust stemmed from the experience of repeatedly losing a trusted physician, nurse practitioner, dentist, or psychologist as these clinicians came and went from rural communities.”
Much of that turnover is driven by the realities of life in Alaska.
“We have a relatively large amount of turnover, over time, because it’s a big program,” Bird says. As the federal tribal contractor for Indian Health Services, Tanana Chiefs Conference serves Alaska Natives living in the Interior, a 235,000-square-mile area that covers 37 percent of the state’s total area, only slightly smaller than Texas. “When I got involved with [SHARP] ten or so years ago, low retainment at that time was a particularly big issue in dentistry.”
Eissler says Peninsula Community Health Services has lost providers, the majority of whom are from the Lower 48, who grew tired of the isolation, weather, or being so far from family. Whether they plan to apply for the SHARP program or not, she says, Peninsula Community Health Services asks providers to commit to a two-year stay, and she does her best during interviews to temper their expectations to maximize the chance they fulfill that commitment.
“When I talk to any candidate who’s coming in, I’m pretty candid about what it’s like living here in Alaska,” Eissler says. “You see all those reality shows on TV and you think, ‘Alaska’s a great place to live,’ but the reality is—it is great, but I don’t want to sugarcoat it because there are some challenges living here. So, I do it as diplomatically as I can.”
Bird says SHARP won’t lure providers with no interest in Alaska, but the program can be enough of an incentive for those on the fence.
“You’re never going to keep everybody, [and] this program is not enough to get people who don’t want to be in Alaska to work here,” Bird says. “So, you have to get people who are already naturally inclined to come up here, but maybe need a nudge.”
SHARP not only acts as that nudge but can also be the catalyst for providers to stay on beyond their initial two- or three-year commitment.
Providers cannot combine loan reimbursement programs, but they can reapply to SHARP at the end of their initial contract. This can sometimes extend what initially began as a two-year job into a longer-term stay.
“People don’t necessarily look at a ten-year horizon all that favorably when they get out of school, but if they’ve already worked four or five years for you, then they’ll typically work the other four to five years,” Bird says.
Some providers remain beyond the two- or three-year contract term out of a sense of loyalty or gratitude.
“Many [providers] are very grateful that they received that loan repayment through working with us,” Eissler says, “so it does give some loyalty to some of the providers that they want to stay longer because we were so helpful.”
Alaska’s SHARP Program allowed Adam McMahan, a primary care physician with SEARHC in Haines, to fulfill his childhood dream of practicing medicine in a rural town.
Making Public Health Competitive
A 2019 analysis of Southeast Alaska’s healthcare workforce prepared by Rain Coast Data found that 88 percent of healthcare administrators considered increased compensation packages to be the most effective tool for recruiting healthcare providers.
But public health and other medical clinics that treat predominantly underserved populations can’t always compete against larger, for-profit entities when it comes to salaries. The SHARP program’s financial support helps bridge the gap between what public health clinics can pay and salaries for-profit medical centers in Alaska or the Lower 48 can offer.
“If we were competing [for a physician] with another agency in town, they may not get the loan repayment at another agency,” Eissler says. “Here, they have the chance of potentially getting up to $70,000 for a two-year contract, so it’s kind of free money for them. So, they come to us in some cases strictly because we’re eligible for loan repayment.”
For providers already inclined to work in public health, the tax-free loan reimbursement is an extra incentive.
“In some cases, they are very clear that they are interested in us, one, for the mission—we are a nonprofit, so you have to want to be here for the mission of helping people—and because we’re eligible for loan repayment,” Eissler says. “If we can get them [because they like our mission] and then because of the loan repayment, that’s an extra bonus too.”
SHARP’s funding cycles are also more flexible and less dependent on what’s happening in the federal government, which makes it more attractive than federal loan reimbursement programs.
“It does help with recruiting for sure,” Bird says. “Federal loan cycles kind of ebb and flow—sometimes there’s tons of money and sometimes there isn’t—and so we’re not part of that same flood of money or drizzle of money as the Lower 48. So sometimes we have money when the feds don’t, so that actually drives people to us, which I think was the original intent of the program.”
McMahan says SHARP’s flexibility and its Alaska focus are big parts of what drew him to the program.
“I feel strongly that rural Alaskans deserve easy access to high-quality healthcare from professionals who live in, come to love, and put down roots in the more remote corners of our state,” he says. “SHARP-1 was the most competitive option of the student loan repayment programs and seamlessly aligned with my goal of providing quality care in rural Alaska where rural residents disproportionately face higher rates of healthcare worker turnover.”