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LARAMIE — Wyoming medical students will double the time they spend in Laramie starting in 2019, as the five-state WWAMI program ceases to bring students to Seattle for their second year of training.

WWAMI is an acronym for the program’s participating states: Washington, Wyoming, Alaska, Montana and Idaho.

The program allows Wyoming students to receive a medical degree from the University of Washington School of Medicine using Wyoming’s in-state tuition.

After those students complete a residency, their entire tuition is paid for if they return to Wyoming to practice as a physician for at least three years.

Since Wyoming joined the agreement in 1996, Wyoming students complete their first year of medical school in Laramie and complete their second year in Seattle.

That changes next fall, after multiple years of work by the University of Wyoming and Ivinson Memorial Hospital to increase the capacity of students they can handle.

The change was prompted by a nationwide reform of medical school that puts greater emphasis on hands-on clinical work and lower physician-to-student ratios.

As a result, reduced capacity led the University of Washington to push for WWAMI states to cease sending their second-year students to Seattle.

Tim Robinson, WWAMI director at UW, said it’s still important for Wyoming students to spend some time in Seattle at the “big time medical facilities that we just don’t have in Wyoming.”

Under the new system, Wyoming has negotiated to ensure its students will spend at least some of their two-year clinic education in Seattle — something that wasn’t guaranteed before.

The two-year clinical period completes a student’s WWAMI education. During that time-frame, the students are rotated throughout rural locations in the five-state WWAMI region.

Wyoming takes 20 WWAMI students each year, even though it has been, until this year, operating in the same facilities designed for 10 students in 1997.

To accommodate 40 medical students in the College of Health Sciences building, a new cadaver lab was completed this summer. Later this month, the program’s new “active learning classroom” will be finished.

In addition to accommodating more students, Robinson said the new “state-of-the-art” facilities will help give Wyoming students access to some of the amenities they’d otherwise miss out on by not going to Seattle for their second year.

The change in medical school teaching styles, along with more WWAMI students in Laramie, meant the program now needs more physicians to teach the key coursework like Clinical Foundations of Medicine.

Aside from the 20 physicians in Laramie and Cheyenne doing preceptor work with WWAMI students, the program had one physician teaching the “foundations” curriculum three years ago.

Now, there are seven physicians teaching that coursework. Ivinson has also added a clinical classroom on-site.

WWAMI was created in 1970 to address the chronic shortage of physicians in rural Western states.

That shortage continues to be a struggle in Wyoming, and state legislators expressed confidence this month in WWAMI being the best method to cultivate future doctors in Wyoming.

Robinson said it costs the state $300,000 for each physician created through WWAMI. Each physician working in Wyoming, however, generates $1.1 million in economic benefits each year, he said.

About 70 percent of all Wyoming students who become physicians via the WWAMI program return to Wyoming to practice medicine.

Of those students who return to the state, about 85 percent will stay past three years.

Those retention rates are higher than the state’s other doctor incubator: UW’s Family Medicine Residency clinics in Cheyenne and Casper.

Because those UW clinic spots are filled by a national lottery system, they typically exclude Wyoming residents, who are more likely to practice in the state long-term.

During last 30 years, less than 40 percent of residents at the UW clinics subsequently practiced in Wyoming.

UW is currently working on plans to partially privatize those clinics to stay compliant with federal rules.

After Gov. Matt Mead requested in 2012 the clinics reduce their reliance on the general fund, the clinics have received increased Medicaid- and Medicare-related reimbursements after becoming designated as a Federally Qualified Health Center.

Clinic revenue is now expected to be $16.7 million during the 2019-2020 biennium, up from $10.7 million in the 2015-16 biennium.

With the increased federal reimbursements, clinic revenue is now 51 percent of the clinics’ budget.

That increased reliance on federal money means more federal requirements, including having a community board. The clinics are currently overseen by the Educational Health Center of Wyoming.

However, federal auditors took issue in 2017 with the board’s lack of budgeting power.

“They were really a board in name only, and sadly the feds noticed that,” said Rep. Sue Wilson, R-Cheyenne, who chaired the task force working on the privatization plan.

She said the reorganization needs to “proceed very expeditiously” to avoid losing federal funding. The current plan would have the community board incorporate itself as nonprofit.

UW governmental relations director Meredith Asay said the clinics’ operations are almost certain to be successful, even without state subsidies.

“There is no one that thinks these clinics would not be financially stable at this point with the influx of federal money that has been made available,” she said.

A legislative task force presented a draft bill for the clinic reorganization to the Joint Appropriations Committee at its meeting.

The task force is asking JAC to sign off on the bill, which would have UW maintain ownership of the Cheyenne and Casper clinics. The physicians at those clinics would stay UW employees, while the nonprofit corporation would take managerial control of the clinics — including the ability to hire and fire its CEO.

However, JAC opted to hold off making a decision about the bill until its December meeting after Rep. Bob Nicholas, R-Cheyenne, requested more information on how UW will divest funding from the clinic operations.

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“There’s a component of separation between the clinic and the residency training bracket,” he said. “I think we have a responsibility to examine how UW is doing it and make sure we agree with it.”

While the residency clinics’ “retention is not as high as we might like,” Wilson said, both she and other legislators said the residency clinics are still an important tool for producing doctors for the state.

The demand for physicians in Wyoming “couldn’t reasonably be met by recruiting out-of-state doctors,” she said.

Eric Boley, president of the Wyoming Hospital Association, said hospitals in the state will sometimes pay up to $70,000 just to recruit an out-of-state doctor — in addition to paying salaries in the 90th percentile.

Boley said recruiting family practice physicians is becoming particularly difficult as more medical students are wanting to become specialists.

“What we’re finding in our hospitals is that it’s not that hard to find a specialist to come here, but it’s the family practice physicians that are more difficult,” he said.

The number of applicants for Wyoming’s WWAMI program exceeds the available spots each year.

Robinson said expanding the program could be possible, assuming there are enough physicians interesting in training students.

One of the biggest obstacles, he said, would be the limit of patients at Ivinson that could prevent more students from being trained there.

Another possibility for the future, he said, would be to have students training with physicians in Cheyenne.

Sen. Charles Scott, R-Casper, said a future WWAMI expansion could be a possibility — but not in the near future.

“When we have $100 oil and $5 natural gas, this would be a competitor on the list of potential things to do,” he said this month. “But at this point, we’re looking to recruit more physicians and I don’t think a major expansion in WWAMI is something we can afford. You can’t say we’ll replace the Family Practice Residency Centers by expanding WWAMI.”

David Jones, interim dean of the College of Health Sciences, also said at the final residency task force meeting it would be hard to greatly increase WWAMI’s capacity without a new building because space at the health sciences building is already so limited.

“I have a vision for how a new health sciences building would look, but that’s more of a dream than anything,” he said.

Hoping to recruit more physicians to the state, the Wyoming Board of Medicine has streamlined its licensing process in the last decade.

“If someone’s got a clean history, we get the basic documents: An application and a few other things that are required by law,” said Kevin Bohnenblust, executive director of the board. “If someone’s got a clean history; they’ve got minimal malpractice claims and they’ve not been disciplined in another state, we issue them a temporary license while we wait for the rest of the paperwork to trickle in. That’s really helped us and it’s really helped hospitals when they’re in a crunch time.”

But despite an increase in licenses, the practice has failed to make more Wyoming residents out of those doctors.

In 2010, there were 2,759 licensed physicians in the state, though only about 1,200 were considered Wyoming residents by the board.

The number of licensees in the state is now about 4,300, while the number of Wyoming residents stayed the same.

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