Understanding the Oregon rural
healthcare landscape:
Rural Health Policy
Summit
June 12, 2010
Lisa Grill Dodson, MD
Director, Oregon AHEC
Associate Professor of Family Medicine,
OHSU
Goals
• Identify supply side issues in rural healthcare
workforce
• Identify demand side issues in rural healthcare
workforce
• Identify key population and community
characteristics related to healthcare workforce
• Understand the economic impact of the healthcare
workforce on rural communities
• Outline potential strategies to address the rural
healthcare shortfalls
Healthcare Access
Access vs. Availability
 In the I-5 corridor the question is access
 In rural Oregon, the question is availability
 Maldistribution of health care providers that is
going to get worse
Too few physicians or too many urban physicians?
• Maldistribution by specialty and geography
(MD, DO, NP, PA, RN, allied health)
• Rural areas have fared less well in the past in
recruitment and retention of health providers
• This will likely worsen in the future
– Increased demand
– Rural infrastructure issues
– changes in provider demographic and expectation
Physician shortage?
• Almost certainly, a shortage
• What is the Magnitude:
– Minimal: Primarily a utilization problem
(Dartmouth Atlas)
– Moderate: 85,000 (GAO)
– Severe: 125,000 (AAMC)
DATA
What’s the data for Oregon?
• January 13, 2010, new OMB licensing
database
–
–
–
–
–
13,008 actively licensed physicians in Oregon
10,088 with Oregon address
1589 Family Medicine or Family Practice
3235 women
Average age of all licensees is 49
Oregon is already experiencing
physician shortages
1.50
Physician data, Oregon Board of Medical Examiners: June 2007
Population data, Portland State University Population Center: Dec 2007
0.38
4.74
2.07
1.43
2.65
1.12
1.57
0.00
2.36
1.12
0.00
0.16
1.86
1.99
1.90
0.65
1.30
0.00
0.77
2.53
0.92
1.34
1.12
0.73
2.22
2.06
2.48
1.87
1.78
0.78
0.93
1.94
1.21
1.59
2.57
Oregon rural and urban care providers
Rural
Urban
Primary care
physicians
Physician Assistants
1:1298
1:720
1:6818
1:3827
Dentists
1:2241
1:1333
Nurse Practitioner
1:2491
1:1842
Is there a doctor in the county?
Number of
physicians/county
Count
Counties
0-9
7
Gilliam, Grant, Harney, Lake, Morrow, Sherman, Wheeler
10-35
8
Baker, Columbia, Crook, Curry, Jefferson, Polk, Tillamook,
Wallowa
36-75
6
Clatsop, Hood River, Lincoln, Malheur, Union, Wasco
76-150
5
Coos, Josephine, Klamath, Linn, Umatilla
150-500
4
Benton, Deschutes, Douglas, Yamhill
501-1000
4
Clackamas, Jackson, Lane, Marion
>1000
2
Multnomah, Washington
DEMAND
Aging Demographics
Population 65 Years of Age and Older: US 1950-2030
80
Number in Millions
70
65 - 84 Years
85 Years and Older
60
50
40
30
20
10
0
1950
1960
1970
1980
1990
Year
2000
2010
2020
2030
Population trends contribute to health care provider
demand
• In 2006, 12.5% of Oregonians were 65+
• By 2025, this number will double to 24%
• Health care reform will potentially add ~576,000 currently
uninsured Oregonians to the system
• Rural Oregonians are, on average:
– Older
– Poorer
– Sicker
• Older people use more healthcare services
Source: PSU Population Center and US Census Bureau, Office for Oregon Health Policy and Research
Supply side
Supply side factors contributing to provider shortages
• Flat med school graduation rate from the 70’s to the late 90’s
– Nationally, failure to produce what is needed
– Declining interest in primary care due to work hours, scope of practice
and lower reimbursement (also true for Dentists, PA, NP)
• Aging physician and nursing workforce
– Nearly half of Oregon’s physicians are 50+ years, ave age 49
– Average age of nurses in Oregon is 49 years
– 22% of physicians will retire within 5 years
• Shifting lifestyle expectations of new physician
• Capped residency training opportunities
Source: Oregon Office of Health Policy and Research, 2006, AAMC, OBME
Hospital care in rural Oregon
Of 35 rural hospitals in Oregon
• 25 are Critical Access Hospitals (25 or fewer beds)
• 6 have discontinued obstetrical services
– Cottage Grove, Reedsport, Bandon, Dallas,
Heppner, Prineville
Medical schools in Oregon
• National: call for 15-30% increase in positions
• OHSU:
– 120 per class, no room for expansion on Marquam Hill Campus, plans
for expansion to OSU/U of O failed to gain funding
• AT Still (Osteopathic) Oregon track:
– beginning 2008, 10 students per year (year 2-4)
• College of Osteopathic Medicine of the Pacific of Western
University, Northwest track (COMP-NW):
– Samaritan Health System, Lebanon,
– starting 2011 with 50-75 students,
– ultimate enrollment ~100/year
Growing our own or importing?
Medical school
• 70% of active Oregon MD licensed physicians
graduated from a US medical school other
than OHSU
• 16% from OHSU
• 8% International Medical Graduates (IMGs)
• 6% Osteopathic schools
OHSU students statewide
•
•
•
•
•
Medical
Dental
Physician Assistant
Nursing
Pharmacy *
OHSU medical students and residents
• Rural and Community
Health Clerkship- 20 years
• Oregon Rural Scholars
program- started 2009
• OHSU graduates now
practicing all over the state,
teaching our students,
caring for patients
Oregon Rural Scholars 2009
Growing our own or importing?
Residency training
• 68% of active Oregon licensed physicians
received residency training outside Oregon
• 25% received residency training in Oregon
• 18% received residency training at OHSU
• 7% received training in Oregon, but not at
OHSU (majority Providence and Legacy)
• More than 50% of residents remain in Oregon
for practice
Residency training (Graduate Medical Education)
GME
• Subject to “caps” on federal assistance with
resident training since BBA of 1997.
• Caps based on existing levels of resident
positions. No federal assistance on positions
above the cap.
• New programs have 3 years to establish their
cap.
• New programs in Oregon at Samaritan Health
Systems, DO only.
Graduate Medical Education (residency)
• Oregon Family Medicine: 3 residencies, 27 slots
– OHSU: 12 slots/yr
– Providence Milwaukie: 7 slots/yr
– Cascades East( Klamath Falls): 8 slots/yr
• Comparison: WWAMI
– Washington: 10 residencies, 80 slots
(plus 2 Military FM residencies, ~20 additional)
–
–
–
–
Wyoming: 2 residencies, 14 slots
Alaska: 1 residency, 12 slots
Montana: 1 residency, 6 slots
Idaho: 2 residencies, 18 slots
Our best and brightest: OHSU class of 2009
Dr. Ashlee Weimar, Spokane,
WA
• OHSU US News rankings
(2010)
– 4th in Rural Medicine
– 2nd in Family Medicine
– 3rd in Primary Care
Dr. Jill RasmussenCampbell, Anchorage
AK
• More than 50% into
primary care (IM, FM, Peds)
Dr. Trisha Adams,
Grand Junction, CO
Build on Oregon’s GME success:
• OHSU Family Medicine ranks in top 5
nationally
• Cascades East:
– Top 15 programs in rural output
– 85% of graduates practice in towns with
population 25,000 or fewer
• Providence Milwaukie: care to urban
underserved populations
GME expansion
• Support development of a consortium for new
graduate medical education programs,
especially in primary care, and in non-Portland
settings
• Bridge funds for GME startups (3 years for
federal funds to flow)
Role of primary care
Does primary care make a difference?
• Vogel and Ackerman 1998
– Socioeconomic factors are best predictor
– Availability of primary care is of lesser but significant importance,
more important for younger than older populations
– Specialist physician supply did not correlate to health outcomes
• Starfield, Shi and Macinko 2005
– Primary care associated with
• Health benefits
• Decreased systems costs
• Decreased health disparities
– International systems based on primary care had better health with
lower cost (industrialized, middle income and developing countries)
When does primary care work?
• First contact access and use of primary care
facilities and practitioners
• Person-focused care (not disease focused)
• Comprehensiveness of primary care services
• Coordination of care outside of primary care
Pipeline/growing our own
Making Progress: Rural Dental rotations
 2007
 10 Students ----5 locations
 2008
 25 Students----10 locations
 4 students are now practicing in the communities where
they did their rotations.
 2009
 40 Students----13 locations
 Over 200 patient visits in August and September
Creating A New Nursing Education System:
Oregon Consortium of Nursing Education (OCNE)
• Multiple campuses
• Distance learning
• Community Colleges,
Colleges and
Universities statewide
• Internationally
recognized model
The pipeline we want
The pipeline we’ve got:
Hopefully, not this one:
The health career pipeline
• Production of health care workers is a
community investment.
• It’s a long pipeline. Post HS education:
–
–
–
–
–
RN 2-4 years
Dentist 4 years
PA 2 years
NP 4-6 years
MD 7-12+ years
Rebuilding the healthcare workforce pipeline
• K-12
– Giving rural and disadvantaged kids a level
academic playing field
– Maintaining interest in math and science though
middle school and high scool
– Giving teachers the tools they need to help kids
succeed
• Community college, College, professions
training
– Mentoring and support
Changes in provider demographics and
expectations
• Fewer rural kids being admitted
– Less well prepared in HS for college (4 day week in
most rural schools)
– Less exposure to health careers/mentors
– Sticker shock:OHSU Medical (instate) >$35,000
– Fewer being admitted to med/dental school
(slightly less problem with nursing due to
community college system and OCNE)
– Leads to a smaller pool with rural
expectation/aptitude
Changes in provider demographics and
expectation
• More women in medicine and dentistry
• Generational expectations of both women
and men
– More time for family/travel/other interests
– Reduced work hours
– Curtailed after hours care (“on-call”)
Changes in provider demographics and
expectation
• Expect to be connected (EMR, telemed, CME)
• Expect community amenities
– Schools/ educational opportunities
– Fitness
– Social outlets
• 2 career couples
• Willing to trade (some) salary for lifestyle
• Scope of practice issues (+/- for rural)
US Data
GAO, 2001
( source HRSA, BHPr)
• ~60,000 MD active, “non metro” (8.7% of
physicians serving 19% of population)
• Non-metro 122 docs/100k population
• Metro 267/100k
• At least 6000 needed “right now” (2001)
• Adjusted salaries may be higher in rural
• 50% rural “starters” stay 15 or more years
Economics
Rural economics 101
• Health care IS economic
development in rural
areas, consistently in
top 3 employers
• Farming, ranching and
extractive industries are
vulnerable in rural areas
• Rural economies are
fragile, margins are slim
Physicians and economics
• “Physicians occupy an unusual spot in the social
structure of rural communities. From an economic
standpoint, they are successful entrepreneurs, wellpaid business people similar to bankers and lawyers.
On the other hand, they are also social servants like
policemen or teachers, just as essential to the welfare
and functioning of the community but paid for through
a fee-for-service mechanism outside of local
community control. This anomalous status requires
some fairly innovative interpersonal and structural
relationships to strike a workable balance.”
– Rosenblatt and Moscovice, 1982
Oregon Healthcare Workforce Institute:
IMPLAN data (preliminary): Coos, Curry, Douglas
Physicians contributed 6-11% of jobs (18-21
direct jobs/physician, 22-27 total)
Total economic output per physician: $2.08$2.46 million (Multnomah ~$1 million)
Estimated Tax contribution related to
physicians: 80-100K per physician
Full report available at OHWI website: www.oregonhwi.org
So what do we need ?
• Improve K-12 math, science, health careers
programs
• College scholarships, mentoring, programs
• Control of tuition at all levels
• Health training scholarships and loan
forgiveness
• Increase enrollment of rural and underrepresented minorities in health professions
training
• Expand residency training, in non-Portland
based sites
• DATA
• Support for practicing physicians
OHSU medical students and residents
• Rural and Community
Health Clerkship- 20 years
• Oregon Rural Scholars
program- started 2009
• OHSU graduates now
practicing all over the state,
teaching our students,
caring for patients
Oregon Rural Scholars 2009
Loan repayment/loan forgiveness
– National Health Service Corp
• $25K for 2 years, renewable at $30K/yr
• Limited sites (by score), extensive application process
– State loan repayment (Office of Rural Health)
• Defunded in 2009 session
• Was $400K/biennium total (unchanged since 1988)
• Small federal program (match from specific hospitals, no state
match made available)
– Private/local funds
• Flexible
• Recruitment incentive
Support for practicing physicians,
especially in rural areas
•
•
•
•
•
Preventing burnout
Ensuring 24/7 coverage
Quality assurance/practice improvement
Teaching
Continuing education
OHSU rural locum tenens program:
• Locum Tenens
– n., pl., locum te·nen·tes
(tə-nĕn'tēz).
A person, especially a
physician or cleric, who
substitutes temporarily
for another.
– Currently serving 6 sites
(more on the wait list)
– 10 faculty and residents
– More than 120 days of
service
– More than 3000 patient
visits
– Startup funding from
AHEC, OHSU, NWHF,
OCF
Rural Community assessment and technical support:
Office of Rural Health
• Rural communities poorly prepared to
compete effectively in a competitive market
• Need to assess and understand their stengths
and weaknesses for recruiting
• Need to engage existing providers for
retention
• Need to be able to address the entire pipeline
• Need to be able to quickly mobilize
OHSU: helping rural communities help themselves
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•
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Recruitment of health professionals
Health professional retention activities
K-12 math/science enrichment
Health occupations training/activities
College scholarships
Health professions student training/GME
Community health literacy/health promotion
projects
OHSU: preparing the healthcare
providers of tomorrow today
•Care for an aging and
increasingly diverse
population
•Adapt to new models of
care
•Interdisciplinary
•Electronic health
records
•Telemedicine
•Simulation technology