How insurance companies pay providers, how universities work with hospitals, how accrediting bodies set requirements, and how students pay for medical school are all factors in workforce challenges that are especially severe in rural areas.
By Courtney Sherwood
From family physicians to occupational therapists, Oregon faces a shortage of healthcare professionals – and getting the right people trained and deployed to the communities that need them most will require fresh thinking and new approaches from universities, hospital systems, insurance companies and lawmakers, among others, experts in the state’s health workforce concluded Thursday morning at a discussion hosted by Oregon Health Forum.
Moderator Robert Duehmig, deputy director of the Oregon Office of Rural Health at OHSU, moderated a panel comprised of:
- Ann Barr-Gillespie, vice provost and executive dean at Pacific University for the College of Health Professions.
- Jana Bitton, executive director of the Oregon Center for Nursing.
- Dr. George Mejicano, senior associate dean for education at OHSU.
- Dr. Lesley Ogden, CEO of Samaritan North Lincoln Hospital
- Dr. Elizabeth Steiner Hayward, a state senator who practices at OHSU.
As the panelists drew on their own expertise to dig into Oregon’s healthcare workforce challenges, the complexity of the issue became clear.
“It’s becoming increasingly difficult to find placements for the students in our programs,” Pacific University’s Barr-Gillespie said.
For non-physician healthcare providers, such as occupational therapists, “We basically have a volunteer system, where practicing licensed providers take students into the clinic,” she said. In an era of tight financial margins, it’s hard to persuade these providers to take students on – and that creates a bottleneck when it comes to training.
Bitton at the Oregon Center for Nursing noted that, on paper, the state appears to have enough nurses – but it’s more complicated than that. Nearly half of all nurses in the state are over age 55, with mass retirements likely in the near future.
And a forecast by the Health Resources and Services Administration that Oregon will have a surplus of nurses fails to take the state’s geography into account, Bitton said. “It doesn’t really matter if you have a surplus of nurses if they are unevenly distributed,” she said. And in rural and remote areas of the state, it’s hard to recruit enough nurses to meet demand.
“It’s a distribution issue, not just a numbers issue,” OHSU’s Mejicano concurred. “But if you have low numbers, you can’t distribute them. It’s not an or, it’s an and program. The other piece that needs to be spoken out loud is the issue of specialization and discipline. Do we have the appropriate mix.”
Accreditation requirements, insurance and Medicaid reimbursement rates and other factors push many recent med school graduates to pursue specialties other than family or internal medicine, resulting in a shortage of generalists, he said.
Bitton also noted that pay is a challenge. A practicing physician can expect a 40 percent paycut to become a professor at OHSU. The difference is even more extreme at community colleges.
“Some community colleges have to limit enrollment because they cannot get enough faculty for their nursing schools,” Bitton said.
It’s also a challenge to get freshly minted physicians to stay in Oregon – and especially, to practice in rural areas, Mejicano said. OHSU has found that graduates who do complete their residencies in the state are far more likely to stay here, and has developed a number of partnerships to create more residency opportunities.
Ogden of Samaritan North Lincoln Hospital said it’s a challenge to recruit professionals to her rural health system.
“Patients in rural areas are poorer, they’re sicker and they are older. That combination makes it very, very challenging for anyone who is delivering care – even more so, when you take our rural communities and have to attract folks who may not be attracted to the rural lifestyle,” Ogden said.
“You are young, you’re single, who in the heck are you going to date in a town of 8,000 or 10,000? Maybe you are one of the few who are already married. What in the heck is your spouse going to do in a smaller community?” Ogden said she has actively begged local employers to “make jobs happen” for spouses of workers she is trying to recruit.
And matching the pay that health providers can earn in urban areas is an added challenge.
Samaritan has adopted a number of efforts to try to boost recruitment and retention: partnerships with Oregon Coast Community College to train healthcare students there; recruitment of physicians from outside the U.S.; education programs for CNAs that are located in Samaritan’s facilities, to boost the amount of local training available; signing bonuses for nurses; and new residency slots in Corvallis.
The growing cost of healthcare training makes money ever more critical to these discussions. When Ogden graduated from medical school, she had $150,000 in debt. Now, debt of $400,000, $500,000 or more is not uncommon for freshly minted doctors. That limits the types of jobs they can afford to take, she said.
Senator Steiner Hayward acknowledged the complexity of the problem – and pointed to one legislative move that she hopes will help address workforce challenges.
House Bill 3261 reauthorized workforce incentive programs, and started a new program that will offer grants to help the state identify and address workforce needs for all manner of healthcare workers.
“Physicians, nurses, social workers,” Steiner Hayward said. “You name it – all the things all of my colleagues have talked about – it will help with startup funds.”
Payment reform will also be necessary to boosting the workforce, she said. Reimbursements for patient visits, rather than results, incentivizes the wrong behavior and makes it harder, financially, for practices to justify bringing on students or residents.
Regulatory reform is also key, she said. State licensing requirements for nurses can be arcane and require unnecessary hurdles for nurses who have long had licenses in other states. More medical school graduates want to go into family care residencies in Oregon than are available – and it will take changes to how those slots are allocated to address the shortfall. And regulations that require more advanced training than is necessary to do a job well can keep qualified practitioners away.
Steiner Hayward also noted that one key component of boosting the state’s healthcare workforce is often not a part of the conversation: the insurance industry.
“We have to have these conversations with people who actually pay for healthcare. Right now, that’s our insurance companies,” she said.
“If you don’t get all the key stakeholders around the table at once, you are never going to solve the problem,” Steiner Hayward said.
“How do we get all the different kinds of regulators — state, federal, accrediting bodies – and all the different educators together, and the policy people, and the Oregon workforce committee. What is the outcome we desire, what do we need to do to get there, and what do we need to do to change in order toget to that outcome?”
“We have to figure out where all the parts of the chain are to change this dynamic, to change this paradigm, and figure out ways to get these people in the same room.”