erally Qualified Health Centers to host. But also, for an institution to offer a residency, it must meet certain requirements: The facility has to perform a certain number of surgeries, births and so on. “Our rural sites don’t necessarily offer the volume that’s necessary,” says Robert Deuhmig, the director of the Oregon Office of Rural Health at OHSU. There used to be only five institutions in the state with primary care residencies—and now there are nine, says Betsy Boyd-Flynn, executive director at the Oregon Academy of Family Physicians (OAFP). At least two of those are in rural areas: Madras and Roseburg. Some of these are collaborations. For example, the site in Madras is a collaboration between OHSU and St. Charles Health System to offer three residency slots per year at St. Charles Madras, a critical access hospital. Residents here also do clinical experiences at a community health center that serves the Warm Springs Indian Reservation. Aviva Health partnered with Mercy Medical Center to develop the Roseburg Family Medicine Residency. Both of these residencies are partially supported by a Healthy Oregon Workforce Training Opportunity grant. HOWTO grants also support a residency in Newport and one in Cascade Locks, at Grain Integrative Health. Finally, insurance companies’ reimbursement rates for PCP visits and the preventive measures that PCPs take — including administering vaccines, ordering blood tests, talking about smoking cessation, etc.—are exceedingly low. And to make matters worse, they are less for those in a private family practice than for those who work for a big company like Cigna, Legacy or Providence, according to people I interviewed who have worked for family practices. PCPs who work for larger health care companies sometimes receive as much as double the reimbursement rates versus a physician who works at a private family practice, due to the negotiating power of a larger health care organization. “Primary care payment has not kept up with payments for procedures and some specialty care,” say Wiser at OHSU. “Most primary care doctors are employed by health care systems, and they invest in lines that pay the bills better. We are a fee-for-service model. We don’t make money to prevent things.” Yet, ironically, primary care is the only part of our health care system that has been proven to save money overall—and improve health, notes Boyd-Flynn. The doctor shortage in rural parts of the state is compounded by the fact that many of these regions lack affordable — or any — housing. Duehmig lives in Astoria and sees that problem close up. “It’s not as easy as being able to supply a house or buy a house, or even give a down payment for a house for somebody to move out, because there’s just limited supply in a lot of our areas. The reality is it’s more than just our doctors, nurse practitioners and physician assistants. Every level of health care worker at a hospital or clinic is struggling for decent housing in a lot of communities.” In its 2025 Health Care Workforce Needs Assessment, the Oregon Health Authority has suggested that increasing compensation for benefits like housing and child care could attract doctors to rural areas—but that only works if there’s housing to rent or buy and child care centers to subsidize. Lack of child care providers is a big problem in rural areas. Clatsop County, for example, is a child care desert. “So to say, ‘I’m going to provide you child care as a provider in the hospital’ is very complicated, because there is no child care in a lot of these communities—for anyone,” says Duehmig. The Cure: Good Policy and Practical Incentives If you look closely at the OHA map, there’s one exception to the rural primary care doctor shortage: Wallowa County. This sprawling county in Eastern Oregon shows a rate of 34.6 PCPs per 10,000 patients. (The Betsy Boyd-Flynn, executive director at the Oregon Academy of Family Physicians, in her office in Northeast Portland, standing by her appointment calendar. JASON E. KAPLAN 24
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