OHSU

July 2013 Newsletter

Newsletter-Banner

Registration Opening Soon

30th Annual Rural Health Conference
Health. It’s More Than Health Care!
October 23-25, 2013
DoubleTree by Hilton-Lloyd Center, Portland, OR

Watch for the registration notice coming soon. Oregon is once again leading the nation in reforming our health care system. This conference will help you understand what the health disparities are in your community at a time when we are implementing CCOs, facing workforce shortages and required to meeting health care outcomes and complete needs assessments.

This conference is for rural providers, administrators, staff and community member that want to better understand how to meet today’s health care challenges.

Capitol Wrap-up

The Oregon legislature ended its 2013 session, formally known as Sine Die, on Monday, July 8, 2013. The legislature took up several issues important to rural health care:

The Rural Practitioner Tax Credit offers a $5000 tax credit for rural providers that practice in a qualifying rural area. The tax credit was set to sunset on December 31, 2013. The legislature extended the sunset and modified various provisions.

Beginning January 1, 2014, qualified providers must remain willing to serve people with Medicare and Medicaid coverage in at least the same proportion to the individual’s total number of patients as those patients represent within the county in which they practice, not to exceed 20% Medicare or 15% Medicaid. Additionally, providers must work a minimum of 20 hours per week in a qualifying area, averaged over a month, in order to qualify for the credit. Legislators also agreed to make eligible all licensed practitioners on the medical staff of Bay Area Hospital in Coos Bay. Bay Area Hospital was designated a rural referral center prior to 1989 so MDs, DOs, and DPMs on the active staff as well as CRNAs employed by or contracted with the facility did not previously qualify.

The Rural Practitioner Tax Credit was originally set to sunset on December 31, 2013. The legislature extended the sunset by two years rather than the typical six-year period. The Oregon Office of Rural Health and the Oregon Rural Health Association have agreed to work with the legislature to review the various rural recruitment and retention incentive programs and report back to the 2014 Legislative Assembly.

The Rural EMT Tax Credit was also scheduled to sunset on December 31, 2013. The program sunset was extended six years and no other changes were made. The $250/year tax credit remains for qualifying rural, volunteer EMS providers.

Both the EMT and Practitioner tax credits were included in HB 3367.

The Oregon Primary Care Loan Forgiveness was funded for $1 million for the next biennium, allowing the Oregon Office of Rural Health to increase the number of loans it offers to students. The program forgives one year of loans made through this program for each year of clinical service in an approved rural Oregon practice site. Participants must be enrolled in a qualifying training program designed to prepare graduates for rural practice. Currently, there are three qualified programs in Oregon; OHSU School of Medicine’s Rural Scholars, OHSU School of Nursing’s Nurse Practitioner rural training track and Pacific University’s Physician Assistant rural training track. Additional rural practitioner training programs are expected to be approved in the future.

The Oregon Primary Care Provider Loan Repayment Program was created in SB 440. The program is a result of negotiation between Oregon and the Center for Medicaid/Medicare Services as part of Oregon’s Medicaid transformation process. With the expansion of Medicaid coverage beginning on January 1, 2014, the demand for additional access will put pressure on already limited provider resources. SB 440 commits $4,000,000 over the next four years to help new providers begin their careers in Oregon. The Oregon Health Authority has published draft rules with a hearing scheduled for August 19th in Salem.

According to the Oregon Healthcare Workforce Institute, there has been a loss of more than 300 primary care providers in Oregon in the last two years. “There are a lot of positive changes happening in health care,” says Scott Ekblad, Director, Oregon Office of Rural Health. “But none of them will succeed if we do not have the providers to offer needed services. We need to make sure we are doing everything we can to attract providers to serve both our urban underserved populations, and our rural communities. Long term investment in the Loan Forgiveness Program, as well as the more immediate short term investment of loan repayment, are critical to meet the growing need for access to health care services.”

While access to health insurance will expand beginning January 1, 2014, it will be important that new enrollees maintain coverage as they transition between CCOs and qualified health plans offered by Cover Oregon. HB 2132, the “Care Continuity Bill”, requires Cover Oregon to develop specific steps to ensure clients are not dropped during these periods.

Community Health Workers are a key component of health care transformation in Oregon. HB 3407 establishes a Traditional Health Workers Commission within the OHA to advise OHA on the adoption of criteria and descriptions for CCOs with respect to certain health workers.

Rural Medical Practitioners Insurance Subsidy Program, which subsidizes the liability insurance for qualified providers, was extended for two more years. No additional changes were made to the program. The legislature continues its attempt to address the issue of liability reform in Oregon. SB 483 creates the Early Discussion and Resolution Task Force, a structured approach to notification, discussion and mediation of serious adverse events.

Administered by the Oregon Patient Safety Commission, the key components of the program are:

  • Notice of event filing process available to both providers and the public;
  • Timely discussion of the event between the provider and the patient;
  • Mediation if the discussion phase does not result in resolution for both parties;

The Governor’s office is currently accepting nominations for Executive Appointments to the Early Discussion and Resolution Task Force.

Cover Oregon—Coming this Fall

Starting October 2013, Oregonians will have a completely new way to access health coverage through an online central marketplace called Cover Oregon. The customers/patients will be able to compare and enroll in health and dental coverage that fits their needs and budget. All plans offered through Cover Oregon will cover essential health benefits including provider visits, hospital stays, maternity care, emergency room care, prescriptions, preventive care, mental health services, dental and vision coverage for kids and more.

Even patients with pre-existing conditions will be able to get coverage and apply for financial assistance to help pay for premiums. For example, financial assistance will be available to individuals earning up to $45,900 a year and a family of four earning up to $94,000 a year.

Cover Oregon will provide clear information on a range of insurance plans so individuals, families and small businesses can make side-by-side comparisons and choose the right plan for them. It will include health coverage from private insurers and public programs like Healthy Kids and Medicaid.

Enrollment begins in October, and coverage begins January 2014. Visit CoverOregon.com to learn more, use the calculator to see if you might qualify for financial help, and sign up for updates. And, if you’d like to get involved with enrollment assistance and outreach in your community, please email .

Additional information on Cover Oregon and how the new health care insurance marketplace will impact rural Oregon will be available during a special session at the Oregon Rural Health Conference.

Oregon Rural Practice-based Research Network’s Research Yields Knowledge of Clinical Best Practices

A Madras case study details one clinic’s process of going pharma-free: “Small steps on the road to practice transformation.”

Established in 2002, OHSU’s Oregon Rural Practice-based Research Network (ORPRN) seeks to improve the health of rural populations in Oregon by conducting and promoting health research in partnership with communities and practitioners.

Recently, one of its studies received some attention related to going pharma-free. The Journal of the American Board of Family Medicine published an article in its May-June 2013 issue discussing clinical research conducted in Madras, Ore., between 2005 and 2006 that ORPRN helped facilitate. The case study, about a practice going pharma-free, earned some publicity, including The Lund Report and the University of Washington School of Medicine.

The article’s lead author is David Evans, M.D., a family physician who practiced at the physician-owned Madras Medical Group (MMG) in central Oregon for 15 years. (Dr. Evans is now an assistant professor of family medicine at the University of Washington School of Medicine.)

Dr. Evans and colleagues in his practice group knew about evidence suggesting that the influence of pharmaceutical representatives and sample inventories of prescription medications produced negative effects on evidence-based care and increased costs.

In response to this evidence, the group initiated a policy to discontinue visits from pharmaceutical representatives and to stop accepting and distributing drug samples. In addition, the clinic removed anything with a drug name or pharmaceutical company logo on it including note pads, educational materials and coffee cups. The practice had to go out and buy new clocks.

In the journal article, Dr. Evans and colleagues concluded that changing practice culture to become a pharma-free clinic is achievable, but that considerable attention needs to be addressed across all levels of the practice – clinicians, staff and patients.

“The culture of doctors seeing drug reps in the office is ingrained in medicine,” said Dr. Evans. “We changed our practice culture with a thoughtful and deliberate process that gathered viewpoints of the whole clinic. Not much is known about this type of change and with ORPRN’s help and support we were able to share our experience.”

ORPRN's Dr. Lyle Fagnan notes that a 2010 study of community-based primary care clinicians who participated in practice-based research network (PBRN) studies reported three needs correlated with clinician motivation:

  • Competence – intellectual stimulation,“the physician as the critical scientist”
  • Autonomy – enjoyment of research without the hassle of academic work-life
  • Relatedness – PBRNs such as ORPRN as the antidote to the intellectual isolation associated with day-to-day primary care practice.

The Madras research also led to a related study headed up by Dan Hartung, PharmD, and colleagues (Haxby and Kramer) at the OSU College of Pharmacy, in collaboration with Dr. Evans, Dr. Fagnan, and Gabriel Andeen, M.D., (then an Oregon Health & Science University medical student).

The study evaluated the effects of the pharma-free implementation on the prescribing patterns of MMG clinicians and found reductions in prescriptions for branded and promoted lipid-lowering and anti-depressant medication. [Hartung DM, Evans D, Haxby DG, Kraemer DF, Andeen G, Fagnan LJ. Effect of Drug Sample Removal on Prescribing in a Family Practice Clinic. Annals of Family Medicine. September/October 2010; 8: 402-409]

Through this research and many other projects, ORPRN has become a resource for disseminating best clinical practices and facilitating practice transformation throughout Oregon. “This is the type of work that demonstrates the value of collaboration between OHSU and community clinics in which the results yield significant benefits for Oregon’s rural practitioners and their patients,” said Dr. Fagnan.

Harvard School of Public Health (HSPH) student Ali Chisti aims to improve health—and health care access—in rural Oregon

Three years ago, Oregon native Ali Chisti, MPH ’13, Carson Scholar, was on course to become a private practice neurosurgeon, studying medicine at Oregon Health and Science University in Portland. During the summers he worked as a caddie at a golf course in Bandon, along Oregon’s rural southern coast, to help pay for school. But in the summer of 2010 he learned about a fellow caddie’s health care troubles. Chisti’s friend had broken his wrist playing basketball. He went to the emergency room at a local hospital. But he didn’t have health insurance—and $12,000 in hospital bills later, he was forced to file for bankruptcy.

It got Chisti thinking long and hard about health care access and inequities—and led him to take a break from medical school to study health policy and management at Harvard School of Public Health (HSPH).

Volunteering at a Rural Clinic

Chisti’s friend could have gone instead to the Bandon area’s safety-net health center—the Waterfall Clinic, which offers reduced rates based on financial need—but the friend didn’t know about it because it had no website and the phone line frequently gave a busy signal. Chisti later learned that the clinic was also critically short on providers and had no system in place for referring uninsured patients to outside doctors or specialists.

Chisti volunteered to help the clinic. “I realized I had the opportunity to impact the lives of my neighbors and friends by helping develop improved health care access and resources in rural Oregon,” he said. For the rest of that summer, Chisti helped the clinic build a website, which he still maintains, and laid the groundwork for a referral network of both physicians and dentists.

He returned to the Bandon area the following summer to work at the Bandon Community Health Center, as part of the Oregon Rural Scholars Program. The program, run by the Area Health Education Center of Southwest Oregon, provides grant support for students pursuing health care careers in rural areas.

Broadening His Scope at HSPH

At HSPH, Chisti has gained valuable skills—both in classes and beyond. He learned how to evaluate a clinic’s finances in an accounting class with Howard Rivenson, senior lecturer on health management. And Chisti plans to use skills gained in a class on qualitative methods in program evaluation, taught by Kate Baicker, professor of health economics in the Department of Health Policy and Management, to evaluate the impact of an anti-smoking/drugs education program for 6th-8th graders he helped develop in Coos County, Oregon in 2011.

Outside of class—prompted by an interest in improving access to cancer care—Chisti did a practicum with a Harvard-affiliated organization called Global Oncology (GO), aimed at improving cancer care and research in resource-limited parts of the world. Chisti helped the group’s website become a platform where volunteers can manage and collaborate on cancer projects. He worked with a Harvard Medical School student to organize a March 28, 2013 talk about cancer care in southern Africa. And at a recent MIT “hackathon” focused on international development—a 28-hour, round-the-clock event that teamed Boston-area programmers with nongovernmental organizations looking to solve particular problems—Chisti helped with GO’s effort to create a crowdsourced interactive map of cancer care outreach around the world. His team won an innovation award from athenahealth, a Watertown-based health services company that cosponsored the hackathon. Now the GO team is developing the platform as a resource to align the global cancer efforts of federal government agencies, university medical centers, and community-based organizations or NGOs. Chisti hopes to use similar mapping software back in Oregon to document public health efforts throughout the state.

Chisti is now considering specializing in oncology when he returns to his final year of medical school in the fall. He hopes to one day join the faculty at Oregon Health and Science University and become a physician leader in public health.

For the near future, though, he’ll pursue an internal medicine residency once he receives his medical degree. “That way,” he said, “I will be able to see patients from the moment they enter the health care system and guide them through to get the care they need.”

– Karen Feldscher

Home Health Group Honors John Day Doctor

One of Grant County’s own medical professionals, Dr. Andrew Janssen, has been named 2013 Home Care Physician of the Year by the Oregon Association for Home Care.

Dr. Janssen was unable to attend the April 19 awards ceremony at the Oregon Association for Home Care’s annual conference at the Eagle Crest Resort in Redmond, but Sylvia Dowdy, BMH Home Health/Hospice director accepted the award on his behalf, and presented it to him later at the clinic.

Janssen is part of a team of physicians – including his wife, Dr. Andrea Janssen – at Blue Mountain Hospital’s Strawberry Wilderness Community Clinic in John Day.

Dowdy listed some of the many people in the community whom Dr. Janssen serves outside the clinic: nursing home patients, jail inmates, and home health and hospice patients in their homes. She said he is a big advocate for home health and hospice, and also hosts residents and students from OHSU, with a patient and willing teaching style.

“He does so much for our small community, and our health care couldn’t be half as good without him. He is so deserving,” Dowdy said.

Janssen and his wife live in John Day with their three children: Isaac, Titaya and Zerihun.

~Blue Mountain Eagle

Morrow County Health District Appoints New CEO

Dan Grigg has been named the CEO of Morrow County Health District. He replaces Michael Blauer who became CEO of Providence Seaside. Dan grew up in Idaho, Oregon and Wyoming and his experience includes 8 years with Salem Health in Salem, OR, with six of those years leading the quality and patient safety programs. “This is my first position in rural healthcare and I am thrilled to have the opportunity to be involved in the community and lead the Morrow County Health District,” Griggs said of his appointment.

The Morrow County Health District was established in 1994 by the county's voters to ensure continued support of medical services in the area. The health district is comprised of a hospital and medical clinic in Heppner, a medical clinic in Irrigon, and home health, hospice and emergency medical services throughout the county.

Funding Opportunities

The Rural Assistance Center website offers summaries of federal, state and foundation funding opportunities. Each funding summary includes information on the program's sponsoring organization, purpose, eligibility, amount of funding, deadline, application procedures, contact for more assistance, and a link to the program website.