Loan Repayment Program Benefits Urban Areas More than Rural

Because the program re-established in 2013 is so focused on serving the Medicaid program, new providers in urban areas that have clinics focused heavily on the Oregon Health Plan are much more likely to receive help than new rural providers. Less than one-third of the recipients are practicing in the state’s hinterlands.

A loan repayment program that was created as part of the federal Medicaid waiver setting up the coordinated care organizations has benefited urban Oregon much more than the rural parts of the state.

In 2013, Senate Bill 440 raised $3.6 million for the Medicaid Primary Loan Repayment Program aimed at eliminating provider shortages, geared specifically toward primary care providers who take care of people in the Oregon Health Plan. About $3 million of that pot has been allocated and helped pay the loans of 33 new providers across Oregon.

But an analysis of those awards shows that only 10 loan repayments benefitted truly rural Oregon communities, while six went to providers working in exurban communities like Canby, McMinnville and Newberg.

Seventeen of the providers are practicing in the state’s urban centers in Eugene, Salem and the Portland metro area.

“The Medicaid Primary Care Loan Repayment Program really came out of Oregon’s healthcare transformation,” explained Bob Duehmig, the spokesman for the Office of Rural Health, which administers the program despite its more urban focus. “We needed to attract providers to meet the needs of this group. It’s focused on the Medicaid population, not really urban underserved areas or the rural provider shortage.”

To help augment the number of providers willing to serve the CCOs, the loan repayment program was designed with that purpose in mind -- the state’s Medicaid population. The loan repayments are for three years and require a provider to see at least 15 percent Medicaid patients. Hilary Henderson who works at the rural health office told The Lund Report that those providers who received help actually had at least 30 percent.

The Oregon Medicaid Primary Care Loan Repayment Program was billed in part as resurrecting an old program designed to help rural Oregon. Started in 1993, the rural loan repayment program helped about 80 medical professionals, half of whom still practice in rural Oregon, before it was defunded in 2009 in the midst of the recent economic collapse.

The dispensing of the loan repayments for the restructured program highlights the differing access issues that exist within Oregon. In rural parts of the state, people of all stripes have trouble seeing the providers they need, regardless of their insurance. But in urban areas, or in the migrant labor communities of Yamhill and Washington counties, access is limited because high concentrations of patients on Medicaid have created a parallel health network of clinics focused solely on Oregon Health Plan members, whose insurance traditionally pays providers less.

An Advantage Dental clinic in Eugene was one of the top qualifiers for the program to help provide a new dentist since 93 percent of its patients are on the Oregon Health Plan. Seventy-eight percent of the patients at the Virginia Garcia Memorial Health Center are on Medicaid, putting the clinic high on the list. The clinic serves migrant communities on the outskirts of the Portland metro area, and two dentists and two physicians who work for the clinic received loan help.

The program is open not just to physicians but a menu of healthcare professions, including dentists, psychologists, social workers, nurse practitioners, and expanded practice dental hygienists. Not all doctors qualify -- a common theme of primary care runs through the eligible positions, although general internal medicine, psychiatry and a handful of other specialities qualify.

Henderson said the program handed out loan repayment packages to nine physicians, 11 nurse practitioners, two physician assistants, nine dentists and one psychiatrist and one advanced-practice dental hygienist.

By giving more awards to nurse practitioners than physicians, the program boosted the overall number of recipients since nurse practitioners pay far less for their educational training.

House Bill 2048, put forward by former Pendleton Rep. Bob Jenson for consideration by the House Health Committee, would expand the list of eligible professions to include occupational therapists. Jenson asked for the legislation on his way out of office as a last request for a constituent, Lorena Hawkins, an aspiring occupational therapist in Wallowa. That county has been decertified to provide hospice to Medicare patients because it doesn’t have an occupational therapist in the community, according to Hawkins.

Lawmakers were generally supportive of HB 2048, but Rep. Knute Buehler, R-Bend, pointed out that the program does not include physical therapists, either, who also might want a cut of the pie.

Rural counties are less likely to have clinics that serve a majority of Medicaid patients, but they remain good candidates because of their high number of low-income people. A new physician in Enterprise, in far northeast Oregon, was able to receive help for her loans primarily because 32 percent of Wallowa County residents are on the Oregon Health Plan, compared to about 25 percent on average.

Duehmig said another program with a very similar name was geared exclusively toward the rural provider shortage -- the Primary Care Loan Forgiveness Program.

That program has spent about $1 million giving scholarships to medical students, nursing students and physician assistant students. After they graduate, they must practice in a rural area for the same number of years they received a scholarship.

The loan forgiveness program is open to students in the rural track at the Oregon Health & Science University’s medical school and nursing school, Pacific University’s physician assistant program in Forest Grove and a rural-focused program at the College of Osteopathic Medicine of the Pacific Northwest in Lebanon.

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