Approximately 250 doctors, nurses, and physician assistants at all eight Legacy Health hospitals across Oregon and Washington filed union authorization cards with the National Labor Relations Board last week, per a press release from the Oregon Nurses Association.

“Legacy Health has received a petition for representation from the Pacific Northwest Hospital Medicine Association on behalf of hospital-based providers,” said a statement from Legacy issued Monday morning. “We respect our providers’ rights to determine union representation through processes overseen by the National Labor Relations Board.”

Eduardo Serpa tells Oregon Business that when he began working as an internal medicine doctor at Legacy Salmon Creek Medical Center four years ago, Legacy administrators were better about listening to workers’ concerns.

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Now that’s changed, says Serpa, who spoke with OB in his capacity as a member of the PNHMA, which already represents hospitalists in Sacred Heart Medical Center in Springfield and which is serviced by the Oregon Nurses Association.

“There has always been great collaboration historically, between the providers and the administrators [at Legacy], and I always felt like our voice was heard. Over the last few years, though, we’ve seen more unilateral decision-making out of the administration and changes to how we deliver care,” Serpa says. “One of the biggest concerns as health care providers, when we work these seven-day stretches, is keeping away burnout. I think the pandemic really showed us that the priorities we had of putting patients first, the hospital second, and ourselves third, is just not a sustainable practice.”

The news comes on the heels of a merger announcement between Legacy and Oregon Health and Science University, which was a point of contention during the negotiations with the Oregon Nurses Association. ONA members voted to authorize a strike against the healthcare system before reaching a tentative agreement last week.

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Serpa says the news that Legacy, which posted $172 million in losses in its 2023 fiscal year,  was being purchased wasn’t a surprise to him or many of the people he works with, but that maintaining bargaining power is increasingly important to providers moving forward. 

“Any change that might be perceived from being acquired by OHSU, we want to be a considerable part of that discussion and really pursue that equity through deliberation as a union,” Serpa says.

The health care providers will meet in the coming weeks to confirm details and schedule an election date. If approved, they will join nearly 700 Legacy nurses and mental and behavioral health professionals represented by the ONA, which has more than 16,000 members across the state.

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Kevin Mealy, communications manager for ONA, says that the NLRB has been approving unions more quickly in recent years, and says the organization could return the decision in a matter of weeks.

The filing follows a flurry of union activity across the state, notably in the health care sector  – including strikes at Providence Health Systems in Portland and Seaside this summer and a strike authorization vote at Oregon Health and Science University in September. In July, 57 employees at Legacy’s Unity Center for Behavioral Health in Portland filed for union recognition with the National Labor Relations Board, voicing concerns about staffing and safety.

Last year 15 health care providers — including doctors and nurse practitioners — at four Eugene-area clinics announced plans to file for union recognition in partnership with the PNHMA. It’s unclear how many Oregon doctors belong to a union, but PNHMA says it has 200,000 members nationwide, and ONA says U.S. physicians are increasingly drawn to unions as “health care systems have become larger and more corporate.”

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Mealy says the growth in union activity among Oregon health care workers is part of a larger movement of organizing around the country. He says President Biden’s visit to Michigan to stand with workers striking against the big three automakers last week was a sign of increasing momentum for the labor movement, and that Oregon workers are setting an example for the rest of country.

“I do think this is a historic moment. ‘Historic’ is an often overuse term, especially these days, but seeing elected officials stand together with active unions is a crystallizing moment in this growth of union activity that we’ve seen over the past few years, and certainly healthcare workers are leading the way in Oregon and across the country,” Mealy says. “We’ve seen renewed healthcare organizing and different types of professions that haven’t traditionally been union-profession positions. And it goes the other direction, too. We’re seeing Starbucks workers organize. I think there’s a new wave of unionism coming because people see a union as a way they can have a voice at work, and make work better for them, and for the people they serve.”

Erica Swartz wasn’t surprised by the wide margins of this week’s strike authorization vote against Oregon Health and Sciences University.

What was surprising, according to Swartz and to leadership in the Oregon Nurses Association, was what preceded it: OHSU’s August announcement that it intends to merge with Legacy Health Systems.

Swartz, who works in the pediatric oncology department at OHSU and as co-chair of the hospital’s staffing committee, says the merger announcement — exactly one week after nurses declared an impasse in their ongoing contract negotiations with OHSU — took nurses by surprise and has created uncertainty and mistrust between nurses and management. When the merger was announced, OHSU nurses and management had been engaged in bargaining since December of 2022 over safe staffing levels, compensation and other issues.

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Nearly 3,000 nurses at OHSU voted to authorize a strike against the health care provider Monday: 95% of those who participated in the vote favor a strike, and 96% of union nurses at the hospital voted.

ONA spokesperson Kevin Mealy told Oregon Business that in April, the ONA bargaining team asked OHSU’s chief financial officer if the hospital aware of any major acquisitions on the horizon, and that nurses were told no.

“[That] was in April and in August, they announced this merger with Legacy so obviously that was already in the making. I think the other piece behind that is there’s a little issue of trust, in this particular discussion, but also more broadly,” Mealy says. “If you weren’t as open about that merger at that point, then we definitely want a backstop or something written in the contract that we will have a role, and not just the CFO or someone else from the executive suite saying ‘Yeah, you’ll have a say; we’re very interested in your input.’”

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Sara Hottman, associate director of media relations at OHSU, told Oregon Business over email that OHSU notified members of the merger once the letter of intent was finalized in August. Now OHSU and Legacy Health are in the due diligence phase of the nonbinding letter of intent, and she says they expect to have a definitive agreement by December of this year. Hottman provided an FAQ about the merger, but did not directly address Mealy’s claim about the CFO’s April comments.

Swartz says she has questions about how her future at the company will look under the combined health care system which OHSU has not yet answered, and could impact the delivery of care to patients.

“So far, OHSU has provided no information to us about how our work environments may change,” Swartz says. “At the bargaining table we have been asking for a memorandum of understanding, which is management agreeing with us that if and when the merger happens, they will return to bargaining and work it out with us if our working conditions were to change. They have not been willing to do so, and have expressed sentiment that it is their administrative right to do as they see fit.”

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Mealy says that while the ONA is still “cautiously optimistic” about the merger but that in general, health care mega-mergers lead to fewer services and higher costs for patients. According to a 2023 literature review by the health care research nonprofit KFF (formerly known as the Kaiser Family Foundation), a growing body of evidence shows that consolidation in health care provider markets has led to increases in prices without clear evidence of increases in quality.

The quality of care at hospitals acquired during recent waves of consolidation either got worse or stayed the same, according to a 2020 study led by Harvard Medical School published in 2020 issues of the New England Journal of Medicine.

Mealy says having a front-line voice during the process of merging the two healthcare systems means patients and workers will have an advocate as the healthcare systems go about the restructuring process.

“I think there’s a sense that having a frontline voice during that merger process, looking at the details and how we work through combining two different systems with two different sets of standards and ways of working, is going to be very important to make it successful and  something that’s actually good for patients and nurses, as opposed to what we’ve seen across the board, which is that mergers haven’t delivered what they promised.”

The nurses’ contract expired June 30, and the two sides have now completed the required 30-day cooling off period after the impasse declared in August. The union is required to give OHSU 10 days’ notice before calling a strike.

“I got tired of being poor,” she says with a laugh. 

Though she was highly motivated, Summer’s dream nearly derailed at the last minute. It wasn’t failing grades, illness or outside pressures that put her graduation from Portland Community College’s rigorous two-year nursing program in jeopardy. 

The threat to Summer’s diploma was coming from inside the house. 

In April 2023, shortly before Summer was set to graduate, Lisa Sanchez-Navarro — the director of Portland Community College’s program — resigned her position. That started the clock ticking: Administrators had just 15 days to find a new director and have them approved by the Oregon State Board of Nursing (OSBN) — or shutter the program. 

After a lot of shuffling and searching, and an extra 15-day extension, PCC administrators hired Cynthia Backer as interim program Dean of Nursing. With an approved director in place, Summer and her cohort of new nurses could get their diplomas and start their nursing careers. 

“The Oregon State Board of Nursing works closely with all of the colleges,” says Janeen Hull, PCC’s dean of academic & career pathways for healthcare & emergency professions. “They would never leave students hanging.”

Yet nursing students, nursing educators, hospitals and ultimately everyone seeking health care in Oregon are all in danger of being left hanging. Nurses are in desperately short supply, but fully qualified nurse educators are really hard to find. In fact, though her résumé is long, even Backer does not meet the full qualifications set by OSBN to become a permanent hire. Finding a permanent candidate to meet those full standards will be challenging. 

“The pool of qualified nurses who want to work in education is small,” Hull admits. 

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The nursing shortage, nursing-educator shortage and connection between the two is old news. The American Association of Colleges of Nursing (AACN) has been highlighting the issue for over two decades, according to an article in American Nurse. Written by Susan Bakewell-Sachs, OHSU School of Nursing dean, along with two other contributors, the article calls the problem behind the nurse-faculty shortage a “matter of great and growing concern.”

A sticky web of interconnected issues — burnout, lack of clinical and lab space, uncompetitive pay for nurse educators, and a fair dose of institutional misogyny — drives this crisis. The COVID pandemic accelerated the pace. And while this is a nationwide problem, Oregon has been hit particularly hard. The state produces the third-fewest nursing school graduates per capita as compared to the rest of the country, according to a study by the Oregon Longitudinal Data Collaborative (OLDC). 

Statewide, stakeholders hunt for coordinated solutions, but the prognosis is unknown. The nursing and nursing-educator crisis has festered for a long time. Can this finally be the moment of change? 

It is not that people do not want to become nurses. Just like Summer, plenty of good candidates dream of starting down this path. For this year’s fall class, Portland Community College alone had 400 well-qualified applicants to their program, according to Hull. The program, however, could only accommodate 32 of them — that is, 8% of total applicants. 

Numbers across the state are a little better, but not much. The OLDC study found that 6,800 qualified people applied to programs in 2020, but only 23% were accepted. On the national level, there were 91,038 qualified nursing applications left on the table in 2021. 

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The fact that most registered nursing programs in Oregon have enough qualified applications and regional jobs to double enrollment is heartening, even as the profession evolves into something more complex. The job has certainly changed from when Backer was in school: “We were trained to give back rubs, help people eat and do bed baths,” she says. “People go into nursing for heartfelt reasons, but there has definitely been a change in expectations.” 

Expectations for nurse educators have shifted as well. The job demands they keep up with an ever-expanding body of health care knowledge, even as textbooks lag behind. 

“You can’t just teach to the book,” says Backer. “Teachers need the most current, online resources and access to real world examples.”

They also need to know how to teach. That means successfully communicating information to a diverse set of students with different learning styles. (Nursing students often need a fair bit of hand holding, Summer says. “We were neurotic,” she says, “and in a state of panic all the time!”)

But anxious students and high expectations are just add-ons to the root causes of the nurse/nursing educator shortage. The biggest problems are a lack of clinical space where students practice and a huge disparity in the pay a teacher can make as compared to a nurse working in the field. 

The situation is no better at private colleges and universities. 

“We absolutely do not have enough nurse educators,” Dean Casey Shillam, School of Nursing & Health Innovations, University of Portland, says.

Even if there were an abundance of educators, the lack of clinical space squeezes the nursing pipeline to a drip. These clinical placements are required for all students. To get them, the schools must foster individual relationships with healthcare placement sites. This forces a competition between the programs where the students are the losers. The longitudinal study found that 95 percent of nursing programs had an individual or cohort denied placement from 2016 to 2020. 

Securing clinical space has always been difficult. The pandemic made it worse. “Placements in off-campus professional practice, hospitals, and community-based, long-term care has all diminished because the health systems are not functioning,” says Shillam. “They have no capacity to take students.”

But perhaps the biggest barrier to becoming a nurse educator is money. Low nursing educator pay is the standard across the nation. According to the latest Nurse Salary Research Report issued by Nurse.com, the median salary across advanced practice registered nurse roles is $120,000. By contrast, AACN reported in March 2022 that the average salary for a master’s-prepared professor in schools of nursing is $87,325.

Payment structures widen the disparity. Nurses are paid hourly; nursing educators draw a salary. That means any extra work outside the contract — like prepping courses, attending orientations or reassuring anxious students — is unpaid. 

Oregon has one of the largest pay gaps between nursing faculty and registered nurses, according to the OLDC study. This makes it easier to lure even the most dedicated faculty away. 

“Even if nurses want to get into academic nursing, the health systems are so desperate for clinicians that they are offering nurses their dream jobs, and I’m losing faculty,” laments Dean Shillam. She reports losing four faculty members this year alone to positions that she admits make her a bit envious. “They are landing fully remote telehealth jobs or working just three days a week in patient intake, receiving full benefits, and making one and a half times more.”

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Why is nursing-educator pay so low, particularly when compared with what medical educators — the professionals who teach doctors — make?

Medical education is supplemented by Medicare. Nursing is not, answers Dean Shillam. And why is that? “Because physicians have more influence in Medicare funding decisions and nursing doesn’t have the same level of influence and impact in how nursing education could be equitably funded.” 

So the nursing-education system is built on the underlying expectation of unpaid labor. Shillam is not ready to call this situation straight-up misogyny but will admit that “historically, physicians were predominantly male and have driven these policies, whereas nurses were predominantly and still are majority female.”

Structural inequities aside, Oregon’s nursing schools and legislators are working to find a solution. 

PCC is expanding its programs, adding options like Certified Nursing Assistant and Licensed Practical Nurse to its course list. These easier-to-
obtain certifications make nursing accessible to students who need to start their careers sooner. The move will hopefully ease labor shortages while giving students a stepping stone to the next level. 

PCC is also opening a brand-new, state-of-the-art nursing education simulation lab at its Sylvania campus. This larger space, filled with sophisticated equipment like simulation mannequins, will make room for another cohort of students, bumping up PCC’s class size from 32 to 40. 

Oregon Health & Science University is hard at work implementing its 30-30-30 plan. Funded in March of last year, the $45 million investment aims to increase the number of clinicians graduated by 30% and increase student diversity by 30% by the year 2030. The money includes an extra $20 million per year to expand class sizes and a one-time $25 million to kick-start the OHSU Opportunity Fund. This money will go to tuition assistance, loan repayment and other resources needed to recruit and retain a more diverse class of learners. 

“We have nurses who are interested in advanced degrees and thinking about taking education coursework that would allow them to teach,” says OHSU’s School of Nursing Dean Bakewell-Sachs. “The 30-30-30 plan is seeking to meet workforce needs for nurses and other professions and seeking to establish a long-term solution.” 

The Opportunity Fund, according to Bakewell-Sachs, is about “building the workforce of the future. We want to align workforces to mirror society. If we increase the diversity of our students, we want to have faculty to align with that as well.”

OHSU also established the Oregon Nursing Education Academy to expand the ranks of preceptors and clinical nursing faculty. This program hopes to train a total of 63 faculty and 92 preceptors from Oregon, Idaho, Washington and Alaska by the fall of 2026. The program is designed for nurses who already have a bachelor’s degree or higher in nursing. 

Nurses that graduate with an associate’s degree from community colleges are already pretty well incented to get their bachelor’s degree. “That’s where the upward mobility is,” explains Hull. “Certain hospitals only want to hire nurses with a bachelor’s.” 

Summer, the recent graduate from PCC, is already planning for hers. She’ll start working as a nurse in telemetry while taking OHSU bachelor’s-level classes online. 

The recently passed SB 523 aims to make it easier and less costly for future community college graduates to get their bachelor’s, particularly for students in rural areas. “The bill tries to capture students who wouldn’t continue on or [would] do it through an out-of-state, for-profit option,” explains John Wykoff, deputy director of the Oregon Community College Association. “This cost-effective option should be more attractive to students.” The program could also help keep rural students in rural communities, where the need is greater. 

But the bill does not wow PCC’s Hull. “I haven’t explored what SB 523 would mean for us,” she says. “I can’t even find enough instructors for our associate’s program.” 

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None of these efforts, however, address the pay disparity between educators and practitioners. The OLDC study analysis found that increasing wages by $6,139 for nine-month nursing faculty would incent and entice instructors. The report stresses that schools should collaborate on pay increases statewide to avoid creating competition between programs. 

Where that money would come from presents another issue. Proposed legislative action, HB 3323, would create a stipend for nurse educators. Hull was a bit more excited about this bill. “Washington state already does something like this. It could be a possible solution.” The bill, however, was still in committee when the House adjourned in June.  

Backer at PCC suggests that some face-to-face recruiting with nurses could help sway them over to teaching. “I see nurses at hospitals that are so good with students,” she says. “We should seek these people out and show them why teaching is a worthy career. We need to advertise to them, let them know it can be fun.”

As far as finding more clinical space, Backer suggests looking for new opportunities outside of hospitals. “What about addiction clinics or homeless shelters? They have to be places where the student is getting nursing experience.”

While these are all good steps forward, fixing the nurse/nurse-educator shortage will be an uphill battle. Burnout among current nurses is extremely high. About 100,000 registered nurses left the workforce during the past two years due to stress, burnout and retirements, and another 610,388 reported an intent to leave by 2027, according to a study released by the National Council of State Boards of Nursing and reported by the American Hospital Association. 

Perhaps this is because of a system that needs nurses yet undervalues their contributions. 

“The system values doctors because hospitals can bill for their work,” Summer says. “They see nurses as a money-suck even though we are essential for patient care.”

Still, Summer holds a lot of admiration for the nurses who helped her along the way. She would like to teach eventually, saying it is on her long-term trajectory. But she’s come across so many nurses suffering from compassion fatigue that she wonders. 

“I chose nursing because I can keep learning. There are a lot of fields to go into, and you can’t do bedside forever,” she says. “Teaching would be a great trajectory. They just need to be paid more.”

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The Oregon Health Authority’s is unable to track and monitor Medicaid prescription drugs prices charged by pharmacy benefit managers, third-party intermediaries between insurers, drug manufacturers, pharmacies, and governments, according to a report published Monday by the Oregon Audits Division, a division of the Secretary of State’s office.

The OAD report was unable to estimate exactly how much the state has overpaid PBMs for prescription drugs, but noted national chains, some of which are owned by PBMs or PBM parent companies, were reimbursed twice the amount independent pharmacies were for selected drugs.

“Pharmacy Benefit Managers have proprietary deals with drug manufacturers and we do not know the true net price after rebates and discounts from those manufacturers,” Ian Green, the audit manager who oversaw the report, tells Oregon Business over email.“OHA needs to monitor six PBMs across 16 different CCOs and each CCO has a different deal with those PBMs. Each pharmacy also has a different deal with the CCOs and PBMs and different reimbursement structures. Preferred drug lists for example may change quarterly or monthly for each of the CCOs and there are many other factors that make this regulation and oversight different for OHA.”

The audit division’s 55-page report titled  “Poor Accountability and Transparency Harm Medicaid Patients and Independent Pharmacies” found PBMs are able to conceal pricing through non-disclosure agreements with Coordinated Care Organizations and other entities they interact with up the supply chain.

“The deals PBMs negotiate with insurers, manufacturers, pharmacies, and other entities are often considered trade secret information and do not have to be shared. This opaque system makes it impossible to understand the actual costs of prescription drugs and has garnered attention at multiple levels of government,” the report reads.

While unable to provide exact figures, the report noted that in 2021, about 11.8 million Oregon Medicaid prescriptions were dispensed at pharmacies, and CCOs reported spending $767 million on prescription drug benefits, while Fee-for-service drug expenditures were only $208 million.

The report called Oregon’s Medicaid system the largest and most complex government program in Oregon, The state’s prescription drug process in Medicaid involves multiple entities interacting, including sixteen COOs, six PBMs, hundreds of pharmacies, multiple drug manufacturers, wholesalers, pharmacy administrative organizations, the OHA and the Department of Consumer and Business Services.

Historically, PBMs were created as claims processing administrators to help insurers contain drug spending. Currently, three largest PBMs control 80% of the U.S. prescription market complex web of prescription drug billing and generate $315 billion annually. PBMs can influence which drugs are covered by insurance companies and whether certain prescriptions can only be filled at specialty pharmacies.

PBMs have already faced federal regulations for their ability to control drug prices. In in 2018, the Patient Right to Know Drug Prices Act, S.2554 and the Know the Lowest Price Act, S.2553 banned “gag clause” provisions between PBMs and pharmacies, which prevent pharmacists from telling patients when the cash price of a drug is less than the insurance copay price.

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The report details a number of best practices that other states have implemented and makes recommendations where it believes Oregon should adopt policies to regulate PBMs. One particular model Green says other states have found success was adopting a single PBM for their entire Medicaid program. Another model Green suggested would be a universal a fee-for-service model for all prescription drugs in the state. Other states require PBMs to be a fiduciaries, which means they must act in the best financial interest of the state and Medicaid patients.

He says other states that have adopted these models have reported hundreds of millions of dollars in savings.

“It’s always important we make sure taxpayer funds are being spent as effectively as possible, and Medicaid is a prime example,” said Audits Director Kip Memmott in the press release accompanying the audit. “It’s the largest and most complex government program in Oregon and provides critical health services to more than one million Oregonians. But the lack of transparency in our current system means it’s almost impossible to tell if we’re truly getting the best use of our funds with these PBMs.”

The Oregon Nurses Association says OHSU management should step up its efforts to reach a contract agreement with its 3,000 nurses before merging with Legacy Health.

“It’s important Oregonians to keep in mind that yesterday’s announcement of a $1 billion commitment from Oregon Health and Science University to fund a merger with Legacy Health comes exactly one week after nurses declared an impasse in their ongoing contract negotiations with OHSU,” says a press release issued Thursday, one day after the two hospital systems confirmed plans to merge. “While nurses at OHSU have been at the bargaining table looking for management to step up and do what is right for their nurses and their patients, OHSU’s management have been short-changing the nurses in their contract offers while also pledging more than $1 billion over ten years to an acquisition.”

But the nurses’ union also expressed optimism that the merger, if approved, would improve conditions for staff and patients at its facilities. The organization said it had lost confidence in Legacy Health’s leadership team.

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“Over the past few years, we have seen significant failures on the part of the Legacy Health System, including, most recently, the attempted closure of the Family Birth Center at Legacy Mt. Hood, and horrific acts of violence in the workplace at Legacy Good Samaritan. ONA does not have any faith in Legacy’s management, so a merger with a public institution like OHSU — which will come with more requirements related to transparency and accountability — is likely to be in the best interests of Legacy’s patients and their 13,000 staff members,” according to the statement.  

OHSU announced Thursday that it had submitted its final contract offer to state that morning, and that it included wage increases and enhanced staffing, both of which were included in ONA’s demands.

The ONA’s statement follows a Wednesday announcement from OHSU and Legacy Health that they have signed a nonbinding letter of intent to merge, confirming reporting from The Oregonian earlier that day. OHSU employed more than 19,000 people as of 2022 and Legacy had 13,000 staff the same year; barring any staffing changes, the deal if approved would make OHSU the largest employer in the Portland metro area, with 32,000 employees at 100 locations.

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Both institutions’ boards of directors approved the letter of intent unanimously, and both parties expect the deal to be finalized by the end of 2024.

The Oregon Health Authority’s market oversight program will need to approve the merger in order for it to go through. The OHA didn’t respond to a request for a comment on the merger ; a spokesperson for the agency told The Oregonian Wednesday she was not aware of the transaction.

In the press release, OHSU president Danny Jacobs referred to a “decades-long relationship” between the two health systems, presumably referring to a staffing partnership at OHSU’s Knight Cancer Institute on the Legacy Good Samaritan campus.

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“Now, we have an opportunity to join together and take a decisive next step that will help deliver on our promise to ensure the best access and care for all who need us, today and in the future,” Jacobs said in the release. “We look forward to our next chapter with Legacy and the exciting potential of our combined strengths and vision.”

“Our mission is to provide good health for our people, our patients, our communities, and our world. By combining with OHSU, we will expand our ability to deliver on our mission,” Kathryn Correia, president and chief executive officer of Legacy Health, said in the release. “In addition to ensuring access to high-quality essential health care for patients, the combined system will continue to be the region’s most exceptional place to work and learn, while supporting research and education for the next generation of health care professionals.”

Both Legacy and OHSU face financial headwinds, and their struggles reflect larger trends in the health care sector. More than half of Oregon’s 27 biggest regional hospitals reported losses totaling $114 million in 2022.

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Though Legacy recorded a $172 million operating loss in 2023, in 2022 it was one of few hospitals in the state running black ink, with $31 million overall operating profit. OHSU suffered $90 million in losses in 2022, which the teaching hospital blamed on the “tripledemic’” of  COVID-19, RSV and the flu. In January OHSU reported a 14% revenue increase and an operating income $58 million above its seasonal budget this year.

As part of the arrangement, OHSU intends to commit approximately $1 billion in capital to over 10 years, financed mostly through bond offerings, to support primary- and community-based services in the new combined hospital system.

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Sales momentum for medical offices slowed significantly in the first half of 2023, totaling $16 million in sales volume, down from the $91 million in sales volume recorded in the first half of 2022, according CBRE’s bi-yearly medical office trends report for the Portland area.

The report also found the Portland medical office market continues to experience strong demand, with health care tenants showing strong commitment to long-term leases.

The report found relocating medical practices posed significant challenges due to serval compounding factors – including disruptions in the global supply chain, increasing costs of construction and lengthy time frames to obtain permits.

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The report, which includes data on all medical buildings 5,000 square feet or largerin the Multnomah, Clark, Washington and Clackamas Counties, found medical office tenants who were faced with the decision to either renew their current lease or relocate preferred to stay in their current setup.

“Medical practices tended to be closely tied to a specific location, and are hesitant to move more than two miles away due to the potential risk of losing their patient base,” the report reads.

The report also found medical office practices unable to adopt a hybrid work schedule, in contrast to the conventional office market in Portland, which has seen growth in companies adopting hybrid work models.

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The Portland medical office market vacancy rate stands at 4.9%, still approximately 30 basis points (0.3%) below the 10-year average.

Available medical office space was most prevalent in Clark County, (24%) and Beaverton, (14%) with Lake Oswego (3%) having the lowest supply.

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Last week 70 hospital physicians at Providence St. Vincent Medical Center in Portland voted to join the Pacific Northwest Hospital Medicine Association, a hospitalists union represented by AFT Health Care and served by the Oregon Nurses Association (ONA).

In response to the vote, Providence released a statement saying the company respects the hospitalists’ decision to unionize, and that Providence has a long history of working collaboratively with caregivers unions.

The summer has been an active one for labor activity in the health care sector. Nurses at Providence Health Systems in Portland and Seaside held five-day strikes. Nurses at St. Charles medical center in Bend authorized a strike against the hospital system but ended up reaching an agreement before the strike began.

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Nurses at Oregon Health & Science University (OHSU) held informational pickets in Portland, Astoria and Hillsboro, as did nurses at PeaceHealth in Eugene and Springfield. 

While, nationally, union membership is at an all-time low, the health care sector is proving an exception.

Increases in labor activity in the health care sector can be traced back to the COVID-19 pandemic, which drove health care employees to raise awareness about their compensation and benefits in addition to safety precautions and access to personal protective equipment and paid time off. 

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Shirley Fox, an obstetrician hospitalist at Providence St. Vincent who voted to unionize, said in an ONA press release after the vote that the decision would reshape the doctors’ relationship to the health care system.

“We want to redefine our relationship with the hospital system, which has increasingly put our concerns aside as it aims to meet corporate priorities. We wish to come face-to-face as respected health professionals to address important issues in the safe delivery of patient care, and to address the sustainability of our current working conditions,” Fox wrote.

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The contractor issued a press release Tuesday saying that on May 30, someone exploited a security vulnerability in Progress MOVEit, a software product several state agencies use. The release says PH Tech learned about the incident on June 16. The information accessed varies from person to person but includes personal information, including names and social security numbers as well as protected health information like member ID numbers, diagnosis codes and claim information.

The company says it disabled access to the platform and fixed the security vulnerability, and has directly contacted customers to offer free identity-theft protection services through IDX, a data-breach response service.

Also Wednesday morning, the Oregon Health Authority issued a press release encouraging OHP members to watch for additional information, to request a free credit report from each of the three major consumer reporting companies — Equifax, TransUnion and Experian — and to contact PH Tech directly if they need further assistance.

“We’re urging OHP members to activate credit monitoring as a precaution,” Dave Baden, interim director at OHA, said in the health authority’s release. “It’s disheartening that bad actors are looking to exploit people in our state and that their actions create a burden for others, who have more than enough to manage already. However, there are important steps that OHP members can take to further protect their data.”

OHA is the second state agency to experience a data breach this year. In June Oregon Driver & Motor Vehicle Services — which also uses MOVEit — confirmed that 3.5 million driver’s license and identification card files were compromised in a hack that happened earlier that month.

Nurses at Providence Health Systems in Portland and Seaside held a five-day strike. Nurses at St. Charles medical center in Bend voted to strike but reached an agreement with the hospital system before the strike was to begin. Nurses at Oregon Health & Science University held informational pickets in Portland, Astoria and Hillsboro, and nurses at PeaceHealth held similar pickets in Eugene and Springfield. 

And — with the exception of the St. Charles strike vote, which happened in late May — that’s just June.

While this summer has so far shaped up to be an exceptional one when it comes to labor activity in health care, it’s not coming out of nowhere. 

First, though the numbers tell a more complicated story, it’s true that there’s more awareness of and support for labor unions in general — and more workers organizing and raising awareness of labor issues. Nationally, the rate of union membership is at an all-time low, with just 10.1% of American workers belonging to a union in 2022, according to Bureau of Labor Statistics data. Oregon tends to have a higher rate of union membership than the nation as a whole, with 15.7% of Oregon’s workers belonging to a union, per the same dataset. But the absolute number of Americans in unions has grown in recent years, and the number of union petitions filed with the National Labor Relations Board was 53% higher in 2022 than it was in 2021.  The number of strikes rose by 52% in 2022 versus 2021, according to Cornell University’s Labor Action Tracker report. The absolute number of work stoppages — 417 strikes and seven lockouts —  is far lower than it was in past decades, though support for unions is at an all-time high, per Gallup polls. 

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Much of that increase in activity was driven by the pandemic, which inspired frontline workers — including retail and warehouse workers — to raise awareness about their compensation and benefits, but also about safety amid the pandemic, access to personal protective equipment and paid time off. 

Health care workers, of course, were in the thick of that. And while public health officials have declared an end to the COVID-19 public health emergency, nurses say they’re still struggling. Recent labor activity has focused less on compensation and more on working conditions, though during actions like the Providence strike, nurses have asked for more compensation in the form of more paid time off and increased access to mental health services.  

“The pandemic for the past two years has only highlighted what has been in existence for decades,” says Anne Tan Piazza, executive director of the Oregon Nurses Association. “The fracture the inequities, the structural barriers in our health care system, our nurses. It’s more than nurses, it’s caregivers and other health care workers who are absolutely at a breaking point. We are frustrated, we’re angry, we’re exhausted, we’re burnt out.”

Chris Rompala, chair of the bargaining team for the two PeaceHealth facilities in the Eugene area and a PeaceHealth staff nurse, told OB nurses were picketing in front of PeaceHealth Sacred Heart Medical Center in Springfield because they had 25 failed negotiation sessions for nurses to get fair wages and safe staffing conditions. 

Tamie Cline, ONA’s president and a nurse at Good Shepherd in Hermiston, said the union is asking for PeaceHealth for the same ratios the House Bill 2697 would require. (These ratios vary depending on the department but are one-to-one in departments like the emergency room and one-to-four in departments like telemetry and postnatal care.) But the hospital system had said they would only adopt the required staffing ratio if the law passes. 

Cline spoke with OB before the legislative session reconvened after a six-week walkout and passed HB 2697. That bill does not take effect until next summer, however. 

Cline says some hospitals in the state have already achieved the staffing levels recommended in the bill, but that PeaceHealth was unwilling to consider such a move unless required to by law. A spokesperson for PeaceHealth did not respond directly to a question about that claim about negotiations, but did say the hospital system would comply with the law.

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“PeaceHealth remains committed to reaching agreements on contracts that our Home and Community and Sacred Heart Medical Center nurses can be proud of and support. We continue to make progress at the table and are hopeful we can reach agreements with ONA soon so that our nurses may benefit from the improvements these new contracts would provide,” said a written statement from PeaceHealth spokesperson Stefanie Valentino. 

“We are committed to making sure we remain an employer of choice so our caregivers want to continue their career here with us. In terms of staffing, this topic is of utmost importance and a priority for everyone. That is why we are also in the process of recruiting over 300 RNs to RiverBend/Sacred Heart. In addition PeaceHealth is committed to following any applicable local, state and federal law,” Valentino added.

“Our nurses need a change to provide the care they know they can provide,” Rompala says.

Kyle Cook, a registered nurse at Providence and member of the ONA bargaining team, told OB during the strike that Providence refused to come to the table for the 10 days between the strike vote and the strike. 

Cook says nurses bargained with Providence for eight months before deciding to strike.

“I don’t feel they were making meaningful movement, and we were,” he says.

The strike had a five-day limit and ended as expected. 

Cook says that for many years there has been a “rising wave against union work.” During the past 3.5 years of the pandemic, “working conditions were morally and ethically unjust,” and nurses have suffered moral injury — a term for mental health distress in response to witnessing or participating in events that go against one’s values. 

After the Providence strike wrapped, the ONA wrote a letter asking Attorney General Ellen Rosenblum to investigate the hospital system’s handling of the strike, specifically in hiring nurses from U.S. Nursing to ensure patient care while nurses struck.

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Providence sent a letter to Rosenblum asking her office to deny ONA’s request, writing, “In the interest of public safety, it is imperative that Providence’s ministries be able to continue caring for patients in the event of a strike.”

Tan Piazza says the problem is not that the hospital hired substitute workers during the strike but that U.S. Nursing has an explicit mission of strikebreaking, which places the hospital in violation of state law against hiring strikebreakers. (Providence has also described that law as outdated.) 

U.S. Nursing’s website says, “Since 1989, U.S. Nursing has been working with healthcare facilities and professionals to provide turn-key staffing solutions during labor disputes.”

Tan Piazza says there are alternative nursing agencies that allow hospitals to hire nurses on contract that don’t advertise in quite the way U.S. Nursing does. 

Looking ahead, Tan Piazza says ONA will continue to bargain and fight on behalf of caregivers — including not just nurses but physicians, physical therapists and others who have begun to organize as well.

“Our members — our nurses and caregivers — know what the actual patient needs are in their hospitals, in their care settings. They will continue to come up in our collective bargaining to advocate for standards that are appropriate and needed for their specific population at that particular hospital or care setting,” Tan Piazza says. “I would say that the continued discussion and conversations around recruitment and retention and respect keep coming back to the same themes. The staffing law, we believe, will make a significant difference in providing a baseline in terms of improving working conditions for nurses. But again, there are specific things that are unique to each care setting and unique to each hospital. That is going to be bargained over.”

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Mendenhall joined CCC in 2017 as senior medical director for substance-use disorder services and became chief medical officer in 2018. He succeeded Rachel Solotaroff, who left the organization last summer after five years as CEO and 16 years total with the organization.

CCC was founded in 1979 as Burnside Consortium and tasked initially with addressing the prevalence of alcoholism in Portland’s Old Town area. The organization purchased and began managing multiple downtown hotels, and assumed management of Hooper Detoxification Stabilization Center in 1982. The organization now manages multiple addiction treatment centers, addiction clinics and affordable-housing buildings in Portland. 

This interview has been edited for space and clarity.

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What is your agency seeing right now that it was not seeing when you started in 2017? 

Central City Concern is an agency that’s been around in the region for, now, 43 years. We provide health care, we provide housing and we provide employment services, and we’re serving upwards of 13,000 to 14,000 people annually. We know that about 75% of the folks that start receiving services here at Central City Concern step into our health-services programming through Hooper Detoxification Center, which has been around for decades and is located near the Rose Quarter. Hooper is a medically supervised withdrawal-management program where we’re serving more than 2,500 individuals annually. It’s a 24/7 program; we serve a ton of folks year-round. We help those individuals get medically stabilized and detoxified from opioids, from methamphetamine, from alcohol, from benzodiazepines and other substances. 

Half of the folks we serve at Hooper come in with a primary diagnosis of opioid-use disorder, and the vast majority of those individuals over the last two years have shifted from using heroin to using fentanyl. Most of those individuals have been smoking fentanyl, but now we’re starting to see a shift back toward injecting fentanyl. And many people report that they have a history of overdose. 

We also have thousands of people who we’re providing a housing resource to. We have about 3,500 people who live with us in our housing continuum. Some of those are folks who have permanent housing with us and some of those are folks who have transitional housing with us. We know that substance-use disorder is represented in the community of folks who live with us. We have, over the last 18 months, been very intentional about developing a zero-overdose strategic approach whereby we are providing wide access to naloxone, which is the medicine used to reverse opioid overdose. It doesn’t mean that there aren’t folks still experiencing overdose. But what it does mean is that all of our housing staff are trained to respond, which is a really significant investment for us. On the back end, the goal is to provide support and to hope to get folks to a place where they’re open to engaging in withdrawal management and, better yet, engaging in treatment.

Talking about that 40% of people who need acute mental health services, what are your thoughts on how the system is both addressing and not addressing the needs of people who are acutely mentally ill but not necessarily substance-affected?

We do not currently have a fully resourced or fully functional continuum of psychiatric care within the region, nor do we have a state mental hospital or mental health hospital system at the Oregon State Hospital that can fully meet the needs of the population of the state of Oregon. That is our truth. Our truth is that we know that there is a significant gap between the demand and the need and the availability of inpatient and residential beds. That has been exacerbated by the COVID pandemic, which had a significant impact in terms of creating isolation; folks with severe mental illness and substance-use disorders need a lot of contact. They need a lot of support and accountability. Many of those regular connections became disrupted.

During the same time period, there was a reduction in the behavioral health workforce, both in terms of psychiatric care and also in terms of substance-use disorders care. The Alcohol and Drug Policy Commission report from PSU and OHSU calculated that we were deficient 36,000 behavioral health care workers in the state of Oregon — in a prepandemic estimate. Central City Concern is one of several agencies in the region that is suffering from persistent vacancies among our behavioral health workforce. 

Then we layer in an inadequate system of care for higher levels of acute psychiatric care that’s been persistent for a long time; all of that is contributing to create the ecosystem that we live in within this region. It’s really difficult for me as a physician — and for me as a leader of the organization — to know that we’re providing housing to individuals who are challenged to take care of themselves: They lack capacity to make decisions and therefore might be deemed incompetent. Our current state commitment standards have a really high bar. I think it’s really important for us in the region and in the state to evaluate our commitment standards to lower that bar, to do a better job of caring for people who lack the capacity to make decisions in their own best interest. It’s a false flag of freedom to think that somebody who lacks capacity actually is making decisions — because again, they lack capacity to make decisions. Let’s not mistake that lack of capacity with freedom more broadly, especially when we’re talking about treatable psychiatric conditions. 

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Policy-wise, what do you feel Central City needs from local governments? What are the things that you’re watching?

I think, most importantly, we’re really watching how we are working together. And I’m really encouraged that Central City Concern and other community-benefit organizations are able to participate in new and different ways with the Joint Office of Homelessness Services, with County Behavioral Health and with the city. I see a level of collaboration and partnership and commitment that is refreshing, is new and unique, and it gives me a great sense of optimism in terms of coordination of strategy. 

We are very hopeful that the Oregon Health Authority will engage in intentional design and strategy work to ensure that folks who need an inpatient level of psychiatric care and stabilization will have access to that resource. In addition, the Medicaid 1115 demonstration waiver is really exciting. It is the functionality that gives states discretionary spending opportunity for the Medicaid benefit. Oregon is one of five states in the country that has a housing benefit as part of the Medicaid waiver. We’re really hopeful that the Oregon Health Authority will see the 1115 Waiver as the opportunity that it is for this region and ensure that there is coordinated deployment of that benefit. It’s an opportunity for the very first time in Oregon for housing to be paid for as a benefit out of the Medicaid system. We know through some pilot work that that saves money and saves a lot of unnecessary spending and health care dollars related to the complications of being houseless. 

We talked about fentanyl. Another thing I hear is that the meth people are using now is different than the meth people were using 10, 20 years ago.

It’s a lot more potent, and it’s a lot cheaper. That is driving a lot of the behavioral health acuity that we see that is distressing for members of the community. And a more potent, more reinforcing drug is also harder for folks to quit. 

I need to emphasize that we have a behavioral health workforce crisis of unprecedented proportion. Folks have simply left the industry. Folks got tired. Folks, in particular, got tired of referring people to nowhere and trying to coordinate people to nowhere. That leads to a certain level of moral injury, emotional fatigue and burnout. It is absolutely critical that we have a statewide strategy for recruiting individuals into the behavioral health treatment continuum of all stripes: drug and alcohol counselors, peers, bachelor’s-level behavioral health folks, master’s-level behavioral health folks. It’s going to take time to build up that workforce, to meet the needs of the state. It is probably the most important part of how we actually get to having enough capacity to meet the community need. 

CCC is working in partnership with a variety of different parties to establish a learning academy. We’re supporting an apprenticeship program with our partners at AFSCME. And we are in a holding pattern right now regarding being able to have enough folks to do the supervision, to actually do the training of the next generation. It’s important for leaders to be courageously patient as we navigate this. I have good reason to be optimistic that the right leaders at the state, metro, city and county level levels and CCO levels are engaged, they’re communicating, they’re starting to row in the same direction. They’re really starting to see this as the public health issue and challenging crisis that it is, and also understand that this is complex and multilayered. The reason to be optimistic is that people are communicating and people are agreeing that we need to be grounded in good public health data in order to align strategies to solve these challenges for the state and for the region. 

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