Reflections on Health Care Past, and Future

The Portland Business Journal recently sponsored a forum entitled Health Care of the Future, providing a glimpse into what Portland companies are doing to disrupt the healthcare system. Panelists discussed new models for healthcare, new technologies that extend the reach of physicians and financing methods. It was a hugely attended event, with a great buzz, fantastic networking opportunities and a lot of great information. But close to the end of the conference, a couple of comments were made by panelists that I found incredibly frustrating reflections of an old, broken, sick health care system that were oddly out of place.


First, Jared Short, the head of Cambia’s Insurance group (Regence BCBS) who recounted diagnostic failure in the primary care setting as one reason for high cost to the system. He brought up a personal experience with his son’s diagnosis of a chronic rheumatic condition that took over two years to diagnose, despite elaborate investigations. Of course we don’t know the clinical details, but that’s why it’s an unfair characterization of primary care.


As an intern, I was responsible for the diagnosis of a case of lupus in a man who had been searching for a cause over ten years. I was not smarter than my colleagues or professors, but rather, the unique evolution of his disease made it impossible to diagnose earlier. Doctors knew that waiting and watching was the best possible strategy and in this patient’s specific case, there was sufficient trust that the patient was content to wait rather than pursue useless investigations. This is always necessary in a market where distortions are introduced by the fact that advanced investigations are essentially subsidized by payers. If patients understood what little value they added at time, they would decline. It is frightening that the head of one of the largest and most powerful payers in the Northwest has such a distorted view of the diagnostic process and value within the system.


If primary care is inadequate, then we should invest in supporting primary care and attracting the smartest minds. You do not get to underinvest in a key health system function for decades and then complain that it doesn’t do its job.


The other inexplicable comment is one I used to hear frequently in healthcare business circles in the past. Martie Ross, a principal in a consulting firm out east, made the point that insurers needed to find mechanisms of transferring risk to health providers with new value-based payment methodologies.


My point is that healthcare providers are not risk bearing entities and should generally be discouraged from doing so. It is not clear which features of ACOs predict their success, but some of the most successful ones have been where the risk was transferred to the ACO, but not necessarily to the providers. Providers should be in the business of taking care of people and doing the right thing, irrespective of the cost. As far as insurers go, their business is the management of risk, not the transfer of risk. To a lifelong family physician, insurance companies transferring risk seems like cheating.


Moreover, the only entities large enough to absorb this kind of risk are large integrated health systems which is the birthplace of perverse incentives for high volume, excessive and sometimes unnecessary care. Small practices arguably do better at quality where large systems are better at collecting data and generating revenue.


The disdain for primary care and the industry’s tone-deaf dehumanization of health to “risk transfer” are part of the reason our old system is broken and we are experiencing this generational opportunity for disruption. This is the health care of the past, not the Health Care of the Future.



Fire Fighting for a Beleaguered Community

This is a story that appeared in The Camas Post-Record, our local weekly, about my EverMed DPC partner, Scott Jonason. It was written by Dawn Feldhaus.




Three people with ties to the Camas-Washougal area recently spent a few days in north-central Washington, to help individuals affected by the Okanogan complex fires.

Scott Jonason, a physician assistant, certified and owner of Lacamas Medical Group, in Camas and Vancouver; Jennifer Kaufmann, a Lacamas medical assistant for 12 years; and George Ryland, a former Camas resident, provided medical support to fire crews and residents of the Tunk Valley area — 20 miles north of Omak.

They were there from Aug. 30 to Sept. 3.

“We were equipped to provide advanced first aide, for wound care, insect bites, dehydration and respiratory illnesses like asthma or COPD flares,” Jonason said.

They also delivered supplies that had been donated from the Camas-Washougal community.

Supplies from this area included water and sport drinks, as well as snacks, such as protein and granola bars for firefighters.

School supplies were also donated.

“Immediate needs have been answered, but they will have ongoing needs,” Jonason said. “There are more humanitarian needs and livestock needs, for those who lost everything.

“The future needs include more sheltering and clothing, as well as food,” he added. “Most of the people are back in their houses and are self-sufficient.”

Additional undergarments, such a T-shirts, underwear and socks, are needed for firefighters, according to Jonason.

“Some of them have been in tents up there for a couple of weeks,” he said. “They could be there for another month.”

The Okanogan complex fires have grown into the largest wildfire in Washington history at more than 256,567 acres.

In addition to addressing medical needs, Jonason said he, Kaufmann and Ryland unloaded trucks of supplies and provided security checks in homes.

There had been some problems with looters, Jonason said.

“We stomped out a couple of hot spots,” he said. “We had shovels and picks in our trucks. We buried it or snuffed it out.”

Jonason grew up in Wenatchee, located approximately 120 miles from Tunk Valley.

His 22 years in the military included service in the Army, the Oregon Army National Guard and the Oregon Air National Guard.

“My feeling was, ‘if I can help, I should,” Jonason said, regarding his recent trip to the areas affected by fires.

Ryland has retired from the Oregon Army National Guard. He was an Army medic with Jonason 25 years ago.

The two friends have previously assisted victims of Hurricane Katrina, in New Orleans.

Kaufmann and Jonason have provided post-earthquake assistance, in Haiti.