Category Archives: Uncategorized

Vaccine opposers lack any evidence

This is important: Dorit Reiss on vaccine misinformation in the Point Reyes Light.  The anti-vaccine crowd is vicious, rabid and unfortunately very poorly informed. Yet they have been able to get the attention of enough media to cast doubt on the effectiveness and safety of the most important medical intervention ever devised.

When the only argument against requiring vaccines for school relies on mistaken beliefs about vaccine safety, it cannot stand. Vaccines are safe, effective and save lives. Immunization mandates make our schools safe. By shoring up California’s mandate, S.B.277 is helping to safely protect our kids and our communities.

Renewed Posting

I found a bunch of unpublished posts some months ago. It seems I don’t know how to work wordpress, or maybe one of the updates threw me for a loop. Well, I kept on  writing, sometimes offline, and finally found the time to fix the problem.

This morning at Rotary, I made the observation that a year ago I had a lot of projects going but didn’t know if I would get traction with any of them. Now I have the opposite problem; everything is firing on all cylinders at the same time. Patient Direct Care came out of nowhere, PanZoe has transitioned to an effort on 360Care, a local integrated charitable clinic. EverMed is pitching for 20,000 lives in the next few months.

This morning Clark County Public Health disseminated the information on 360Care’s community meeting.

Paul Levy feels his direct reports should be practiced at writing at least 1000 words a day, in order to communicate with their stakeholders. It is time to jump back on that bandwagon.

So if you see posts dated some time ago that weren’t there before, please accept my apologies. I’m still catching up.

House Bill Aims to Curb Employers Ability to Force Doctors to Leave State

I prepared this potential op-ed prior to the death of HB 2931 in the Washington legislature. Non-compete clauses (also known as restrictive covenants) in physician contracts have had a devastating effect on the primary care workforce in Vancouver, Washington and other border regions of the state.

I understand the need to protect employers from the costs of recruiting a physician who then turns around and threatens to compete from across the street (really… who does that?) On the other hand, large groups in the state have thrown their weight around and hospital systems have thrown temper tantrums. I would prefer to eliminate restrictive covenants for family physicians, but there is good evidence from numerous sectors fo the economy that putting sharp limits on the enforceability of restrictive covenants is good for the economy. The best example is Silicon Valley,  where companies treat their employees very well, manage them extraordinarily well and continue to work with the intellectual capital they attract long after it leaves to spin off new entities and foster even more innovation.

Other physicians need the support, but so do baristas, hairdressers, nail spa workers and tattoo artists, who are unfairly unlimited by the legacy companies. I have to believe it makes these companies lazy and less considerate than they would be otherwise.

There were several bills, but I addressed the one widely regarded as the most likely to cross to the senate. In the Senate there was SB 6625 sponsored by Senators Conway, Hasegawa, Keiser, Chase, which restricted non-competes to 6 months for hourly wage workers. HB 2406 was sponsored by Representatives Manweller, Sells, Stanford, Magendanz, Tarleton, Moscoso, Ormsby and S. Hunt and stipulated that non-compete clauses were null and void in the case of a listed number of low hourly wage work such as fast food and dry wall applicators. HB 2931, sponsored by Representatives Stanford and Ormsby was the most sophisticated of the three and tried to outline certain parameters for which it is inappropriate to impose a non-compete. In short, if you are not an executive, non-competes would not be enforceable beyond one year.

None of the bills proposed geographic limits as “reasonable” in a non-compete.

All I can say is “we’ll be back,” even though I am poised to become an employer of physcians and stand to benefit from the applicability of these absurd covenants. There is still this thing called “doing the right thing.” Here is my unpublished opinion piece.

 

House Bill 2931 limits how employers can impose non-compete agreements on prospective employees and will be good for all industries in the state, although it will have an unexpected beneficial effect on health of Washingtonians. The bill received a vote on the House Floor Tuesday and will now go to the Senate for consideration.

 

Non-compete agreements in health care protect hospitals and larger medical groups, ostensibly from the high cost of physician recruitment. However, once a doctor agrees to be employed by a medical group, these agreements become a not-so-subtle means of controlling the doctors. An unhappy doctor could be required to leave the city, county or state because the agreement states that he or she is not allowed to practice their profession under any circumstances within the exclusion area. Since doctors have families and children, the non-compete agreement becomes a leash which can only be broken at substantial personal cost, which many families simply are not willing to accept. In one draconian example, one employer in Southwest Washington defines the geographic exclusion area as three counties. The doctor is often left with a Hobson’s choice of staying at an unhappy job with incompetent and potentially dangerous management or leaving town. No one is left to advocate for you, the patient.

 

Non-compete agreements are outrageous and unethical in healthcare. They disrupt the doctor patient relationship and hurt our workforce. When physicians leave the state, even for a short period of time, they rarely come back. Most medical groups spend a huge amount of money recruiting, but nobody tracks losses when doctors leave. In the end, it is the patients who suffer when they lose a trusted provider. I have never seen an administrator look an elderly woman in the eye and explain how his contract forced her doctor out of town.

 

It should come as no surprise that the Washington Hospital Association is profoundly opposes HB 2931. The Washington State Medical Association debated the issue heatedly, and emerged officially neutral. At least one large group made veiled threats to leave the association if even a watered down proposal were considered. The Washington Academy of Family Physicians is the only group that supports the bill, reflecting the public health orientation of primary care sector. Oddly enough, Republicans tend to like bills like HB 2931, because they foster free markets. Democrats like them because they protect employees. This is a bipartisan issue that aims to clip “Big Corporate,” not “Big Government.”

 

In many industries, non-compete agreements are merely an over-reaching effort to own their workforce. As one misdirected lobbyist asserted at the House Labor Committee, “our people ARE our intellectual property.” One wonders how Silicon Valley has thrived, since California is a place where these covenants are nearly completely unenforceable. Perhaps economic development is constrained when tech companies are allowed to impose draconian non-compete clauses?

 

There are numerous options which would make covenants more fair to communities, patients and doctors, but none of the corporations that run the state’s health care apparatus will even discuss the matter. It is time to reclaim the natural rights of individuals to work where they please without undue interference from anonymous corporations. Now it is up to the Senate to make HB 2931 law.

 

Coaching, Counseling – What is the difference?

There remains a remarkable stigma over mental health. Counseling is profoundly personal and incredibly effective when the chemistry is right between patient and counsellor.

One of the neat things about health coaches is that they can offer mental health counselling but also practical advice on motivation, behavior change, diet and exercise in relation to chronic disease.

It;s a great combination that expands the usefulness of a behaviorist working hand in glove with the family physician.

 

What about people who don’t need “therapy?”

Well the longer you’ve been around, the more you realize everyone needs therapy. But for those where the posture is too much, realize that life coaches approach therapy from a really practical perspective, rather than the stereotype of a navel gazing, pipe smoking “shrink.” Also for those whose counselling needs are not very acute, we can always stand to improve ourselves, be more effective in relationships, health habits and goal achievement.

 

Is it Tax Deductible?

DPC fees are not tax deductible or applicable to health savings accounts (HSA’s) due to an IRS regulation that views DPC as insurance, although it is clearly not. Several state legislatures ahve passed enabling legislation that specifically states DPC is not insurance, nor is to be treated as such. Currently, Senate Bill 1989 at the Capitol will make this the law of the land and open the possibility of allowing Medicare money to be directed by patients to primary care physicians who are willing to accept such payments.

 

 

Addressing Primary Care Gaps

I recently met Diane Lund-Muzikant, publisher, editor, organizer and all ’round charm for The Lund Report.

Every state should have such a publication focused on the local health system. And a fireplug to match Diane’s energy. She said I could write an editorial whenever I would like to highlight primary care issues.

Here is my first effort published September 22, 2015.

The greatest success of Obamacare, is the reduction in the number of uninsured. Most of this improvement has come in lower income groups, who disproportionately suffer the burden of illness and the most difficult social circumstances, including poor employment prospects. So it is unsurprising that Medicaid expansion accounts for over 2/3 of the newly insured, according to the Heritage Foundation. The political partisans use this as a weapon arguing that Obamacare resulted in little more than the expansion of the Medicaid entitlement. The other side feels that more has to be done to cover the remaining 10 million uninsured.

What about the social value of medical coverage to vulnerable populations, the economic benefits of health care to this group and a questioning of the cost relative to the benefits? Sometimes it is OK to spend tax money if there is value and accountability. If our nation is to spend public money on healthcare, it is incumbent on policy-makers to ensure the greatest value for the effort.

The greatest public value derived from modern medicine is derived from immunizations, maternal-child health and primary care. When the newly insured report that they do not have access, they mean primary care docs who understand their situation and listen to their concerns. Unfortunately, the healthcare system as it stands commoditizes primary care and works against the functions of primary care, especially continuity. Each time someone looks for new primary care provider, the system has failed.

Because healthcare in the US is purchased through employers, their entire family would change provider when jobs turn over. As health plans move to narrow networks, odds are increasing that their doctor will not be in the network offered by the next employer. This interferes with continuity of care over time and erodes outcomes.

The situation is worse for low income individuals and the Medicaid population. Some in this population suffer from mental health problems and are easily overwhelmed by the normal demands of life. They find it difficult to hold onto jobs for a long periods of time. Unstable insurance source from a Medicaid provider to a narrow network and back, repeatedly forcing them into new primary care relationships.

Long term relationships between doctors and their patients build trust. It is the trust built on years of knowing the person embedded within the context of family and community which improves outcomes and reduces costs. The lower the income level, the greater the vulnerability, the greater the risk of bouncing on and off Medicaid, with lapses and fluctuating access determined by deductibles and coinsurance.

Erika Bliss, the CEO of QLiance, a Direct Primary Care company in Seattle, suggested to me a few months ago an idea that could help bolster how primary care improves health system performance. Perhaps it is time to consider a primary care benefit that is portable from employer to employer and continuous with Medicaid. It is easy to carve primary care out of traditional insurance, where it should always represent the top dollar of healthcare spending. This is the idea behind the growing Direct Primary Care movement where high impact primary care is paid for on a monthly subscription basis. First, this helps maintain continuity between a doctor and their patient, a foundation stone of primary care. Second, it serves to create a sustainable business model for medical students to do what they idealistically entered medicine to accomplish and attract more smart people to primary care specialties. Third, primary care increases the efficiency of healthcare systems around the world, which seems to be the fundamental motivation behind the notion of value-based purchasing. If you want to buy value, invest in primary care not MRIs and pay as much as you reasonably can.

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.

Media Mentions for EverMed and DPC, Another Grant Request for PanZoe

We got a couple of media mentions a couple of weeks ago for EverMed’s DPC efforts. They were brief, one more or less accurate and the other word-for-word the way we would have like the issues framed.

From Elizabeth Hayes of The Portland Business Journal comes the following:

A Vancouver-area company is launching a new model of delivering primary care services in the Portland area, one designed to give patients direct access, regardless of their insurance plan.

EverMed Direct Primary Care of Camas isn’t itself insurance, but layers on top of a patient’s existing plan. A member pays a set monthly fee and receives comprehensive primary care services.

While most Director Primary Care companies employ doctors directly, EverMed is seeking established, independent primary care clinics. About 30 clinicians at eight clinics have signed up in Clark County and about half a dozen clinics are in various stages of the contracting process in Portland, said Seth Sjostrom, director of business development.

EverMed charges patients $45 to $85 a month for unlimited access to a primary care doctor for wellness exams, basic diagnostics and other non-emergency needs.

“The principle of DPC is that you don’t need insurance for day-to-day care. It’s for catastrophic illnesses,” said Dr. Dino Ramzi, EverMed’s chief medical officer and a physician with Lacamas Medical Group in Camas.

Members can enroll directly, though many have come through self-funded employer medical plans. Ultimately, EverMed would like to partner with an insurer who would devise a plan that doesn’t include primary care, Ramzi said.
So far, EverMed has signed up 75 members and five corporate clients. Sjostrom said the company is now promoting itself with insurance brokers in hopes of attracting more business during the 2015-16 enrollment season this fall.

More and more patients have gravitated to “bronze” plans, with high deductibles. Faced with copays or an unmet deductible, these patients may defer care, which ends up costing more in the long run when a patient ends up at an urgent care clinic or the ER. Highly effective primary care could save the health system a third of its costs, Ramzi said.

This upset Seth, as noted above, our Director of Business Development. It turns out I misrepresented our pricing structure, essentially because it has undergone several changes. My momoery is not what it used to be. In fact, as we prepare to enter the employer market more profoundly, there are signals we may have to make further changes. Pricing is an important component. We want to make sure providers get good value, but it is telling that employers are falling over themselves, given the price of assured primary care is remarkably low from tehir perspective.

The Direct Primary Care Journal did a perfect job representing our efforts. (Duh, it was a press release.)

Direct Primary Care clinics have been popping up all over the country, it was only a matter of time before the Portland marketplace became a part of the revolution in healthcare.

Born from the concierge clinic concept, Direct Primary Care (DPC) is the iteration for the masses. As one of EverMed DPC’s marketing tag lines states, DPC is “genuinely affordable health care”.

Direct Primary Care is a healthcare benefit option where members pay a set, low monthly fee to receive comprehensive primary care services. DPC is not itself insurance, it is an affordable option to access primary care needs for the member and their family.

EverMed DPC is a new spin on the growing Direct Primary Care marketplace. While most DPC offerings are staff model enterprises (the physicians work for the DPC business), EverMed DPC seeks out independent primary care clinics that are already established in the communities they serve.

“One of our key objectives as EverMed DPC is preserving the viability of the independent primary care practice. We see Direct Primary Care as a way for clinics to not only survive, but thrive,” says founder and clinician Scott Jonason, PA-C.

EverMed DPC makes accepting direct primary care patients a turn-key proposition for clinics. “We handle nearly everything for clinics – marketing, contracting, payroll and bank withdrawals, enrollments – all the clinics we serve really have to do, is see their patients,” Director of Business Development, Seth Sjostrom states.

With their network in southwest Washington established, growing northward into Seattle and across the river into Oregon were natural next steps. “If anything, we were overwhelmed by the positive response we received. We quickly realized growing slowly was not an option,” Sjostrom says.

EverMed DPC’s plan? Having enough clinics spread throughout the Portland metro in time to have homes for primary care patients opting for DPC membership during the 2015-2016 healthcare enrollment season.

“Our second objective is to truly remove finances as a barrier to primary care,” Jonason explains, “Working with the healthcare broker community and employers, we provide an affordable way to provide quality care while at the same time, driving down costs.”

EverMed DPC aims to add value to employers and individuals by minimizing the number of urgent care and emergency room visits, thereby reducing the overall total healthcare spend. “When patients are concerned about paying copays or worried about unknown costs of seeking care, they tend to avoid seeking treatment until it is too late and then they end up in the ER. With DPC, if they have a concern or even unsure if they need to come in, they can call, visit or even use secure email or text depending on the clinic,” Jonason adds.

“We believe when physicians have genuine relationships with their patients, quality of care improves. Timely care that values the relationship and is focused on the whole patient means that doctors are in the position to respond quickly and guide the patient to the right diagnosis, coordination or medical management as efficiently as possible. The hallmark of quality primary care is taking care of the individual, not the visit,” Dr. Dino Ramzi, EverMed DPC’s Chief Medical Officer states.

With healthcare reform, many individuals and even businesses opted for plans with higher deductibles in order to secure lower premiums. Direct primary care serves those with high deductible plans to manage their day to day health, knowing their insurance is in place should they require more extensive care. The trend across the country is to increase individual out-of-pocket expenses. This trend is unlikely to reverse, but DPC makes those expenses more budget-friendly.

“We have had a number of members who purchased a Bronze plan through the exchange but signed up for DPC to take care of their more common needs, assuming they wouldn’t hit their deductible. We have had several taking part in Christian medical share programs that also saw DPC as a way to bridge the gap,” Sjostrom shares.

“Our most common membership, though, has been through employers with self-funded medical plans. They see DPC as a fixed variable in their annual medical cost plan while serving as a way to manage costly medical interactions by avoiding unnecessary Urgent Care an Emergency Department visits.”

How do businesses and individuals enroll in EverMed DPC? “Members can enroll directly through our website or 800 number, but we strongly encourage prospective members to learn more about DPC through their licensed insurance broker. Healthcare can be complex, we want to be part of a package that really meets our members’ needs,” Sjostrom says.

Direct primary care programs on their own do not meet the obligations required in the Affordable Care Act, though they can be a complement that makes sense for a lot of people and companies seeking for a solution that provides real healthcare value.

“No copays, no deductibles, the smallest administrative burden…with EverMed DPC, we return the focus of healthcare to the patient,” Sjostrom adds.

Meanwhile PanZoe‘s efforts to raise funds for a national giving effort for DPC is going strong as we apply again to the Community Foundation of Southwest Washington.