Unknown Speaker 0:00
We did not hear patients expressing frustration or anger at their physicians. We heard over and over this theme that I know my doctor wants to do the best for me. I I feel bad for my physician. I see their hands being tied or they're being restricted.

Unknown Speaker 0:29
Welcome to Off the Chart, a business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today.

Unknown Speaker 0:45
In today's episode, Medical Economics senior editor Richard Payerton sat down with Dr. Rebecca Schumm, an associate professor of public health at Pacific University in Oregon, and a board member of Healthcare for All Oregon, which advocates for universal healthcare. She's also one of the authors of Moral Injury in Medicine, a March report from the single-payer advocacy group Physicians for a National Health Program, in the report's national survey of more than 1,200 practicing physicians, nearly half said they often or always lack time to give patients optimal care, and 27% said they'd already left a job because of moral distress.

Unknown Speaker 1:15
She and Richard also discussed corporate acquisitions of Oregon medical practices and a 2025 state law limiting corporate control of them before turning to the state's push towards universal health care.

Unknown Speaker 1:25
And one quick note before we get into it: this interview was recorded earlier this year when the state's universal health plan governance board faced a September 15th deadline to deliver its plan to lawmakers. In August, the board voted unanimously to push that deadline to December 1st, citing unresolved questions about how to pay for the plan.

Unknown Speaker 1:40
With all that said, Dr. Soon, thank you for joining us. And now let's get into the episode.

Unknown Speaker 1:52
Thank you for joining us today.

Unknown Speaker 1:54
Hi, Richard. Thanks for having me. I'm looking forward to our discussion. And today we're going to discuss how Oregon might be an example or a microcosm of what's happening in some trends in healthcare around our country. Before we get to that, can you introduce yourself and describe your training and experience? Sure. So,

Unknown Speaker 2:12
as you noted, I'm an associate professor of public health at Pacific University. So I teach a wide range of classes that include health policy, health systems, topics such as that, and then in my work with Healthcare for All Oregon, I'm also deeply involved in the policy reform landscape in Oregon.

Unknown Speaker 2:35
Oregon has long been known as a leader in health policy reform. We've been a test lab for a lot of important advances in improving healthcare quality, access,

Unknown Speaker 2:45
affordability, extension of care, so it's it's an exciting time to be in Oregon, but a very

Unknown Speaker 2:54
critical time as well, as we see problems in the health system become more acutely felt than ever. So my my research interests span the whole

Unknown Speaker 3:05
range of issues, but centered around equity, affordability, access in healthcare.

Unknown Speaker 3:12
Regarding that latest report by Physicians for a National Health Program, how did you come to be involved with that? Yes, that was a great collaboration between Physicians for National Health Program and Healthcare for All Oregon. So this was a Robert Wood Johnson funded study,

Unknown Speaker 3:30
and really had a national scope and also a kind of local Oregon based piece. So PNHP Physicians for a National Health Program

Unknown Speaker 3:39
came to Healthcare for All Oregon with this proposal, and that was essentially wanting to explore and investigate

Unknown Speaker 3:46
the the incidence of of what's called moral injury among physicians and healthcare workers in our current system. So, moral injury

Unknown Speaker 3:57
is again feeling this conflict and tension between the ethical requirements and the desires of healthcare professionals working in the field,

Unknown Speaker 4:06
but that tension that can arise within the kind of for-profit, market-driven constraints of how the system is currently structured. So

Unknown Speaker 4:15
the the larger program was consisted of I should say larger project consisted of a nationwide survey of physicians,

Unknown Speaker 4:24
focus groups, really exploring these themes, and then the Oregon component, which I helped run, was really a kind of deeper dive into a broader context. So we're seeing

Unknown Speaker 4:41
the the the responses, the experiences described by physicians and healthcare workers, but the case study was meant to kind of widen that and describe

Unknown Speaker 4:50
larger factors and really policy approaches to try to hopefully improve address these these issues we're seeing. So healthcare for all Oregon.

Unknown Speaker 5:00
Was contracted by PNHP to a help run the patient focus group portion of the study. So the main section was listening to physicians share their experiences, but we also wanted to complement that with voices of patients, what they are experiencing on their end, getting care in this in the system, and then also a case study looking at the legislative context. So, how has this financialization,

Unknown Speaker 5:28
what we saw, increased over time, and also what are legislative policy reform

Unknown Speaker 5:34
strategies that could that could counter and improve what we're seeing?

Unknown Speaker 5:38
The report says Oregon can serve as as an example of at least two trends in healthcare: that rampant financialization of healthcare systems and the state legislation and community actions to resist that financialization.

Unknown Speaker 5:54
To start with that financialization, can you describe what's been happening in recent years as corporate entities have completed some transactions in Oregon.

Unknown Speaker 6:03
Yes, what we're seeing in Oregon is really an echo of a phenomenon that's happening across the country. But we've seen a rampant increase in private equity takeovers,

Unknown Speaker 6:16
insurance companies buying up medical entities. There are some really, I'd say, two instances where that received a lot of media attention in Oregon, and that was where Optum, a subsidiary subsidiary of United Healthcare,

Unknown Speaker 6:32
acquired Oregon Medical Group in Eugene, Oregon, and also the Corvallis Clinic in in Corvallis, Oregon, and these were takeovers that were really, like I said, it garnered a lot of attention in media. The community was opposed to it largely, and we've now, you know, it's nascent, it's new, but we are watching the impacts that can be felt

Unknown Speaker 6:57
that were felt pretty immediately. So when Optum acquired OMG, 32 physicians immediately resigned, and one of the issues that

Unknown Speaker 7:08
we can talk about further, you know, some of the problems that are occurring with these private equity or insurance acquisitions

Unknown Speaker 7:16
is the imposition of a lot of

Unknown Speaker 7:19
strict requirements on physicians. So one of those are requiring all physicians to sign non-compete clauses. So in Eugene, it was a two-year non-compete clause. So we saw physicians unwilling or unable to kind of meet the the demands. The you know private equity will require X number of visits per day. They'll restrict certain certain ways that these medical

Unknown Speaker 7:50
entities are are run. So, but then you have physicians not wanting to work in those contexts, and then basically driven out of the region because they can't open up their own practice or or seek

Unknown Speaker 8:04
work in in other entities because of these non compete clauses. So

Unknown Speaker 8:09
yes, you know we also saw Amazon acquiring primary care facilities in Portland, private equity buying up urgent care urgent care clinics in Bend and Redmond. So it's a it's been a growing trend and not stopping in a lot of places.

Unknown Speaker 8:24
To continue along with the the other element that the report really highlighted was,

Unknown Speaker 8:30
as that has happened, what are some of those state and community actions that have been taking place to counteract that corporate ownership and influence? Right. So this is a this is a hopeful story. Oregon, as I said, has often been a leader in health policy reform. And

Unknown Speaker 8:47
one thing to note: there's been a long history of regulatory recognition that there is a conflict of interest, a tension between business interests and the ethical practice of medicine. So dating back to the 1800s, there have been again a patchwork of laws and regulations limiting the corporate practice of medicine. In Oregon, really, it was 1947 that our Supreme Court passed a law

Unknown Speaker 9:15
banning the ownership

Unknown Speaker 9:18
or control of medical entities by corporations, so that was on the books. It was a good law. It was well constructed, but over time,

Unknown Speaker 9:28
those restrictions were-I

Unknown Speaker 9:32
would say-corporate entities found a way to work around them to skirt those restrictions. So really, we saw this come to rise in the 1970s and 80s with the rise of managed care organizations. So,

Unknown Speaker 9:46
over time, legislation was passed that allowed

Unknown Speaker 9:51
professional corporations, which still have a majority ownership by medical professionals, as well as LLCs and LLPs.

Unknown Speaker 10:00
Two own medical entities,

Unknown Speaker 10:03
hospitals were also given a carve out. So, as I said, over time these

Unknown Speaker 10:08
pretty strict limitations were eroded, and what we've seen in this current era of private equity ownership,

Unknown Speaker 10:17
there's a there's a particular strategy

Unknown Speaker 10:20
that's been invoked, where a private equity firm will

Unknown Speaker 10:25
establish what's called a managed services organization, and then they will contract with a physician who technically owns the medical entity, but it's really kind of a shell

Unknown Speaker 10:41
construct where the there's a there's a technical physician who owns the medical entity, but they contract with the MSO to run all of the operations. That includes hiring, firing, putting in

Unknown Speaker 10:55
staffing schedules,

Unknown Speaker 10:58
all sorts of things that impact the practice of medicine. So where does the where does the state level

Unknown Speaker 11:04
and community based organizations come in? We in Oregon saw that this erosion had occurred, and we were seeing the negative impact, seeing all of these acquisitions, and

Unknown Speaker 11:15
there was an Oregon House representative by the name of Ben Bowman who became really concerned. He really became an advocate in the legislature to restrict this. And Healthcare for All Oregon partnered with him,

Unknown Speaker 11:29
really primarily Hayden Brook Lay, who's a published legal scholar on this issue. He's a board member of HCAO, so he worked really closely with Representative Bowman to help draft and steward the legislation

Unknown Speaker 11:45
of a an extension bill to that 1947 bill,

Unknown Speaker 11:51
so we got that passed in June, and it's been a it's called the strictest law in the nation banning corporate practice of medicine. So even though there was that original ban, this new bill in 2025,

Unknown Speaker 12:06
for example,

Unknown Speaker 12:08
their the entities that are purchased by private equity can no longer do non compete clauses, so it restricts what they're able to impose on the the medical practitioners affected.

Unknown Speaker 12:22
What you're talking about, some of those business elements, as well as the human element, are issues that our audience deals with a lot,

Unknown Speaker 12:30
especially regarding medical economics traditional audience in independent practice physicians. In your studies, have you noticed any trends or differences, you know, among physicians that are practicing in those corporate settings and those in independent practice,

Unknown Speaker 12:46
in your state, I guess what would how would you describe the environment for independent practice? Then,

Unknown Speaker 12:51
it's it's challenging, and and I would say medical providers in both of those settings face very

Unknown Speaker 12:59
prominent and but distinctive challenges. So as we mentioned, physicians in corporate settings are finding themselves increasingly bound by these external limitations set by management service organizations. For clinicians in individual practices, they might have more autonomy and control, and that's that's the entire purpose of

Unknown Speaker 13:24
these reform efforts in Oregon. The the passage of the recent CPOM extension was based on the value of preserving

Unknown Speaker 13:32
the kind of sacred

Unknown Speaker 13:34
autonomy of physician decisions made with their patients. So in that setting, in individual clinic settings, we find that doctors are also experiencing burnout and moral injury, but more due to insurance barriers. So the pre-authorization, the onerous burdens of pre-authorizations, the denials, the step therapy that's required. So this experience of knowing what is the best regimen for your patient

Unknown Speaker 14:07
and not being able to prescribe that. There's also the administrative burden, which again I don't have to tell your audience this; they're the ones telling us this.

Unknown Speaker 14:16
But the the paperwork, you know, there are studies now showing that in an individual clinic setting, physicians are spending an average of 25% of their time on actual patient care, 50% of their time on administrative paperwork, and that is not you know what we're hearing from physicians. That's not why they got into the the practice, and that's it. Doesn't have to be that way. That is a that is a symptom of our particular, what I often call Frankenstein Frankenstein patchwork of

Unknown Speaker 14:47
of the way we finance healthcare. So we're we're seeing the same themes of burnout, moral injury

Unknown Speaker 14:54
among physicians in in both types of practices.

Unknown Speaker 15:04
Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven, real-world tactics you can plug into your practice today. Whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch, but the best ideas don't all come from our newsroom. They come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at kreynolds@mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute.

Unknown Speaker 15:56
You know what? I wanted to maybe switch gears slightly and talk about something that is related and that I think is going to inform the discussion

Unknown Speaker 16:04
even more because, and I I don't know how many of the states have done this, but as I understand it, in 2019 the Oregon legislature created a task force on universal health care. Can you talk about what that is and what it does and sort of how that formed

Unknown Speaker 16:22
or informed, I should say, some of the research that went into the more recent report regarding moral injury.

Unknown Speaker 16:28
Right. So when we are looking at the impact of this larger system on medical providers, you know, there's the delivery side, which is really the the CPOM legislation protecting that patient-provider relationship, protecting physician autonomy, but there's also the financing side of a health system that, as we just said, creating the administrative bloat, the administrative overload.

Unknown Speaker 16:53
So in Oregon, trying to trying to protect that autonomy through CPOM legislation, but also we are making great strides. I think we're leading in terms of states in the nation

Unknown Speaker 17:05
at

Unknown Speaker 17:06
implementing systematic reform of the financing side. So, what are we talking about there? A universal healthcare system. So, in 2019, the state legislature created this joint task force on universal healthcare, and they worked for several years to essentially research the issue: what would be the impact on Oregon,

Unknown Speaker 17:27
and to make recommendations. So the results of that report were released, and around the same time of that report release, back in 2020, I think that was 2022, might have been 2021. We also

Unknown Speaker 17:43
saw a ballot measure presented to Oregonians, and Healthcare for All Oregon was deeply involved in

Unknown Speaker 17:50
both getting the legislation to create that joint task force to study universal healthcare, and also to put this

Unknown Speaker 17:58
measure on the ballot. And the ballot measure was very simple. It essentially asked Oregonians, "Do you think

Unknown Speaker 18:06
healthcare access to healthcare should be a fundamental right added to our state constitution? And it passed just barely, but it did pass. A lot of Oregonians wondered what the impact, or really what it would do.

Unknown Speaker 18:21
But what it accomplished is it then created a legislative mandate. So now it's in our constitution. Healthcare is a fundamental right of every Oregonian, which then creates again a responsibility of the legislature to fulfill that. So healthcare for all Oregon, again working with advocates in the legislature,

Unknown Speaker 18:43
then developed helped develop some subsequent bills, which created what's called the Universal Health Plan Governance Board. So this is really where the real work is happening.

Unknown Speaker 18:56
The Governance Board it consists of nine experts who are deeply familiar with the Oregon policy and healthcare delivery landscape? They were appointed by our governor, and their job these last couple of years has been to actually design a proposed system. So the joint task force was doing background research. This current universal health plan governance board is designing.

Unknown Speaker 19:21
You know how is it paid for? What is it going to cover? Who's eligible? How will it be implemented? So that work will really culminate this September when we have they have a deadline to present the full proposal to the legislate to the Oregon State Legislature.

Unknown Speaker 19:39
To continue along with

Unknown Speaker 19:42
some of the examination about healthcare financing.

Unknown Speaker 19:46
Have there been any any preliminary reports or discussion or proposals about exactly how to finance a universal healthcare system at the state level?

Unknown Speaker 19:55
So they're looking. That's still in progress. Again, the final version isn't due.

Unknown Speaker 20:00
Until September, and that is one of the biggest pieces. You know, with with coverage, there was a lot of even from the Joint Task Force recommendations. There was already a lot of consensus around wanting to echo, you know, the public employees benefit package with some extras. But the financing side is the the piece that's often the most complicated. Even just getting the initial data of what's currently spent, all the different revenue streams that go into that. So currently, this is all just draft,

Unknown Speaker 20:29
but they're looking at a combination of

Unknown Speaker 20:32
income tax, payroll tax,

Unknown Speaker 20:35
corporate, various corporate taxes. the The

Unknown Speaker 20:39
goal is again equity and affordability.

Unknown Speaker 20:43
So,

Unknown Speaker 20:44
you know, the important piece for the general public is that

Unknown Speaker 20:50
in this situation, we likely would see an increase in income taxes. But for the vast majority, it would be a net savings from what they are currently paying via their premiums,

Unknown Speaker 21:05
their deductibles, the copays, so it's a savings. And the one thing that is really interesting about conversations around universal health care is cost is usually the the first concern. How can we afford it? When as a health systems researcher, the data are really clear on this. The United States spends far more per person than any other industrialized nation, all of whom have universal health care. The United States is the the radical, bizarre experiment of trying to extend care through a a profit driven model. So what we've seen in the data are that is that converting to universal healthcare saves money. I'll add one more kind of wonky note to that. The number one driver of high healthcare expenditures in the U.S. is the administrative bloat that we just talked about.

Unknown Speaker 22:01
So a a universal healthcare system

Unknown Speaker 22:06
reduces everything to one set of billing codes.

Unknown Speaker 22:09
You know,

Unknown Speaker 22:11
standardized fee schedules.

Unknown Speaker 22:13
You know, in in countries with universal healthcare, the patient comes in. There's a documentary I show my students that that tracks the billing process. It takes the billing

Unknown Speaker 22:24
staff person about 45 seconds to input the information, and two weeks later, the physician gets paid. It's done.

Unknown Speaker 22:31
Compared to in that same documentary, when an American patient comes in and it takes the clinic like six months of calling back and forth and arguing with the insurance company, multiple efforts just to get payment for that

Unknown Speaker 22:46
111, care visit. So, you know, from from our perspective, universal health care not only simplifies the system enormously, it also frees up physician time to actually give care, to focus on patient care rather than fighting with insurance companies.

Unknown Speaker 23:05
You know what? One of the issues that I think you touched on

Unknown Speaker 23:08
in in our conversation so far, not least with, for example, some of the moral injury that physicians and other clinicians feel,

Unknown Speaker 23:18
and patients had a chance to also express themselves at the ballot box. It sounds like

Unknown Speaker 23:22
there was patient focus groups in Oregon to examine effects on their care. As you were doing some of the research, can you explain some findings or experiences that patients shared?

Unknown Speaker 23:35
Yes, I'm. I'm really happy to. One of the you know, as a researcher, we go in with our questions, and we are open to whatever emerges. But as these patient stories unfurled, I I just felt it is an ethical responsibility to share these voices and experiences. It was overwhelming

Unknown Speaker 23:56
the the extent of negative experiences that patients are are going through navigating our system.

Unknown Speaker 24:03
They mentioned you know certain themes emerged, such as seeing a decline in the quality of care,

Unknown Speaker 24:10
just in terms of being able to access a primary care physician,

Unknown Speaker 24:15
feeling like their appointments were restricted to a certain time period. They could only bring up one health issue, and again, we know on the back end that a lot of these restrictions are coming directly from these managed service organizations. It's not that the physicians want to restrict their patients

Unknown Speaker 24:35
in terms of what they share,

Unknown Speaker 24:38
but so yes, access to physicians and the quality of that relationship, they also saw wait times increase dramatically

Unknown Speaker 24:49
in Eugene, Oregon, where we did one of these focus groups.

Unknown Speaker 24:53
Patients talked about wait times for a certain specialist going from three months to about nine months.

Unknown Speaker 25:00
Because specialists left the area, so physician shortages were also

Unknown Speaker 25:06
talked about extensively.

Unknown Speaker 25:09
They also, you know, this predated these this these private equity takeovers. But battling with insurance companies was a. I think every single focus group participant spoke about that.

Unknown Speaker 25:23
It was a really highly, I would say, informed group of patients

Unknown Speaker 25:29
about what was happening. A lot of them mentioned that physicians were talking with them very openly about some of these factors and forces that were affecting the the quality of the care, and there was a lot of sympathy. So we did not hear patients expressing frustration or anger at their physicians. We heard over and over this theme that I know my doctor wants to do the best for me. I I feel bad for my physician. I see their hands being tied or they're being restricted. So that was a really prominent theme, also, but they did. You know, doctors would talk very openly, like, "Look, here's the medication that we want to give you. However, I know it's not going to be approved. We're going to have to go through these other two first.

Unknown Speaker 26:14
And and you know, this is something that we just accept in our in our system. You know, the the norms of step therapy, but from a patient perspective, that means that whatever condition they came in with, that they're suffering with, they're being forced to really live with those symptoms and have it worsen over time. And again, that moral injury, the physician knowing that that's the case, yet having to go through that steps, that was a theme that that was discussed a lot. Another one I'd like to bring up

Unknown Speaker 26:45
was the psychological toll of having to navigate this system.

Unknown Speaker 26:51
A lot of participants spoke about depression, that they're having to manage the health condition itself, but having to

Unknown Speaker 27:00
go through four, five denials, these or these cycles of again pre-authorizations,

Unknown Speaker 27:07
just left them feeling that they're trapped in a system that is not built to get them the care they need. In fact, it's a system that's

Unknown Speaker 27:17
set up to protect the profits of the insurance companies, and they have to fight that in order to to

Unknown Speaker 27:24
get the care. One one quote that still kind of sticks out in my mind.

Unknown Speaker 27:30
One participant noted, like, "Wow, it's it's so it's so strange that we all know so much about the system. Like, like we shouldn't we shouldn't know this much about the intricacies of of health insurance, but we've had to learn it because if not, we die.

Unknown Speaker 27:46
And that

Unknown Speaker 27:49
the stakes that came up from a patient experience

Unknown Speaker 27:54
again still stay with me. And looking at the larger PNHP physician survey, we hear we hear that from the the qualitative part of that study, the quotes that emerged, physicians carrying that burden with them, seeing what their patients are going through, and feeling

Unknown Speaker 28:11
powerless to

Unknown Speaker 28:13
to improve

Unknown Speaker 28:15
it. I'm Richard Payerchin, reporting for medical economics. My guest today has been Rebecca Shun, an associate professor of public health at Pacific University Oregon, and a contributing author to the report "Oral Injury in Medicine, published by Physicians for a National Health Program. It's been a great conversation. We're going to have a lot more to talk about in the future. Thank you for being here.

Unknown Speaker 28:51
Once again, that was a conversation between medical economics senior editor Richard Payerton and Dr. Rebecca Shun, an associate professor of public health at Pacific University and board member of Healthcare for All Oregon. You can find links to the moral injury in medicine report and Oregon's universal health plan governance report in the show notes below. But with that said, my name is Austin Latrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, solutions for your practice. You can find us by searching "Off the Chart" wherever you get your podcasts. Also, if you'd like the best stories that Medical Economics and Physicians Practice publish, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the Chart, a business of medicine podcast, is executive produced by Chris Masolini and Keith Reynolds, and produced by Austin Latrell, medical economics and physicians practice are both members of the MJH Life Sciences family. Thank you.

Transcribed by https://otter.ai