The paradigm shift – Q&A with President Robertson on health care reform

This article appeared originally in Bridges - the School of Medicine's alumni magazine. It features a conversation with OHSU's president on the transformation taking place across Oregon's health care system and OHSU's role in it.

Dr. RobertsonPolite and self-deprecating in a way that calls to mind his small-town Indiana roots, Joe Robertson Jr., MD R '82, MBA, arrived at OHSU in 1979 as a resident in ophthalmology. Other than a year in private practice, he's served on the OHSU faculty ever since, wearing just about every hat possible: educator, researcher, clinician and administrator, including School of Medicine dean from 2003 to 2006.

In 2006, he was appointed university president. Two years later, the economy fell into a deep recession, OHSU faced its own financial crisis and the health care reform debate burned hot across the nation. Dr. Robertson waded in, making tough, but strategic decisions that would position the university for long-term ‑financial health. He also took a stand on reform. Th­at year, OHSU adopted Eight Essential Principles for Health Care Reform.

In 2009, Dr. Robertson was appointed to the Oregon Health Policy Board, a role that taps his experience working on the original Oregon Health Plan in the early 1990s. ­The board is the policy-making and oversight body for the state's Oregon Health Authority, which is responsible for implementing health care reform statewide. In addition, Dr. Robertson and other OHSU leaders work closely with the governor's office and state legislature to share information and offer perspective on reform initiatives.


Q&A with Dr. Roberston

You were a resident from 1979 to 1982. Did you ever imagine you'd be in the president's office, not only leading OHSU but helping shape Oregon's health care system?
Nothing could have been further from my imagination. All I wanted to do was learn enough to pass my ophthalmology boards and provide good care to patients.

In your position, change seems to be a near constant these days.
Change is uncomfortable. Yet, here's the way I see it: Do you want to be a little bit uncomfortable now or do you want to end up some place you really don't want to be in ‑five to 10 years? I ‑find it a lot better to tolerate some uncertainty and discomfort in the short-term in order to engage in something that is beneficial over the long term. I'm an advocate of trying to determine the future rather than letting others determine it for you.

GovKitz_Joe_Medicaid-300x200What is your view of the changes to Oregon's health care system? The Coordinated Care Organizations (CCOs) being formed?
Some road to universal coverage has to be found, not only from the perspective of equitable social policy, but to achieve national and state financial stability. Oregon's Coordinated Care Organizations, and the associated changes in payment for health care delivery, offer a path to a better health care system.

But the operative word is coordinated. When you're creating the proverbial paradigm shift, you have to coordinate and collaborate. Not only is it about the patient-centered primary care home, it's about multiple parties working together to prevent readmissions. It's about the integration of mental health with physical health. It's about using evidence-based medicine to allocate how we spend our dollars and decide which treatments are effective and which ones aren't. Coordinated—that is doing things differently.

There are plenty of people opposed to reform. Why should they participate? What's at stake?
By the early 2020s, nearly half of the patient population is either going to be covered by Medicare or Medicaid. These are demographic facts. The principles of providing integrated, outcomes-based care that the CCOs will pioneer, starting with the Medicaid population, will eventually, in my view, influence delivery in the Medicare population. In time, this then will expand to the private insurance sector, too. If you're not involved, you are not learning new methods to deliver better health care, nor are you helping to shape these new methods. This is a pivotal moment in the evolution of our health care system and we all have something to contribute, we can all learn from each other.

How is OHSU taking part in this change?
As Oregon's only academic health center, we, as a public entity, have a great responsibility to participate in both the formulation of health policy and also in the eventual implementation of that policy

But won't reform hurt the university, particularly the hospital?
In the short term, it will be difficult for OHSU because it means there will be significantly diminished margins in the clinical arena, which help support our academic and research missions. So if you look at it only from the financial perspective, OHSU should try to resist change because there will be a short-term negative effect. But ultimately, that won't work. We are trying to purposely help change our state's health care system, one in which we're very successful, because that system can be better, it must be better. We are confident OHSU will find a role in a new system where we can continue to provide great value to Oregon. It'll be challenging, but very exciting, and it is the right thing to do.

Say you're a physician for the moment and not OHSU's president. Do you see health care reform differently?
As a physician, you're the individual patient advocate. That's historically how we've been trained. There are many reasons why that is laudable and why aspects of that must be preserved. But when I have my OHSU president hat on, I must acknowledge that the state and nation have a limited set of resources for health care. I ask myself: How do we use those resources to create the most health for this patient population?

OHSU_L5098_web-300x200What do OHSU students think of health care reform and changes to the system?
They're excited. They can see that preserving the status quo won't work over the course of their career. They want to enter a system that works. So they're some of the biggest supporters of reform.

What role does research play in all this?
Ultimately, it's research that holds the greatest promise through finding less expensive treatments, discovering more efficient systems and applying discoveries in new ways that prevent disease. It's absolutely paramount to reform's success, and one of the means by which we'll get there.

Let's look into the future, say 20 or 30 years down the road. What does Oregon's health care system look like?
There will be many organizational changes, some of which are still being worked out, but most important, the patient experience will be much improved. We'll have made progress toward providing everyone in this country with a basic benefit plan. Care will be coordinated and rigorously tied to outcomes. In Oregon, we'll be utilizing our resources according to the Triple Aim of improving the lifelong health of Oregonians, increasing the quality, reliability and availability of care for all Oregonians and lowering or containing the cost of care so it is affordable for everyone. The citizens of Oregon, as a whole, will live longer and be healthier. That's what I hope to see, and by embracing the changes that are inevitably coming and working together in a coordinated fashion on health care transformation, we can build something better.


Pictured above: (top) President Robertson; (Middle) Gov. Kitzhaber and President Robertson at a May 4 press conference about the CCO/Medicaid agreement; (bottom) President Robertson meets with School of Medicine students to discuss health care reform and other issues

- Written by Tim Kringen and Kathleen McFall