A Model for Vermont Healthcare

Health Center, Plainfield, VT

The Vermont healthcare system, infrastructure, and vision are broken, and Vermonters of all economic strata are the losers.

The soul of the system is fine if you can afford it or access it when you need it. That is, the quality of care provided by medical staff from nurses to nurse-practitioners to physicians’ assistants to doctors is generally good.

But a major legal tenet of healthcare is “standard of care,” which is early diagnosis and treatment. If a Vermonter can’t afford or get timely access to care, the existence of a healthcare system is meaningless to them. I have several male friends who, between their entry into the system seeking help and an eventual diagnosis of late-stage prostate cancer, waited from eight to 13 months because appointments were so hard to come by. What if any is the healthcare system’s liability?

Failure to address such a critical statewide problem trickles down from the top. While having proven himself a solid crisis manager during the pandemic, Governor Scott is not by nature one to address complex strategic issues and has not used his leadership voice to address and correct system failures at the policy and regulatory levels.

Instead, he has focused on his “affordability agenda,” a false economy since it continues to generate cost-inefficient healthcare expenses at the remediative level. Our out-of-scale investments in curing sick people and our willful resistance to adequately funding mental health and addiction treatment, prevention, education and regulation are filling our emergency rooms and our jails. There is no more expensive way to fund population health.

Our failures elsewhere are integral to our failures in healthcare. A world authority on healthcare, Don Berwick M.D. states in his classic “moral determinants of health”: “Circumstances outside health care nurture or impair health…., most hospitals and physician offices are repair shops, trying to correct the damage of causes collectively denoted ‘social determinants of health.’ Shift some substantial fraction of health expenditures from an overbuilt, high-priced, wasteful, and frankly confiscatory system of hospitals and specialty care toward addressing social determinants instead.”

Here in Vermont, poverty, expressed as lack of access to housing, adequate nutrition, physical, dental and mental healthcare, substance abuse treatment, early childcare, and a non-toxic environment, all contribute to stressors that produce the sicknesses that sustain our hospital businesses.

We must move our investment upstream to education, prevention, and serious regulation of pharma and the chemical and industrial food industries if we want to improve population health. That’s the only way to reduce the chronic diseases that drive so much healthcare expense now.

The Legislature tries hard, but with little policy and research support and a two-year window for action and a one-year budget cycle, they can do little more than tinker around the edges of a floundering behemoth, making it more expansive and expensive.

In theory, a governor would convene knowledgeable voices and stakeholders to derive a consensus and form a vision for population health in Vermont. This vision would inform and integrate all agency initiatives across state government.

The Vermont Dept. of Health (DOH) is a public health agency. Their obligation does not rise to ensuring “population health” or setting policy as it relates to designing a functional healthcare system, but rather focuses on protecting and promoting Vermonters’ health as it relates to clean air and water, environmental hazards, immunizations, stop smoking/drug abuse initiatives, safe-driving initiatives like seatbelts and infant car seats, and collecting mortality data. They are neither funded nor equipped to envisage and deploy an effective and cost-accessible healthcare infrastructure from physician offices to clinics, hospitals, and nursing and residential care facilities.

So, who does own the vision and set policy for healthcare infrastructure in Vermont? Today, it’s a legally nonprofit sprawl of free-market businesses.

The Green Mountain Care Board (GMCB) should regulate healthcare infrastructure based on healthcare policy. But that is a vision we have yet to articulate. The lack of a boundary between policy and regulation and the necessity that they come from different agencies muddles the GMCB’s understanding of its role today.

Furthermore, the medical profession’s “guild mentality” segregates physical from mental care, as well as from dental care and treatment, even as established research and brain imaging have shown scientifically that they’re integrated physiologically.

By way of example:

  • Periodontal disease causes congestive heart failure.
  • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) inflammation tests show us how psychological stress, anxiety, depression and other mental health conditions compromise the immune system and open the way for chronic disease.

We must finally lay to rest the self-serving falsehood that these are distinct channels of healthcare and move to a fully-integrated system that supports population health.

A Model for Healthcare Delivery in largely rural Vermont:

Deploy a spectrum of services running from sole practitioners to small group practices to community health centers including federally qualified health centers (FQHCs) to critical-access community hospitals to secondary-care hospitals like Rutland, Berlin, Copley, and Southwest, and finally to our two tertiary-care hospitals UVM and Dartmouth.

Of Vermont’s 14 hospitals, of which eight are critical-access hospitals, we probably only need six geographically-dispersed hospitals and trauma-service ERs with allocated specialty practices such as dialysis and joint replacement. The others can be repositioned as expanded community health centers with a broad focus on access, urgent care, diagnostics, chronic-disease management, nutrition and mental health counselling, dentistry, prevention, and education. The Health Center in Plainfield is a fine example of such a rural healthcare delivery facility.

A patient’s point of entry would be based on symptomatic acuity, the first best choice in non-traumatic injury being a local primary-care facility. Major trauma cases would be air or surface-ambulanced to a tertiary-care trauma center. True cost-effective care and timely access are achieved by directing patients to local services from whence they can be referred up the system to more sophisticated services based on diagnosed acuity. Emergency rooms should be used only for true emergencies, not for primary care.

Telemedicine for certain presenting systems can add system capacity. There’s also strong evidence on the effectiveness of self-care interventions in the fields of communicable diseases, non-communicable diseases, mental health, and sexual and reproductive health and rights. Guidelines exist covering conditions including depression, drug and alcohol use, stress management, migraine, hypertension, coronary heart disease, and HIV, among others.

And emerging capabilities in artificial intelligence (AI) combined with electronic health record (EHR) systems may help address data-entry accuracy and the need for more doctor-patient time together.

In summary, I’m increasingly convinced that investing in alleviating the stressors that we as a society continue to tolerate is our most cost-effective, long-term approach to healthcare – we already know there’s enough money invested in treating the dire results of these stressors to fund most of these societal needs.

Upstream investments in healthcare education, prevention, regulation, primary care, mental health, chronic disease management, addiction prevention and recovery will reduce the staggering sums we spend on fixing sick people, often with mediocre outcomes.

A national program of universal healthcare is ultimately the only way to reduce the $4.1 trillion or $12,530 per person we now spend annually on healthcare. Here in Vermont we spend $6.5B or $10,442 per Vermonter  ̶  not that much less than the $8B annual budget for the entire State of Vermont. No other country in the world spends what we spend on a healthcare system that produces outcomes ranked 28th in the world.

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