Comments to Copley Board Strategic Planning Meeting: Trapp Lodge 102822

Background:

I grew up 500 feet from the original 1932 Copley Hospital. I had my tonsils and appendix removed there by Doctor Phil Goddard, our family doc, and he set my broken arm when I broke it skiing in our backyard.

In 1957, my mother Cynthia Couture helped raise funds for the new hospital in Mr. Farr’s hayfield next door. Our house was recently bulldozed to add to your expanding parking lot. My sister Claire Hancock for three decades has been your head of social services. I have a long history with your wonderful institution.

As a VTDigger columnist, I’ve written and spoken extensively about the current state of healthcare in Vermont and recently led three classes on the subject for Vermont elders. My pieces are available at Schubart.com.

Personal Biases:

I’m a firm believer in Dr. Berwick’s Moral Determinants of Health as published in Jama in June of 2020. Berwick is a world authority on the delivery of high quality health care defined through his ground-breaking work with the Institute for Health Improvement, a Harvard Medical School think-tank and through his experience as a former administrator of the Centers for Medicare and Medicaid Services (CMS).

I quote: “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, nutrition, physical, dental and mental healthcare, substance-abuse treatment, childcare, education, and a non-toxic environment are all drivers of illness that are increasing to varying degrees in our state.

Also, childhood toxic stress resulting from adverse childhood experiences(ACES) is driving a lot of physical and mental illness. ACE diagnostics should be universal in early education with trauma-informed counselling available to families to help heal young people.

Furthermore, medicine’s “guild mentality” has managed to segregate physical, mental, and dental care and treatment, even as established research and brain imaging have shown scientifically that they’re integrated physiologically.

• 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 they’re distinct channels of healthcare and move to a fully-integrated system supporting population health.

While Governor Scott focuses on his “affordability agenda,” this false economy continues to generate cost-inefficient healthcare expenses at the remediative level. Our outrageous investments in physiological healthcare and our willful resistance to adequately funding mental and dental health are jamming our emergency rooms and our jails  ̶  the most expensive way to deal with population health. We must move those investments upstream to education and prevention, and get serious about regulating pharma and the chemical and industrial food industries to improve population health and reduce chronic disease.

Finally, I’m convinced that a national program of universal healthcare is ultimately the only way to reduce the $4.1 trillion or $12,530 per person we spend annually on healthcare. Here in Vermont we spend $6.5B and that is just below the $8B annual budget for the entire Vermont government. No other country in the world spends what we spend on a healthcare system that produces outcomes ranked 28^th in the world. See Yale study.

For further perspective, I would urge you all to read Dr. Gabor Mate’s book The Myth of Normal. It’s a driving force behind much beneficial change.

A Model for Healthcare Delivery in largely rural Vermont:

We must deploy a spectrum of services running from sole practitioners to small group practices, to community health centers and 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-capable ERs with allocated specialty practices. The others can be repositioned as expanded community health centers with a broad focus on access, urgent care, diagnostics and local treatment.

With the further integration of telemedicine for certain presenting systems, we can also add system capacity. And new capabilities in artificial intelligence(AI) combined with electronic health record(EHR) systems may help address the challenges of doctor-patient time, diagnostics, privacy management (HIPAA) and data-entry accuracy.

In such a system, a patient’s point of entry would be based on their symptomatic acuity, the first best choice in non-traumatic injury being a local primary-care facility. Major trauma will 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 or for sheltering indefinitely young people in psychiatric crisis or admitted addiction cases.

In summary:

I’m increasing convinced that investments in alleviating the stress that we as a society continue to tolerate is our most cost-effective, long-term solution – we already know there is enough money invested in treating the results of this stress to fund most of our 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 and producing mediocre outcomes.