Future of Vermont Healthcare Council

Mission: To refine, design, and advocate for a healthcare system that delivers quality, equity, access, and affordability for Vermonters.

Academic alignment and fiscal agent (501©3): Dartmouth Institute

Funding Resources: Turrell Fund, VT Community Foundation, Windham Foundation (conferences), Johnson Family Foundation

Media Initiatives: VTDigger, SevenDaysVT, Vermont Public, Addison Independent, WDEV Radio, 28 locals, YouTube channel

Legislative Healthcare: leadership: Rep. Lori Houghton and Alyssa Black

Sen. Nadir Hashim, Brattleboro

Sen. Ruth Hardy, Addison

Rep. Mari Cordes, Addison

Sen. Martine Gulick, Burlington

Theresa Wood, Chittenden

Jill Krowinski, Speaker

Sen. Andrew Perchlik

Sen. Tom Chittenden,

Tanya Vyhovsky, Chittenden

Mike Fisher, former legislator (MFisher@gmavt.net)

Vision: Our patient-based healthcare system will use a spectrum of facilities starting with an evenly distributed network of community-based primary care and diverse social services. This will include sole practitioners, group practices, and small clinics. Next will be larger regional clinics and critical-access hospitals. And, finally, secondary and tertiary-care hospitals such as Dartmouth, UVM, and Albany Medical Center. The system’s point of entry will be local primary care except in the need for emergent care. In consultation with their primary care provider (PCP), a patient may escalate through the system based on acuity and their need for more sophisticated procedures.

Current Analysis:

Vermont is at a crossroads. For almost eight years, Vermont has pursued a healthcare reform project, the “All-Payer Model,” intended to reduce healthcare costs, improve access and affordability, and improve quality. It has accomplished none of those goals.

The Accountable Care Organization (ACO), responsible for implementing much of the model, has failed to improve care or lower costs and, in fact, is serving a decreasing number of Vermonters. The situation gets worse by the day and Vermonters suffer as a result.

Health costs have risen dramatically, averaging 15+% annually, while access has deteriorated.
44% of insured Vermonters are underinsured and cannot afford care and still others struggle with medical debt.
Primary care physicians, nurse practitioners, physician assistants, nurses and mental health professionals are leaving the field and not being replaced.
Although we’ve committed in principle to mental and physical health parity, the mental health system is hopelessly under-resourced, leaving many unable to access basic care.
There’s a severe shortage of substance-abuse professionals, while overdoses are at an all-time high.
School budgets are being voted down in large part because of the high cost of employee healthcare and our schools’ need to offer a range of health services to students that are otherwise unavailable in their communities.

Vermont needs to make a choice.

Discussions are underway about whether or not we should pursue the “AHEAD” model sponsored by the Centers for Medicare and Medicaid or take a different approach. The AHEAD model won’t solve our problems. Another approach is needed.

Vermont needs to undertake a comprehensive review of what services are best provided and where. One step would be to redirect administrative funds currently spent on our struggling ACO, OneCare Vermont.

Fortunately, we know what needs to be done and how to do it. But we need a funded organization to engage and educate the public and the legislature about the current state of healthcare and what we must do to build broad support for systemic change.

There are two key drivers to this change.

First: Focus more on health education, prevention, and keeping Vermonters healthy and out of hospitals by investing upstream in our communities, funding primary care, mental health, home health and other community services.

Second: Make our hospital system more cost-efficient by removing wasteful and avoidable spending. One critical data point in hospital spending is the ratio of money spent on clinical care (patients) vs. administration and management, a metric where our hospitals fare poorly. Reallocating wasteful expenses upstream to prevention and primary care will help accomplish goal one and lower costs and keep people healthier. We know from the broadly accepted social determinants of health that community services and care drive good health.

Our shared vision for a better healthcare system:

An accessible and affordable healthcare system will focus on prevention, education, and robust community wellness services.

Primary and mental healthcare will be available in community services like group practices, local and regional clinics, homecare, hospice, chronic disease management, addiction services, and support for the ageing.
Regional critical-access hospitals will manage emergency trauma and diverse specialty procedures such as dialysis and orthopedics.
Our tertiary-care hospitals ̶ UVM Medical Center and Dartmouth ̶ will only treat high-acuity patients who cannot be treated in their communities.

There is no more expensive and less efficient primary care than in emergency rooms.

The data show that Vermont hospitals provide a substantial amount of avoidable care ̶ care that could have either been treated locally or prevented altogether with early intervention or local care after hospitalization.

To realize this more accessible and equitable system of community services we must also address current hospital spending.

The Green Mountain Care Board has the legal authority to set limits on hospital spending. The board needs to do just that. Tools such as rate-setting, reference-based-pricing and global budgets are available. The money saved can and must be redirected to community services.

A Mathematica study in 2022 (right link?) stated that 10-34% of care in Vermont hospitals was “avoidable.” This waste, which is in the tens of millions of dollars, must be reallocated into communities for primary care, mental health, and home health. Lower spending in the hospital system will also lead to lower insurance costs.

Expanding and improving local primary care will also require investment in recruiting more physicians and nurses, raising salaries for primary-care staff, subsidizing medical school debt and reducing the administrative burden on providers.

We must embed Adverse Childhood Experiences (ACES) training and screening in all primary care. We must train all professional care-givers in the critical epigenetic role that trauma plays in creating and exacerbating not just mental but also physical illness.

Hospitals will have to rethink their role in their communities and re-structure or consolidate services, possibly even reallocating staff from hospital settings to community services. There will be no loss of jobs, since there’s a growing demand for services and for professional staff.

Home-health services also have a critical role to play in helping people stay out of the hospital by monitoring chronic conditions and helping people leave the hospital with post-discharge rehabilitation. Home-health also provides invaluable but grossly underused hospice services. Investing in our community systems is far more cost-effective than sustaining double-digit increases for hospital care. It also improves healthcare equity.

We long ago committed to the principle of equitable access to physical and mental health care for Vermonters but have consistently failed to deliver. The system’s been allowed to deteriorate for years. Universally available mental health will require a large investment over time. To replace acute-care beds and incarceration we’ll need therapists, in-patient beds for youth, emergency services, law-enforcement training, and designated treatment facilities.

Finally, hospitals in Vermont require a “certificate of need,” which means by legal definition and governance, that they are not-for-profit. Nonprofits are legally held accountable for delivery on mission not profitability. Our hospital governing boards must come to understand their institutions as mission-driven rather than as lucrative businesses. But there are strong forces working hard to preserve the status quo. No significant healthcare reform has emerged over the past eight years despite declines in access and increases in costs.

Vermonters are ready for a different approach. This will require political leadership and will. Our plan is to develop a grassroots initiative to advocate for the necessary changes described above and engage our legislative and administrative leaders in undertaking the work necessary to transform our system to achieve the shared goals of population health… quality, access and affordability.

Vermonters can show the rest of the country that a patient-centered, evidence-based healthcare system can and will deliver on this vision.

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