Future of Vermont Healthcare: Goal and Vision



Future of Vermont Healthcare Council

  1. Goal: For Vermonters to find consensus on and advocate for a healthcare system that delivers quality, equity, access, and affordability for all Vermonters.

A broad consensus exists among healthcare reform advocates. We know what needs to be done and how to do it.

We need a funded organization to publicly support the work of the Green Mountain Care Board (GMCB), engage the legislature, and the public about the current state of healthcare and what we must do to build broad support for systemic change.

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

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

Media Outreach: 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

Tanya Vyhovsky, Chittenden

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

Chris Pearson, former legislator (christopherap@gmail.com)

  1. Vision:

Our patient-based healthcare system will use a spectrum of facilities the head of which will be an evenly distributed network of community-based primary care and social services. The 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. As such, our healthcare investments must move upstream into community-based primary care, prevention, education, chronic-disease management, aging, in-home recuperative care, and family support systems. Savings from reductions in hospital over expense and waste avoidance will fund this.

  • Community: sole practitioners, group practices, and small clinics.
  • County: Regional clinics, federally-qualified health centers (FQHCs), and critical-access hospitals.
  • State: Secondary/tertiary-care academic medical centers such as Dartmouth, UVM, and Albany Medical Center.

This goal is reflected in the VT Blueprint for Health:

“The Blueprint’s design work responds to the emerging needs of Vermonters and the latest opportunities in health and human services reform, creating change in the delivery system. This work began with patient-centered primary care and community health, then a system of treatment for opioid use disorder, and is now addressing the social determinants of health. The Blueprint Network of locally-hired Program Managers, Community Health Team Leaders, and Quality Improvement Facilitators work with ACO and community-based partners to lead the implementation of these innovations in practices and communities across Vermont.”

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.

Nor has the Accountable Care Organization (ACO), responsible for implementing much of the model, done much to improve care or lower costs and is, in fact, serving fewer Vermonters. The situation deteriorates 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 and not being replaced.
  • Although we’ve committed in principle to mental and physical health parity, the mental healthcare 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.

Action Plan:

  1. Authority: The Green Mountain Care Board has the legal authority to realize this vision. Tools such as rate-setting, reference-based-pricing, and global budgets are available. Money saved can then be redirected to community services and cost reduction.
  2. Review: Vermont must undertake a comprehensive review of what services are best provided and where. A funding source might be the administrative funds currently spent on our struggling ACO, OneCare Vermont.
  3. AHEAD Model: A plan to pursue the “AHEAD” model sponsored by the Centers for Medicare and Medicaid is in the works at the Green Mountain Care Board (GMCB) and at the Agency of Human Services (AHS). Although there is dissent on its utility, authorities believe it is consistent with and will advance Vermont’s healthcare goals.
  4. Make primary care primary: 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. We know from the broadly accepted social determinants of health that community services and care drive good health.
  5. 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. Some hospitals will have to reassess 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.
  6. Avoidable care: 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. We must make our hospital system more cost-efficient by removing wasteful and avoidable spending. A Mathematica study in 2022 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 or primary care, mental health, and home health. Lower spending in the hospital system will also lead to lower insurance costs.
  7. Hospital Budgets: 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 excess administration and management expenses to prevention and primary care will help lower costs and keep people healthier. Emergency rooms are the most expensive delivery system for primary care.
  8. Mental Health: Our commitment to equitable access to physical and mental health has consistently failed to deliver. The system’s been allowed to deteriorate for years, and 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, mental health first-aid training, and designated treatment facilities. We must embed Adverse Childhood Experiences (ACES) training and screening in all primary care and train professional care-givers in the critical epigenetic role that trauma plays in creating and exacerbating not just mental but also physical illness.
  9. Governance: Finally, hospitals in Vermont require a “certificate of need.” By legal definition and governance they must be nonprofit. Nonprofits are legally held accountable for delivery-on-mission not profitability. As such, our hospital governing boards must 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.

Conclusion: 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, support the GMCB in their reform work, 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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