Healthcare: a self-driving truck with no GPS
I cannot pretend to know what motivated the University of Vermont Health Network’s(UVMHN) recent announcement about suspending its future mental health plans. I can only hope that our region’s dominant tertiary-care hospital recovers its lost sense of mission and focus on “population health” and the wellbeing of Vermonters rather than business expansion and asset-accretion.
So, please read the above headlines carefully. What do they say to you about UVMHN’s much-touted commitment to “population health?”
- Do they tell you, as they wish, that given the rejection by the Green Mountain Care Board(GMCB) of its midyear request for permission to raise its fees another 10% on top of the 6% increase they just got for the current year, that they cannot address one of the most serious health problems we face in Vermont, the mental health care and wellbeing of all Vermonters, especially children, adolescents, and young adults?
- Is it a simple quid-pro-quo hostage tactic to ultimately get a double-digit increase in 2023?
- Or, given the need for reform focused on population health, is it actually a beneficial outcome that they won’t be expanding given their present medical model of inpatient psychiatry? UVMHN has not had a stellar history in mental health services and may lack the creative vision that providing quality mental health services demands.
The fact that these questions are in play means that UVMHN is essentially failing Vermonters, as each question is inconsistent with any vision for patient-centered care.
As to the first question, here are some important data regarding UVMHN’s comparative costs:
Vermont’s academic medical center is one of the most expensive in the country.
As of 9/1/2020, UVMHN has $194,792,000 in cash reserves and $544,279,000 in “Board-designated assets.”
According to page 7-8 of UVM Medical Center’s(2020 990 tax form The three “total” columns on page 8 add up to $16.9M a year for 26 UVMMC administrators ̶ an average annual salary of $650,000 each.
As to the second, is UVMHN holding Vermont’s mental health system hostage in its negotiations for hospital budget increases?
When the GMCB declined the Network’s(UVMHN) request for 10% rate hikes, the Network announced that these projects, so critical to Vermonters, and, especially, young Vermonters, have slipped again in priority.
Is Vermont’s debilitated mental health system being used as leverage for the GMCB approving substantial budget increases in years when they project losses, while allowing the Network to keep revenue overages in years when the budgets produce significant positive fund balances?
Furthermore, UVMHN has just announced it will not renew its contract with a number of nursing homes for whom it has supplied medical directors and on-site physician visits, both of which are mandated by state regulation. Nursing homes cannot admit patients without this physician component and will, as of June 30, be left out of the network while patients remain stuck in hospitals. Is this a pattern?
No other regulated entity in Vermont would be allowed these liberties with Vermont dollars, nor should they be. Holding the mental wellbeing of Vermonters hostage in defiance of mission is indefensible.
The third case is probably the best outcome of all, given UVMHN’s mixed history with mental health care provision, which ranges from evasion to inpatient care remote from family and community.
Especially with young people, hospital diversion to community-based resources, which are better-equipped to handle acute mental health issues, makes more sense than storing young people on gurneys in emergency rooms for lack of in-hospital mental health beds as is currently the case.
It’s also important to hold the State accountable here. Since closing its flooded State Hospital in Waterbury in 2011, Vermont has never had an appropriate vision and policy for providing for those with chronic mental health issues. Off-ramping care to hospitals with no clear state vision or policy is equally unconscionable.
UVMNH’s proposed 25-bed psychiatric facility at the Central Vermont
Medical Center(CVMC) in Berlin was put on hold because estimates for the project, which included upgrades to CVMC, came in at $150 million. So, let’s take the $150 million and invest it in community-based mental health where it would go a long way to producing tangible improvement in mental health care at the community level where it belongs.
Further points in question:
UVMHN’s current strategy denies the necessary collaboration between independent primary care practices, federally qualified community-health centers(FQHCS), critical-access community hospitals, tertiary-care hospitals, and health insurance providers. Only an organic design that acknowledges the unique role and mission of each will ever deliver on the promise of “population health.”
Now that UVMHN has crossed an ethical Rubicon and become both a healthcare provider and a commercial insurer with its Medicare Advantage insurance business ̶ businesses currently being snapped up by private equity because of the immense profit potential at the expense of policy holders ̶ how will they reconcile the inevitable conflict when they deny care to their policy-holders through “claim denials?”
How much money did they spend in public relations and marketing to acquire the modest number of UVM Medicare Advantage policy holders, money that could have gone to patient care and caregiver salaries?
Does the UVMHN Board of Trustees have any sense of how the institution they manage is perceived by those who need it? Why is there no longer a public comment period at each Board meeting? Why are there no community stakeholders on the search committee for the new CEO, Dr. John Brumsted’s ultimate replacement? Does the Board perform annual 360 performance reviews of their CEO with stakeholder input? Does the Board regularly review performance-against-mission for the institution they govern? How many on the Board are also highly compensated employees of the UVMHN system, and is their intrinsic conflict managed? Do Board members know and understand its mission?
If UVMMC’s costs as compared to other regional academic medical centers are so high, how does this align with access and affordability, both intrinsic to its mission?
The final issue, and perhaps the most troubling, is the State leadership’s absence from this discussion.
When then Governor Shumlin moved the functions and mission of the Department of Health(DOH), which oversaw the health of Vermonters, into the Executive Office, they never got clearly returned and are now six free-standing departments of health within the Agency of Human Services:
- The Dept of Mental Health
- The Dept of Health Access
- The Dept of Health
- Disabilities, Aging, and Independent Living
- Dept for Children and Families
- Dept of Corrections
Do these agencies not share a single mission supported by different aspects of their work? What is the coordinating and oversight role of the Agency of Human Services in articulating, ensuring, and regulating the healthcare infrastructure to deliver population health to Vermonters?
What was or is the role of the Green Mountain Care Board? That depends on whom you ask and when you ask it. Con Hogan’s answer would have differed from Kevin Mullin’s. Is it the source and overseer of Vermont’s mission with regard to the wellbeing of Vermonters or is it simply a financial regulatory body whose role is to sustain the flagging hospital business models?
Governor Scott, whose crisis management of Covid has been by all measures excellent, must be asked what the State’s role is in overseeing the wellbeing of Vermonters and the access and affordability of its healthcare infrastructure. Until he answers that question, we’ll continue to stumble.
We Vermonters are aging and will need a cost-efficient and effective infrastructure for healthcare. Where will it come from? And how will we support young families considering a move to Vermont when it comes to housing, healthcare access, educational quality, childcare, paid family leave … all elements of “population health?”
I have no desire to join the growing number of Chittenden County Vermonters and others in the Northwest who have chosen to bypass the University of Vermont Health Network and its flagship hospital to make the two-hour trip to Dartmouth to find accessible care.