Healthcare… A Way Home
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So, to envision and create effective change in our healthcare system, we must be honest with ourselves about the challenges and opportunities that deter or impel strategic change.
I. Challenges:
Ineffective nonprofit board governance: Hospital boards (as well as many other nonprofit boards) rarely seem to understand that they’re ultimately responsible for the success or failure of the institutions they govern. The president or executive director serves solely at the will of the board, which oversees the leader’s hiring, firing, compensation, and does an annual 360 performance review based on his or her effective delivery on mission. UVMHN is one of the most expensive academic medical centers in the country. Anecdotes about Vermonters struggling to access care are rife. UVMHN’s board is exclusively accountable and liable for their institution’s success or failure. Vermonters know it’s failing. Yet UVMHN’s immediate past CEO earned more than $2M. In December of last year, the UVM Health Network (UVMHN) Board awarded its current president a $481,648 bonus on top of his yearly salary of $1.354,712. Like the prior president, the current one earns close to $2M when all perks, retirement contributions, and performance bonuses are considered. One might expect this to be a reward for delivering on the mission of “population health,” meaning quality, affordability, and timely access. Vermonters who’ve given up accessing the system or can’t afford healthcare may wonder why the Board is awarding almost half a million dollar bonus for this performance.
A culture of arrogance… pervades the network of large hospital leaders, many of whom seem to believe that despite an often-touted “population health” mission, they know better than regulators, legislators, and the community they serve about how best to deliver healthcare. They often cast a shroud of “process-complexity” over hospital operations, believing this will camouflage their business-driven principles over a nonprofit’s obligation to deliver on mission. In a recent commentary in VTDigger, UVMHN’s CEO uses narrative capture (when an industry, company, or group changes the common narrative for their benefit) to make his case that UVMHN is succeeding in its mission when the impending Oliver Wyman report due Sept 18th may indicate otherwise. Another example and one that highlights resistance to any oversight: at the request of Delaware Republican legislators, the former UVMHN president recently traveled to Delaware to make a case to the Delaware legislature against establishing a healthcare regulatory agency along the lines of the Green Mountain Care Board which served as a model to Delaware legislators.
Ineffective gubernatorial leadership: Vermont has a much-respected governor who proved his mettle as a crisis manager during Covid, though less so during the recent flooding events. But he has wholly failed Vermonters on other key issues that affect their lives like affordable, accessible healthcare, meeting hunger and affordable housing needs, reducing homelessness, financing public education, and mitigating man-made environmental damage. Vermont has an equally popular lieutenant governor whose main interests appear to be advancing his political status and menses. The good news is that we have a State Auditor laser-focused on the issue of healthcare costs and a State Treasurer equally engaged in quantifying and remediating Vermont’s skyrocketing healthcare costs, now 19% of our GDP. (see slide 12).
Competing government understandings about who should oversee and regulate Vermont healthcare infrastructure: There are four “healthcare” agencies inside the Agency of Human Services (AHS) cabinet architecture. In 2014, the “Department of Health” was lassoed into Governor Shumlin’s office and was never fully returned to AHS. The current Secretary of Human Services believes that healthcare oversight belongs in AHS, as opposed to the Green Mountain Care Board. This power struggle is playing out in ambiguous statements from the Secretary and certain allied legislators, but the establishing statute is clear about the role and functional authority of the GMCB.
II. Opportunities:
In spite of significant underfunding, the Green Mountain Care Board (GMCB) is now providing effective, strategic regulation: After some 13 years of allegiance-muddled regulation, Vermont’s healthcare regulatory authority, established in 2011, has taken up the gavel and is analyzing, offering guidance, regulating, and holding accountable Vermont’s $6.37B healthcare industry (see slide 8). Its time has come.
A committed though seriously under-resourced bicameral legislature, hampered by ineffective and outdated traditional process: For the most part, Vermont legislators are deeply committed to solving Vermonter’s durable problems, but they do not have access to the analytical, scientific, and policy resources to make legislative headway on many of Vermont’s most daunting problems, including healthcare. Sadly, on many of the key issues, they rely on lobbyists deemed “educators.” At its best, this is advocacy. At its worst, it is corrupt influence-peddling. But the Vermont Legislature has the authority and the will, if not yet the resources, to solve these problems.
The Vermont Business Roundtable (VBR): A Vermont business community with over 100 members is waking to the knowledge that the accelerating cost of healthcare for their employees — currently at some $13,300 annually — is an unsustainable business expense. But with Dr. Sunil “Sunny” Eappen, president of Vermont’s largest private employer, UVM Health Network on the Vermont Business Roundtable’s Board of Directors and with UVMHN as one of the largest contributors to Roundtable membership fees, based on gross business dollar volume, VBR must balance the interests of their members against the interests of their largest contributor whose president is a Board Director.
A seriously back-logged and under-staffed judiciary system but one that could conceivably play a role in advancing healthcare in Vermont: Former executive director of ACLU-VT Allen Gilbert pointed out in his 2016 book Equal Is Equal, Fair Is Fair the importance of the Vermont Constitution’s “common benefits” clause (Chapter 1, Article 7). It was the basis for the Vermont Supreme Court’s 1997 Brigham decision on educational funding equity, as well as the basis in 1999 for the Vermont Supreme Court’s Baker Decision on same-sex marriage benefits (civil unions). Gilbert raises the legitimate question of whether Vermont’s unique common benefits clause might also be applied to move the State towards universal healthcare access for all Vermonters.
III. Delivery:
Together, we must articulate a consensus on a vision for the key design imperatives for a sustainable Vermont healthcare system that delivers on the mission of population health – quality, access, and affordability.
- Legal definition:, all Vermont hospitals must be nonprofits and licensed with a certificate of need (CON). They must be governed by a governing board of trustees. Nonprofit boards are self-perpetuating. Trustees are not chosen by the hospital chief executive, who, in fact, serves solely at the will of the board. The independent board hires, fires, compensates, and reviews annually the performance of the hospital’s chief executive with a focus on mission delivery.
- Regulatory authority: Authorize a sustainable government authority to provide oversight, guidance, regulation and accountability — the Green Mountain Care Board (GMCB)
- Community-based: Proximity to served populations: Move current downstream investments in large, consolidated hospital systems upstream into education, prevention, and funding community level resources, the most important of which is primary care including trauma-informed counselling.
- Collaborate, don’t compete: Currently, most hospitals compete for market share by acquiring other healthcare facilities. Nonprofit hospitals must not compete for market share but rather collaborate and allocate services among one another to create a sustainable system that meets the goal of “population health for Vermonters.” The current consolidation has escalated healthcare costs and insurance premiums rather than creating efficiencies.
- Patient acuity (seriousness of patient condition needing care) will determine point of entry into the system: Instead of urging all patients to present at urban emergency rooms where the cost of primary care is highest and wait times are the longest. Patients will generally seek help in their communities.
- Scale: In a functional model, hospitals will be scaled in size and scope of services to market limitations and federal reimbursements from Medicare, on which some 70% hospitals comparable to UVMMC break even or earn modest revenue (see slide 4).
- Tertiary-care hospitals such the UVM Medical Center and Dartmouth Hitchcock, will be no more than that and will be prevented from offering services that belong in local communities, such as primary care, hospice, chronic-disease management, parent-child centers, aging & disability assistance and local and regional clinics.
Were we to draw a straight from servicing a patient at home all the way up to the regional tertiary-care hospital it might look like this:
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- universal periodic home visits by medical paraprofessionals or visiting nurses
- community-based healthcare agencies (parent-child centers, agencies on disability and aging, chronic-disease management, hospice) and community solo and group medical practices
- local clinics and federally qualified health centers (FQHCs)
- critical-access hospitals (6, not 8)
- regional hospitals (4, not 6)
- tertiary-care hospitals (UVM and Dartmouth Hitchcock)
Over the decades, we Vermonters have usually found solutions to our most enduring problems and together we can again, but only if we acknowledge what and who stands in our way.
