The Inversion: Make Primary Care Primary and Hospitals Secondary

Photo supplied by UVM Medical Center

We’re at an inflection point in healthcare reform in Vermont.

The number of Vermonters who can’t access or afford healthcare is a rising tide of expense, pain, and premature death. Meanwhile, an agreement among healthcare reform advocates about a shared path to reform that promises to deliver cost-efficient population health to Vermonters is also cresting.

There is emerging consensus.

We must invert our flawed policy of shoring up the finances of our fourteen hospitals and focus instead on investing in a network of community-based primary care health centers with integrated trauma-informed counseling and robust community support systems for families. Research shows increased primary care spending is associated with fewer ER visits, fewer hospitalizations, better health outcomes, and lower costs. But this path will require rightsizing some superfluous hospitals as community health centers and moving some of their secondary and tertiary services to regional hospitals.

Hospitals are not a gateway to wellbeing. Instead, they provide life-saving specialty services that can’t be offered at the community level: advanced diagnostics, surgeries, trauma and inpatient care. But the point of entry into the healthcare system must be community-based primary care health centers not regional emergency rooms, which are the most expensive point-of-entry and are chronically overcrowded and understaffed. Emergency rooms are for emergencies, not for primary care.

Today’s hospitals have built their business models on the misconception that they can be all things to all people, from primary care to home care and hospice and everything in between   ̶   “a well-being mall.”

This model’s failure to deliver access or affordability to Vermonters or, for that matter, even create a functioning financial model for themselves without endless rate hikes, only underscores the need to pursue a more effective design for Vermonters’ healthcare.


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Imagine a streamlined system where patients go to their local health center, are seen within minutes, diagnosed, triaged by severity and treated onsite for physiological, mental health, or dental issues. Education and counseling are also available onsite when the complaint originates from poor nutritional, environmental, economic, or social behaviors and conditions, such as adverse childhood experiences (ACEs). Being integral to their communities, health centers can better connect patients and their families with local services and support networks. Many federally qualified health centers (FQHCs) also offer reduced-cost on-site pharmacy services.

Community-based diagnosis, triage, counseling, and treatment when possible will reduce the crowds routinely filling emergency rooms today. Diagnoses that exceed the treatment capacity of the community health center escalate to regional hospitals, which can then better schedule specialist care and advanced procedures.

In response to this consensus about the vital importance of primary care access, the Vermont Legislature has introduced a Universal Primary Care bill (H.156) that calls on the Green Mountain Care Board (GMCB) to implement over the next decade “incremental implementation of Green Mountain Care,” starting with publicly financed primary care in the first year and adding preventive dental and vision care in the second, with no deductibles or copayments. As written, the bill does little more than express many legislators’ belief that community-based primary care in all its forms should be accessible to all Vermonters. As usual, it doesn’t say how, leaving it to the GMCB to figure out. But still, it’s another positive indicator of the gathering consensus about primary care. The bill, introduced by Rep. Brian Cina, Progressive/Democrat – Chittenden, said he does not expect the bill to move forward as written, but believes that just hearing testimony on his bill will be a win.


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Diagnostics: The Current System

Impact of Federal Policy: As former Governor Shumlin learned, the policies, regulations, and finances of Vermont and the nation are inextricably linked, making it impossible for Vermont to go it alone in healthcare. But this does not mean that we can’t pioneer and significantly reduce the current barriers denying or delaying healthcare to so many Vermonters.

Underinsured Vermonters: Last year, 38% of all insured Vermonters (187,800) were determined to be underinsured.Underinsured” is defined as “persons with insurance but whose policy does not sufficiently cover current medical costs.” Although fully-insured, they can’t access care due to the high cost of co-pays, deductibles, and co-insurance. Among the underinsured with past-due medical debt, 84% owed money to hospitals and 16% to outpatient facilities, and 34,500 Vermonters have used up all or most of their savings to pay medical bills.

Uninsured Vermonters 18-to-64-years-old were 3 to 7 times more likely to defer care due to cost than insured Vermonters, depending on the type of care. And in 2019, Vermont hospitals reported $85 million in medical debt, not including bills paid off with credit cards or put on long-term payment plans.

Cost-effectiveness of OneCare VT: The Green Mountain Care Board (GMCB) is questioning the fiscal performance of OneCare Vermont against its stated mission to “represent a cooperative effort of providers who have pooled their resources and expertise to deliver care that is better coordinated, yielding better health outcomes and greater satisfaction… .OneCare supports providers through three key core capabilities: network performance management, data and analytics, and payment reform.” Notably absent from this quote is either “lower costs” or “improved access.”

But according to a December VTDigger report on OCV’s hearing with GMCB, tough questions resulted in few answers about the costs behind OCV’s results: “OneCare’s funding between 2017 and 2021 totaled more than $133 million, according to the organization’s audited financial statements. Of that, around $66 million was spent on administration and software to combine and analyze electronic health records and distribute results to providers.”

Half spent on administration and data?

UVMHN Consolidation and Expansion:

  • UVMHN with MVP created its own UVM Medicare Advantage Plan, crossing the traditional boundary between provider and payer.
  • In July last year, UVMHN eliminated any authority of its individual governing boards and the working committees of its affiliate Vermont hospitals. UVMHN owns three Vermont hospitals: UVMMC, Porter Hospital (Middlebury) and Central Vermont Hospital (Berlin). Henceforth, UVMHN will manage each hospital’s financing, budgeting, and strategic planning, making all the decisions for the three hospitals it owns, no longer with community input.
  • In the fall of 2021, OneCare became part of UVMHN, giving it control over all of OCV’s claims data. (All Vermont payers ̶   Medicaid, Medicare, commercials  ̶   give their claims data on ACO-attributed lives to the ACO.) Giving claims data to an independent ACO (OneCare) is one thing, but giving that same claims data to the biggest healthcare enterprise in the state is altogether different.
  • UVMHN recently sent a letter to its 8800 employees ordering a language change: “In place of the word “affiliate,”we’ll use the words health care partners to refer to each of the organizations that are part of the UVM Health Network (our hospitals and healthcare organizations, including the UVM Health Network Medical Group and Home Health & Hospice). We’ll use the words academic partners to refer to our health system’s essential academic partners, the UVM Larner College of Medicine and the UVM College of Nursing and Health Sciences. To note relationships with certain community and philanthropy organizations, we’ll use community partner”… an overarching master brand that brings together organizations that make up the health system and connects to academic partners, resulting in an Integrated Academic Rural Health System. The words we use to universally express ‘connection’ and ‘shared’ inside and out – can help us together build a stronger UVM Health Network brand.”
  • UVM Health Network (UVMHN) has applied to the Green Mountain Care Board (GMCB) for a “certificate of need” (CON)) to build a new $130M ambulatory outpatient surgery center. How does this square with the prior fiscal year’s $90M reported operating loss? Can we believe UVM Medical Center’s (UVMMC) president Steve Leffler’s claim that they will recover the cost of the new facility from operations within six months? If so, at what additional cost to patients?

The article in Digger paraphrases UVMHN: “fully staffing the new center would require filling an additional 78 positions, for which the hospital plans to begin recruiting 18 months prior to opening. Hospital leaders said that they do not anticipate either staffing or financial concerns would stall the project.” This begs the question of why UVMMC has for several years been unable to hire sufficient full-time hospital nurses and has had to rely on expensive “travelers.”

And how is it that the desperately needed inpatient psych facility proposed a few years back for Berlin was cancelled because of cost? Could it be that ambulatory outpatient surgeries more profitable than desperately needed inpatient psychiatric care?

Franklin Northeast Supervisory Union Superintendent Lynn Cota testified February 9th before the House Committee on Education that children’s mental health in our schools is “dangerously close to a breaking point.” UVMMC hospital and Porter have both reported publicly that on any given day they have many young people in their emergency rooms presenting with severe psychological disorders  ̶  self-harm, suicidal ideation, eating disorders, depression, adverse childhood experiences (ACEs), and substance-abuse issues. There are few if any referral options and many young people spend days or weeks in the emergency room (ER) sleeping on gurneys in paper clothing awaiting help.

We are clearly at a crisis point and the urgency we face demands immediate action.


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Proven to be a more cost-efficient means of delivering population health to Vermonters, our future efforts must be to fund and support primary care and put the well-being of Vermonters first.

We must:

  • understand that nutrition & food systems, housing, education, social justice, livable-wage employment, and a healthy environment are all integral to sound healthcare policy,
  • move our social investments upstream to prevention, education, diagnosis, trauma-informed counseling, and early treatment,
  • invest our resources in people, families, and communities where the cost-efficient support systems are, not in expansive health enterprises seeking greater market share.

Vermonters are coming together to do this now.


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