Vermont Healthcare: A Mare’s Nest

As I’ve written in the past, we’ll never sort out the hot mess that health care’s become in Vermont and in the U.S. until we agree on the fundamental question of whether health care is a definable right or just a lucrative business.

Our persistent ambivalence only extends its cost and complexity with second-class outcomes. With a total domestic cost of $3.8 trillion (17.7% of G.D.P. / $11,600 per American) and worse health outcomes than those of our peers abroad, we can no longer evade the question. Reduced to its simplest terms, today the health of Vermonters must compete with the privilege of those who makes billions out of misfortune.

My knowledge about the health care industry dates from 2002-2006 when I was recruited to chair the recently consolidated Fletcher Allen Hospital, just as its former president Bill Boettcher was indicted for lying to regulators about the hospital’s expansion and began serving a two-year jail sentence. My cram course in the health care industry left me full of questions about its future.

Where to start?

The arcane lexicon of health care doesn’t help. Know what “denial management,” “capitated payments,” “open-source wellness,” or “OneCare,” mean? Join the crowd.

To begin with, do 620,000 people living in such a small state need fourteen hospitals? Arguably not. Adding five to the eleven hyperlocal Federally Qualified Health Centers (FQHC) we currently have would more cost-efficiently serve Vermonters’ health needs –  a key focus of Senator Sanders. Our two tertiary-care hospitals, UVM and Dartmouth, and perhaps six regional critical-access hospitals collaborating (rather than competing) on allocated specialty care and procedures would enhance quality while lowering system costs.

It might also help alleviate the severe shortage of health care professionals. From nurses to nurse-practitioners, physician-assistants, primary-care doctors and specialists, hospitals are struggling to find staff. And the well-documented lack of primary care doctors turns the system on its head from a cost-efficiency perspective.

Before becoming chair, I  chaired the “physicians’ compensation committee,” and learned that contrary to conventional market-demand algorithms, the doctors most in demand were at the bottom of the pay scale while the few marquee surgeons earned more than the CEO. Why? Because compensation was based on billing potential rather than need or systemic – read preventive – value. It’s encouraging that UVM Medical Center (UVMMC) is currently reviewing their compensation philosophy.

At UVMMC, this personnel shortage is leading to long delays in patient scheduling. Patients seeking orthopedic, spinal, or pain treatment can wait months for an appointment. I was initially told it would be four to six months before I could get a hip replacement. Many prospective patients now resort to the growing number of for-profit specialty clinics popping up around Chittenden County or travel to Dartmouth where these procedures are more accessible.

Governor Scott, celebrated nationally for his management of Covid in Vermont, remains curiously silent on the broader issue of health care strategy. So, who owns health care vision and policy formulation in Vermont: the Agency of Human Services (AHS) with its six departments, including the Vermont Department of Health, Department of Health Access, the Department of Mental Health, the Department of Corrections, or… The Green Mountain Care Board? Is it not the Governor’s task to lead or assign responsibility?

Who will be the driver and champion of a vision for improving health care access, affordability, and outcomes and deploying OneCare if not Governor Scott, his AHS Secretary Mike Smith, the Green Mountain Care Board, or John Brumsted, CEO of VT’s largest health care delivery system?

Without OneCare becoming a reality across our network of health care delivery systems, our Medicare waiver will not work nor will we ever be able to manage the consumer cost escalations for those who can afford access.

This disturbing lack of vision, leadership, policy formation, and accountability in health care strategy is at the root of the problem.

The Green Mountain Care Board’s (GMCB) original 2011 mission called for experienced leaders in health care policy to:

  1. improve the health of the population;
  2. reduce the per-capita rate of growth in expenditures for health services in Vermont across all payers while ensuring that access to care and quality of care are not compromised;
  3. enhance the patient and health care professional experience of care;
  4. recruit and retain high-quality health care professionals; and
  5. achieve administrative simplification in health care financing and delivery.

Under Governor Scott, with the appointment of Sen. Kevin Mullin (R-Rutland) as chair, the focus of the GMCB tilted from visionary goal-setting by experienced health care professionals to more bottom-line cost-control overseen by financial experts. The 50-member GMCB Advisory Committee (of which I was a member) shrank to less than half, many of whom are now stakeholders in the current system.

Although Vermont has partnered with the federal government and bought into the concept of OneCare, it still faces stiff headwinds – not because it’s a faulty concept but because it lacks government leadership. OneCare’s core tenet is philosophical. To quote Ben Franklin, “An ounce of prevention is worth a pound of cure.” Move the $6B spent each year in Vermont in transactional costs upstream into prevention and “population health.” But OneCare is misunderstood by many in the health care and legislative communities. Often confused with single-payer and multi-payer systems, it works with either, although the latter is clearly becoming the norm.

As one hospital administrator put it, and I paraphrase:

We’re dependent on a steady stream of broken people for our survival. We repair and bill transactionally. The sum of those transactions keeps our doors open. If we were simply given our annual budget against an accountable and measurable commitment to invest in prevention, education, and maintaining population health, we would save money and see fewer sick Vermonters.

If we are ever to achieve “population health,” it must involve committing to an integral understanding of physiological and mental health from a care perspective. We closed most of our “mental hospitals,” such as they were, and built more prisons. Now we have the tragedies surrounding teens and adults being housed in emergency rooms for lack of any resources in mental health, which is shameful. The Howard Center and Brattleboro Retreat are at capacity and underfunded. Until we integrate physical and mental health, we’ll succeed at neither. Do we also not understand that poverty, homelessness, hunger, abuse, and lack of access to health care are all precursors to mental and physical illness? Is the prison endgame at $50,000 per prisoner per year really cheaper than population health?

We have the resources and the money to get this right. There are cutting-edge resources in the Vermont Dept. of Health, as we’ve seen in the crisis management of Covid. Our two colleges of medicine, Larner at UVM and Geisel at Dartmouth, are doing world-class research, have a trove of relevant data, and a cadre of committed professionals. We have the legislative and regulatory resources. What we’re lacking is the leadership to deploy these resources to forge and execute a vision for preventive managed care.

True leaders don’t try to satisfy everyone. They take political risks. They pioneer. If pleasing everyone, positive polling, and re-election are leadership’s goals, we’ll never see change. Governor Scott has vastly outperformed his peers in Covid crisis-management. He must now understand health care itself as the crisis and lead.