What a Functional Vermont Healthcare System Might Look Like
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I’m often asked what an ideal Vermont healthcare system would look like. Many working in the field of healthcare reform in Vermont have put forward similar models and we share broad agreement on the elements of a model that could provide Vermonters with “population health.”
The key design imperatives are:
- proximity to served population (local first),
- patient presenting acuity (seriousness of patient condition needing care) determines point of system entry,
- sustainable government authority provides oversight, guidance and regulation, the Green Mountain Care Board (GMCB)
- system-wide, nonprofit governing board-driven accountability to the mission of “population health,” as measured by clinical quality, access, and patient affordability.
Currently, most hospitals compete for market share regardless of the cost of such competition, putting them at severe financial risk and placing them beyond both access and affordability for most patients. And “quality” is of little use to those who can neither access it nor afford it.
In a functional model, hospitals will be scaled in size and scope of services to market limitations and federal reimbursements from Medicare, on which many hospitals either break even or earn modest revenue. A tertiary-care hospital, such UVM Medical Center or 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.
If we draw a straight service line from the at-home patient to the regional tertiary-care hospital, it might look like this:
> 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)
> community medical practices
> local clinics
> federally qualified health centers (FQHCs)
> critical-access hospitals (6)
> regional hospitals (4)
> one tertiary-care hospital
Two critical principles underly such a system:
All hospitals are, by legal definition in Vermont, nonprofits and are governed by a board of trustees. The board is self-perpetuating, and trustees are not chosen by the hospital chef 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 toward delivery on mission.
Hospitals do not compete for market share but collaborate and allocate services among one another to create a sustainable system that meets the goal of “population health for Vermonters.”
