The Dangerous Drift of Vermont’s Health Care System

When he was governor, Peter Shumlin made a big push on health care reform. It didn’t end well for reform or for Shumlin. Since then, the system has become less functional and more expensive but there’s been no appetite for another push.

With one major exception, and that’s OneCare Vermont. It has soldiered on in its effort to rein in health care costs by paying providers for outcomes rather than treatment. It has spent a tremendous amount of money, but so far there’s not much evidence of impact.

That’s troubling, and it’s more so when you read VTDigger’s piece about the latest Green Mountain Care Board meeting. Beyond that, there’s a broader critique of our health care system in a recent series of essays by journalist and health care policy analyst Hamilton Davis. Taken together, it looks like a huge sector of our economy (upon which our physical and financial well-being depends) is drifting along with a bunch of people who call themselves “Captain” staying as far away from the helm as they can.

The Digger article makes the leaders of OneCare look like The Gang That Couldn’t Shoot Straight. The GMCB, especially its new members, were asking questions that shouldn’t have been tough to answer. For instance, do you have any evidence that your system is working? Can you point to measurable results in terms of cost savings or improved outcomes?

OneCare leaders seemed to be taken aback by this line of questioning.

Thom Walsh, who was appointed to the board in December, asked OneCare CEO Vicki Loner to name the organization’s top three key performance indicators, or metrics of success. Loner declined to name any, saying, “They’re going to our board to be reviewed.”

Walsh pointed out that OneCare has been on the job for “five or six years,” and they’re still figuring out how to measure their progress?

Christ on a bicycle.

Another OneCare exec argued that increased enrollment is “a valid measure of improvement” even if the organization can’t prove results. Which is kind of like saying “I gained 50 pounds so I must be really healthy.”

OneCare COO Sara Barry said that “it’s going to take years, decades, generations” for all this to play out. That’s an awfully long wait considering all the money we’re pouring into the effort.

Important caveat. I’m sure that OneCare’s plans have been deeply affected by the Covid pandemic. If they had had a solid program, the pandemic would have knocked it for a loop. But in that case, couldn’t its leaders have said “We’d be much farther along if not for Covid, and here’s how it affected our progress”?

We have put all our cost-containment eggs in one basket and now the weaver can’t tell us whether it’s strong enough. Yikes.

In a series of three essays (and counting), Davis takes an equally dispiriting look at the drift in our health care policy embodied in the GMCB. The first essay is a critical look at the Board’s performance, which he damns as the “dog that wouldn’t bark.” The Board was designed to be the all-powerful overseer of health care costs. If it’s not doing the job, that’s a real problem. Davis identifies the Board’s “incompetent and irresponsible performance” in this summer’s deliberations on hospital budgets. His key criticism: The Board went hard on the University of Vermont hospital system while ignoring problems at the 11 community hospitals around the state.

There’s a critical caveat here as well. Whether or not community hospitals are the most efficient, they do serve important roles in their home communities and they bring health care much closer to rural residents. If I lived in St. J or Bennington, I might prefer a lower quality level that’s nearby instead of a better alternative that’s two hours away. Any effort to recast the entire system as Davis suggests would have to balance cost and quality with the value of having a hospital — even a small one — within driving distance of most Vermonters.

It’s a much more complex problem akin to the restructuring of the Vermont State College system. Leaders had to balance efficiency with valid community interests. They came up with a plan that kind of drew equal scorn from all sides, which is maybe the best outcome they could have hoped for.

Davis’ second essay documents the problems at community hospitals. Bottom line: “We now operate 14 full-service hospitals, when we actually need four, with the remainder stepped down to clinics of various sizes.”

You can see how that would play in the host communities of the other 10, including Brattleboro, Middlebury, St. Johnsbury, Newport, Bennington, Randolph, Springfield, St. Albans, Morrisville, and Windsor. But Davis says these institutions are not cost-effective and are too small to deliver top-quality care. If we’re interested in limiting health care costs, this is an obvious (if uncomfortable) place to look.

These findings came from a report commissioned by the GMCB from a selection of national-class health care consultants — a report that the Board received and then ignored, per Davis.

Finally the third essay slams the Board for, in the words of the title, “Running Away and Hiding From the Data.”

Ouch.

He’s referring to the reatlively friendly budget reviews for the community hospitals and the tougher handling of UVMMC. Davis says our biggest and best medical center — and the most crucial piece of our hospital system — has been “routinely cut… to damaging levels.”

Again, his metric is efficiency in cost and health care delivery. There are other criteria worthy of inclusion, but he does have a valid argument.

Since the budget review, the Board has experienced significant turnover in its membership. The consequences have yet to play out; in an upcoming fourth installment, Davis will take a look at how the new Board might act.

I cannot overstate how problematic all of this is. OneCare are still trying to establish proof of concept for the single most important cost containment effort in years. Meanwhile, the Board is acting inconsistently at best, and ignored its own consultants’ findings on the hospital system.

Davis doesn’t directly say so, but it seems clear that the Scott administration has enabled this drift or actively encouraged it. The Board may have been a bad idea from jump; it’s more of a remnant of Shumlin’s reform push than a concept that’s sound on its own merits. Either way, Scott’s been in office long enough that it’s his baby now. As of last month, all Board members are Scott appointees. In some cases, the new members replaced old Scott appointees. He owns its performance, which in Davis’ view has been subpar.

So we just signed up for another two years of the same. This has the advantage of avoiding discomfort in the moment, but it postpones and worsens the inevitable day of reckoning. How much more expensive and dysfunctional will our system become before someone, sometime, takes on the whole problem once again? How will budget cuts harm the performance of UVMMC? Will we get to a point where we’ll be taking a meataxe to rural health care instead of productively recasting it? What do we do if it turns out OneCare is a pig in a poke?

There’s a cloud lot of uncomfortable questions around our health care system. The GMCB’s effectiveness is, at best, open to question. Ditto OneCare. The balance of services at rural hospitals and major medical centers may be wholly inappropriate, and being decided on political grounds instead of best practices. The shortcomings of regulators may be contributing to the high cost of health care instead of reining it in.

There are serious questions about our current health-care regime and how it’s regulated. There seems to be little political appetite to face the health care reform monster that ate the Shumlin administration. I see no sign that the Scott administration will do anything more creative than try to limit cost increases regardless of quality implications. We’re drifting, and nobody wants to take the wheel.

2 thoughts on “The Dangerous Drift of Vermont’s Health Care System

  1. bombaysapphiremartiniupwithextraolivesstirred

    OneCare should relocate to cheaper digs. My dermatologist is in the same building and I honestly believe the rent has to be outrageous. Actually, i think they could all work remotely.

    Reply
  2. Walter Carpenter

    “We’re drifting, and nobody wants to take the wheel.”

    Good metaphor. I haven’t yet read Davis’s essays. The thing to note is that OneCare, the ACO, and this whole concept of yet another form of managed-care is yet another attempt to avoid taking “the wheel,” and quietly handing our system over to UVM and BCBS and no one wants to stop this. If I remember right, and I’m not exactly sure, the GMCB was mandated in several legislatures ago to implement this OneCare, an absurd concept to begin with. I also thank the new board members for asking these questions of OneCare. We should keep asking them.

    Reply

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